Advanced Pediatric Assessment

Advanced
Pediatric
Assessment
ELLEN M. CHIOCCA, RNC, MSN, CPNP

Assistant Professor of Clinical Nursing
Loyola University Chicago
Marcella Niehoff School of Nursing
Chicago, Illinois
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9 8 7 6 5 4 3 2 1
Library of Congress Cataloging-in-Publication Data
Chiocca, Ellen.
Advanced pediatric assessment / Ellen Chiocca. —1st ed.
p. ; cm.
Includes bibliographical references.
ISBN 978-0-7817-9165-6
1. Children—Medical examinations. 2. Children—Diseases—Diagnosis. I. Title.
[DNLM: 1. Child. 2. Physical Examination—methods. 3. Adolescent. 4. Age Factors.
5. Infant. 6. Pediatrics—methods. WS 141 C539a 2010]
RJ50.C487 2010
618.92—dc22
2009037355
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DEDIC AT IO N
This book is dedicated to my cherished daughter, Isabella Grace Pan Di,
whom I love beyond all words, and to her “sisters” everywhere.
To my darling Ralph, the most wonderful, kind, loving, and supportive man
I have ever known. I love you.
And to the memory of my father
FRANK JOSEPH CHIOCCA, JR.
1939–1987
who taught me, by example, the value of education,
scientific inquiry, perseverance, and diligence.
ACKNOWLEDGMENTS
It was both an honor and privilege to write a pediatric who has now become a dear friend. It was so easy to
health assessment textbook for Lippincott Williams work with Jane. She taught me so much in the process
and Wilkins. I will always be grateful for their faith of writing this book. I would especially like to thank
in me and for the opportunity to express my vision Jane for her infinite patience, for always believing in
of child health and my approach to child health me, always encouraging me, and telling me to hang
assessment. in there when hanging in there became very difficult
I would like to thank my friend Ken Kasee, formerly to do.
of Lippincott Williams and Wilkins, who first ap- I would like to thank my sister and friend Mary Beth
proached me and asked me to write this book. Kamba, who always makes me laugh.
I offer a sincere thanks to Elizabeth Nieginski, I would like to show my appreciation to my brother
Executive Acquisitions Editor, who has been extremely Michael Chiocca and to my nephew George Kamba
kind, encouraging, and supportive to me from the very who always asked me how the writing was going, and
first day. I am especially thankful for her infinite pa- then listened to the answer.
tience and for how she worked so hard to move my Thank you to Brandon Bosch for being such a good
book proposal forward. and loyal friend and helping me with childcare so I
I would also like to thank Michelle Clarke, Product could find time to write.
Manager, and Jean Rodenberger, Acquisitions Editor, Thank you so much to my adored, beloved, and pre-
for their patience and support at the end of this cious daughter Isabella. Thank you for being so patient
project. all this time while I was working on my book. I’m all
I sincerely appreciate the work of my brilliant chap- yours now.
ter contributors, and I thank them for sharing their And last, but not least, I want to thank my wonderful
knowledge and expertise. I owe thanks to my patient husband Ralph Zarumba who provided me with con-
friends and colleagues, who have hung in there while I tinuous encouragement, support, and love throughout
disappeared into the writing of this book. this process, as well as practical help around the house,
A very personal thank you to Jane Edwards, Devel- including those wonderful home-cooked meals. I am
opmental Editor, who is excellent at what she does and the luckiest woman in the world.
v
CONTRIBUTORS
Colleen Andreoni, MSN, APKN, BC-NP
Instructor
Niehoff School of Nursing
Chicago, Illinois
Diane B. Boyer, CNM, PhD

Professor Emerita, Maternal-Child Nursing
Charleston, South Carolina
Shirley A. Butler, PhD, RN

Assistant Professor of Nursing
Health Management and Risk Reduction
Chicago, Illinois
Pat Hummel, MA, APN, NNP-BC, PNP-BC

Department of Nursing, Neonatology, and Pediatrics
Loyola University Medical Center
Maywood, Illinois
Gloria A. Jacobson, PhD, RN

Dean and Professor
School of Nursing
Saint Xavier University
Chicago, Illinois
Lisa M. Kohr, RN, MSN, AC-PNP, MPH, CCRN

CICU PNP
Children's Hospital of Philadelphia
Philadelphia, Pennsylvania
Joanna M. Kouba, PhD, RN, LDN

Assistant Professor
School of Nursing
Maywood, Illinois
Patricia A. Sullivan, BSN, MSN, FNP-BC

Part-time Faculty
Chicago, Illinois
vii
REVIEWERS
Linda K. Calhoun, RN, MNSc, NNP, CNS
Faculty and Coordinator, BSN Program
College of Nursing
University of Arkansas for Medical Sciences
Little Rock, Arkansas
Evelyn Cesarotti
Associate Professor
Arizona State University College of Nursing and Healthcare Innovation
Phoenix, Arizona
Angela Chia-Chen Chen, PhD, RN

Assistant Professor
Arizona State University College of Nursing & Healthcare Innovation
Phoenix, Arizona
Nan M. Gaylord, PhD, RN, CPNP

Associate Professor
College of Nursing
University of Tennessee
Knoxville, Tennessee
Anna Marie Hefner, RN, MSN, CPNP

Associate Professor
Azusa Pacific University
Azusa, California
Ann Linguiti Pron, MSN, CRNP

Assistant Clinical Professor
Department of Nursing
Temple University,
Philadelphia, Pennsylvania
Mary Jo Vollmer-Sandholm, MSN, RN, C-PNP

Lead Faculty—PNP Program
Loma Linda University and Children’s Hospital
Loma Linda, California
ix
PREFACE
Pediatric health care experts agree that the health The remainder of the book is divided into three
care needs of children differ vastly from those of the sections. Section 2, Obtaining the Pediatric Health His-
adult. From infancy through adolescence, a child tory, contains chapters that are devoted to communi-
experiences many dramatic physiological, psycho- cating with children, family, and cultural assessment,
social, developmental, and cognitive changes. Thus, and obtaining the pediatric health history. Section 3,
it is critical for the pediatric health care provider Physical Assessment, begins with a chapter that details
to possess specialized knowledge and skills to accu- specific approaches to the pediatric physical examina-
rately assess children during health and illness. Con- tion, including assessment techniques, developmental
cepts related to the health assessment and physical approaches to examining children and adolescents,
examination of the adult cannot be applied to the and sequencing of the physical exam according to
care of children. age and developmental level. Chapters on safety as-
The goal of Advanced Pediatric Assessment is to em- sessment, well child examinations, nutritional assess-
phasize the uniqueness of children when conducting ment, and detailed assessment of the neonate are also
the health assessment. Emphasis is placed on the phys- included in this section. Clinical chapters follow in
ical, psychosocial, developmental, and cultural aspects Section 4, Focused Assessments, which detail the as-
of child assessment to an extent not possible in across- sessment of each body system. The content of each of
the-lifespan assessment textbooks. As such, this book these chapters is organized in the following way:
has a dual focus: to serve as a course textbook in edu-
• Anatomy and Physiology
cation and as a reference for the practicing pediatric
• Developmental Considerations
health care provider.
• Cultural and Racial Considerations
This book provides two introductory chapters that
• Health History
provide a general overview describing how the ap-
• Physical Examination
proach to child health assessment differs from that
• Common Diagnostic Studies
of the adult. Chapter 1 begins with a discussion of
• Sample Documentation
the anatomic and physiologic differences that exist
between infants, children, and adults, and contin- This uniform presentation of content helps the learner
ues with a brief summary of growth and develop- begin to think in a systematic, organized manner.
ment, communication skills required to work with Section 5, Assessment of the Whole Child, includes
children, understanding the parent–child relation- chapters that address psychosocial issues, specifically,
ship, and general strategies involving the approach the assessment of various types of child abuse and
to obtaining the child health history and physical neglect, peer victimization, and mental health assess-
examination. Chapter 2 provides a more detailed dis- ment, including screening for addiction, depression,
cussion of the general principles of growth and devel- and suicidal ideation.
opment, including selected developmental theorists. Child health care is becoming more complicated
Both physical and psychosocial growth and develop- and challenging in many ways. I believe that each and
ment are included, including gross and fine motor every child deserves the most safe, comprehensive,
development, language development, and psycho- detailed, culturally sensitive health care possible. It is
social and emotional growth and development. De- my sincere hope that Advanced Pediatric Assessment will
tailed tables list normal growth and developmental assist in achieving that goal.
milestones of birth through adolescence, as well as
developmental red flags and selected developmental Ellen M. Chiocca, RNC, MSN, CPNP
screening tools. Chicago, Illinois
xi
CONTENTS
Acknowledgments v
Contributors vii
Reviewers ix
Preface xi
Section 1: Growth and Development
CHAPTER 1
Assessment of Health and Illness in Children: An Overview 1
ELLEN M. CHIOCCA
CHAPTER 2
Assessment of Child Development and Behavior 17
ELLEN M. CHIOCCA
Section 2: Obtaining the Pediatric Health History
CHAPTER 3
Communicating with Children and Families 44
PATRICIA A. SULLIVAN
CHAPTER 4
Cultural Assessment of Children and Families 56
ELLEN M. CHIOCCA
CHAPTER 5
Assessment of the Family 76
GLORIA A. JACOBSON
CHAPTER 6
Obtaining the Pediatric Health History 89
ELLEN M. CHIOCCA
CHAPTER 7
Assessing the Health and Safety of the Child’s Environment 109
ELLEN M. CHIOCCA
Section 3: Physical Assessment
CHAPTER 8
The Pediatric Physical Examination 138
ELLEN M. CHIOCCA
CHAPTER 9
The Health Supervision Visit: Wellness Examinations in Children 161
ELLEN M. CHIOCCA
xiii
x iv • C o nt e nt s
CHAPTER 10
Assessment of Nutritional Status 182
JOANNE KOUBA AND ELLEN M. CHIOCCA
CHAPTER 11
Newborn Assessment 199
PAT HUMMEL
Section 4: Focused Assessments
CHAPTER 12
Assessment of the Integumentary System 230
ELLEN M. CHIOCCA
CHAPTER 13
Assessment of the Head, Neck, and Regional Lymphatics 258
ELLEN M. CHIOCCA
CHAPTER 14
Assessment of the Ears 278
ELLEN M. CHIOCCA
CHAPTER 15
Assessment of the Eyes 302
ELLEN M. CHIOCCA
CHAPTER 16
Assessment of the Face, Nose, and Oral Cavity 325
ELLEN M. CHIOCCA
CHAPTER 17
Assessment of the Thorax, Lungs, and Regional Lymphatics 348
ELLEN M. CHIOCCA
CHAPTER 18
Assessment of the Cardiovascular System 366
LISA M. KOHR
CHAPTER 19
Assessment of the Abdomen and Regional Lymphatics 391
ELLEN M. CHIOCCA AND COLLEEN ANDREONI
CHAPTER 20
Assessment of the Reproductive System 413
ELLEN M. CHIOCCA AND DIANE B. BOYER
CHAPTER 21
Assessment of the Musculoskeletal System 436
ELLEN M. CHIOCCA
CHAPTER 22
Assessment of the Neurologic System 458
ELLEN M. CHIOCCA
Contents • xv
Section 5: Assessment of the Whole Child
CHAPTER 23
Assessment of Child Abuse and Neglect 493
ELLEN M. CHIOCCA
CHAPTER 24
Assessment of Mental Disorders in Children and Adolescents 513
SHIRLEY A. BUTLER AND ELLEN M. CHIOCCA
APPENDICES
Appendix A Normal Vital Signs in Infants, Children, and Adolescents 527
Appendix B CDC Growth Charts 532
Appendix C Michigan Alcohol Screening Test: Brief Version 542
Appendix D Drug Abuse Screening Test 543
Appendix E Substance-specific Criteria for Substance Intoxication 544
Appendix F SAD PERSONS Scale 545
Index 547
SECTION 1
GR O WT H A ND DE V E LO PM E NT
CHAPTER
Assessment of Health
1 and Illness in Children:

An Overview ELLEN M. CHIOCCA
INTRODUCTION ANATOMIC AND PHYSIOLOGIC

DIFFERENCES IN INFANTS AND
Understanding the unique differences between adults
and children is imperative when providing care to CHILDREN
the pediatric population. Children experience dra-
matic changes in their bodies and minds from infancy Knowledge of the normal anatomic and physiologic
through adolescence. Because of these anatomic, phys- differences that exist between infants, children, and
iologic, and developmental changes, it is crucial for the adults is essential to recognizing any abnormalities
health care provider to possess specialized knowledge found during the physical examination. Because
and skills to assess children accurately during health each body system is immature until at least age two
and illness. Concepts related to the health assessment years, it is necessary for the provider to alter his or
and physical examination of the adult patient cannot her expectations for physical findings according
be applied to children; they are not simply little adults. to the child’s age. In addition, an infant or young
For the health care of children to be safe, thorough, child’s physical condition can go from stable to life-
and developmentally appropriate, it is essential that threatening very quickly because of immature body
the pediatric health care provider base a complete pe- systems that lack fully developed feedback mecha-
diatric health assessment on a thorough knowledge of nisms. This also explains the varied physiologic
pediatric anatomy and physiology, pathophysiology, responses infants and children have to illness and
pharmacology, child development, the child’s family injury and why infants and young children absorb,
and community, and the family’s primary culture. In distribute, metabolize, and excrete drugs very differ-
addition, this assessment must involve knowledge of ently than adults. The frequency, timing, and length
current clinical practice guidelines for children (see of pediatric health care visits can also be impacted
Chapter 9). Effective communication skills are essen- by these differences. Table 1-1 presents an overview
tial to working with children of different ages and de- of the major anatomic, physiologic, metabolic, and
velopmental levels and their families or caregivers, as immunologic differences between infants, children,
well as to providing clear and objective documentation and adults, and the corresponding clinical implica-
of assessment findings. tions of these differences.
1
2 • S e c t i o n 1 GR O W T H AN D D EV ELO PM ENT
TABLE 1-1
Anatomic and Physiologic Differences in Infants, Children,
and Adolescents
ANATOMIC/PHYSIOLOGIC AGE-GROUP
BODY SYSTEM DIFFERENCES AFFECTED CLINICAL IMPLICATIONS
Integument Thin stratum corneum Infants until Blood vessels visible through
approximately age 2 to newborn’s skin, causing ruddy
3 years, when skin appearance; increased absorption
becomes thicker because of topical drugs; skin burns
of daily friction and easily; prone to hypothermia and
pressure dehydration
Thin layer of subcutaneous fat Newborns Affects temperature control
Epidermis more loosely Birth through early Skin layers separate readily, causing
bound to the dermis (Ball & school-age easy blistering (e.g., adhesive tape
Bindler, 2006) removal); susceptible to superficial
bacterial skin infections and more
likely to have associated systemic
symptoms with some skin infections;
skin is a poor barrier, contributing to
fluid loss
Sebaceous glands active in Neonates; adolescents Milia develop in neonates; acne

neonate because of maternal develops in adolescents
androgen levels (Hockenberry
& Wilson, 2007) and again at
puberty because of hormonal
changes (Ball & Bindler, 2006)
Eccrine glands functional Birth to preschool-age Palmar sweating occurs; helps to

at birth; full function not assess pain in neonate
occurring until age 2 to 3 years
(Vernon & Barber Starr, 2004)
Apocrine glands nonfunctional Adolescents Function of apocrine glands at

until puberty (Vernon & Barber puberty causes body odor
Starr, 2004)
Production of melanin reaches Birth until adolescence Affects assessment of skin color as
adult levels by adolescence child ages
(Ball & Bindler, 2006)
Greater body surface area Birth until age 2 years Increases exposure to topically
applied drugs; may result in toxicity
in some instances
Head and Neck Proportionately large head Infants until age 2 years Increased potential for injury
because of cephalocaudal because of weight of head during
development. At birth, head falls or collisions where body is
circumference exceeds chest thrown with head in front; reason
circumference; does not for high incidence of head trauma in
become equal until age 2 years this age-group
Cranial sutures not fully fused Posterior fontanel should Full anterior fontanel can indicate
at birth to accommodate brain be closed by 2 months; increased intracranial pressure;
growth anterior fontanel should sunken anterior fontanel can
be closed by 12 to indicate dehydration
18 months
Brain growth very rapid; half Birth to age 2 years Head circumference should increase
of postnatal brain growth is as a reflection of brain growth
completed by age 1 year; brain
reaches 75% of adult size by
age 3 years (Hockenberry &
Wilson, 2007)
C H A P T E R 1 A s s e s s m e n t o f He alth an d I lln e s s in Ch ildren: An Over view • 3
Brain reaches 90% of adult size School-aged children; Reflection of brain growth
by age 6 years (Hockenberry & adolescents
Wilson, 2007); brain reaches
adult size by age 12 years
Short neck and prominent Infants through age 3 to Increased potential for injury
occiput (Macfarlane, 2005). 4 years in infants and toddlers; airway
Neck lengthens at age 3 to 4 structures closer together; affects
years (Hockenberry & Wilson, intubation technique in children
2007) younger than preschool-age
Eyes Eye structure and function not Neonates; infants Affects expected findings in physical
fully developed at birth: pupils examination
are small with poor reflexes
until about 5 months of age;
transient nystagmus and
esotropia common in neonates
younger than 6 months of
age (Ball & Bindler, 2006);
irises have little pigment
until 6 to 12 months of age
(Hockenberry & Wilson, 2007)
Vision undeveloped; by age Neonates to school-age Affects expected findings in and

4 months, infants can fixate approach to physical examination
on an image with both eyes and vision screening
simultaneously; ability to
distinguish color begins by
age 8 months; children are
farsighted until about age 6 to
7 years (Ball & Bindler, 2006)
Ears Newborns can hear loud sounds Neonates Newborns react to loud sounds
at 90 decibels (Hockenberry & with startle reflex; they react to
Wilson, 2007) low-frequency sounds by quieting;
differences affect techniques for
hearing assessment
Short, wide eustachian tube, Birth until approximately Fluid in middle ear cannot easily
lying in horizontal plane age 2 years drain into pharynx; prone to middle
ear infections and effusions
External auditory canal is short Birth to age 3 years Pinna should be pulled down
and straight with upward curve and back to perform otoscopic
examination
External auditory canal Age 3 years and older Pinna should be pulled up and back
shortens and straightens as to perform otoscopic examination
child grows
Mouth, Nose, Saliva minimal at birth; Infants Increased aspiration risk; presence of
Throat, and increases by age 3 months; drooling does not signify teething
Sinuses salivary secretions increase after
age 3 months (Hockenberry &
Wilson, 2007)
Deciduous teeth should erupt Infants; toddlers Delay may signify hypothyroidism
between ages 6 to 24 months or poor nutrition
Obligate nose breathers Birth to 4 to 5 months Nasal passages easily obstructed by

secretions; affects airway patency
and ability to feed
(continued)
TABLE 1-1
and Adolescents (Continued)
Airway and nasal passages are Infants through age Increased potential for airway
small and narrow; larynx is 5 years (Swamy & obstruction and infection;
narrowest at the level of the Mallikarjun, 2004) endotracheal intubation difficult,
cricoid cartilage (subglottis) and accidental extubation more
(Swamy & Mallikarjun, 2004); likely with movement (Swamy &
1 mm of edema can narrow Mallikarjun, 2004)
an infant’s airway by 60%
(Macfarlane, 2005)
Large tongue in proportion Birth until age 8 to Potential for airway obstruction is
to mouth size (Swamy & 12 years when mandible greater
Mallikarjun, 2004) has a growth peak
Proportionately large soft palate Birth to approximately Any soft tissue swelling increases the
and large amount of soft tissue age 11 to 12 years risk for airway obstruction
in the airway (Fregosi, Quan,
Kaemingk, Morgan,
Goodwin, et al., 2003)
Ability to coordinate Birth until 4 to Increased risk of aspiration and

swallowing and breathing 5 months gastroesophageal reflux (GER)
immature (Swamy & (Swamy & Mallikarjun, 2004)
Mallikarjun, 2004)
Proportionately large, floppy, Birth through school- Increased potential for airway
and long epiglottis (Swamy & age obstruction with swelling;
Mallikarjun, 2004) endotracheal intubation difficult
Maxillary and ethmoid sinuses Birth until age 3 years Often early sites of infection; can be
small and undeveloped visualized on radiograph by age 1 to
(Hockenberry & Wilson, 2007) 2 years (Brady, 2009)
Sphenoid and frontal sinuses School-aged children; Sphenoid sinuses become site
become visible on radiograph at adolescents of infection by age 3 to 4 years;
5 to 6 years of age (Brady, 2009) frontal sinuses by age 6 to 10 years
(Brady, 2009)
Thorax and Hypoxic and hypercapneic Neonates; infants until Periodic breathing (i.e., apnea
Lungs drives not fully developed age 3 months ⱕ10 seconds) without cyanosis or
(Swamy & Malliakrjun, 2004) bradycardia is within normal limits
because of neurologic immaturity
of respiratory drive. Central apnea
lasts longer than 20 seconds and is
outside normal limits
Chest circumference Infants; toddlers Assists provider in assessing normal

should closely match head growth
circumference from age 6
months to 2 years; chest
circumference should exceed
head circumference at age 2 years
Easily compressible cartilage of Infants to age 2 years Limits tidal volume; lowers functional
chest wall (Macfarlane, 2005) residual capacity; rib cage is flexible
with very little musculature and provides little support for lungs;
negative intrathoracic pressure poorly
maintained, causes increased work
of breathing (Swamy & Mallikarjun,
2004); soft thoracic cage collapses
more easily during labored breathing
Rounded thorax in infancy: Birth to age 3 years Limits tidal volume (Macfarlane,
ribs lie in horizontal plane; 2005); ribs flexible and provide very
xiphoid process moveable little support for lungs; negative
(Macfarlane, 2005) intrathoracic pressure poorly
maintained; work of breathing thus
increased
Alveoli are thick walled at Neonates through age Affects gas exchange; oxygen
birth; infants have only 10% 8 years consumption in neonate almost
of the total number of alveoli twice that of an adult (Swamy
found in the adult lung; over & Mallikarjun, 2004); increases
the child’s first 8 years of life, respiratory rate; a child with
alveoli increase in number pulmonary damage or disease
and existing ones grow in size at birth can regenerate new
(Swamy & Mallikarjun, 2004) pulmonary tissue and may have
normal pulmonary function;
contributes to high number of
respiratory diagnoses when infant
or child acutely ill; respiratory
failure common in premature
infants because of surfactant
deficiency, causing alveolar collapse
(Macfarlane, 2005)
Less lung volume; tidal volume Birth to 10 years High respiratory rate, which falls to
proportional to child’s weight adult values by adolescence
(7 to 10 mL/kg) (Ball & Bindler,
2006)
Newborns produce little Neonates Increased susceptibility to respiratory

respiratory mucus (Pillitteri, infections
2003)
Mucous membranes lining the Infants; toddlers Potential for airway edema is greater,
respiratory tract are loosely causing potential airway obstruction;
attached and very vascular more respiratory secretions
produced, increasing the potential
for obstruction or aspiration
Larynx is located 2 to 3 cervical Birth until approximately Child vulnerable to aspiration

vertebrae higher at level of age 8 to 10 years
C3–C4 (Macfarlane, 2005;
Swamy & Mallikarjun, 2004)
Proportionately small and Birth until adolescence Great potential for airway
narrow oropharynx; trachea obstruction, mucus, and foreign
is proportionately shorter and body; resistance to airflow; air is
has a small diameter (Ball warmed and humidified much less
& Bindler, 2006). Tracheal effectively
cartilage is elastic and collapses
easily. The trachea continues
to grow in diameter until age
and triples in size between
birth and puberty
Right bronchus significantly Beginning age 2 years Breath sounds loud and high in
shorter, wider, and more pitch; easily heard through thin
vertical than the left (Brady, chest wall; inhaled foreign bodies
2009); trachea bifurcates at easily aspirated into right bronchus
higher level than adult’s
(continued)
TABLE 1-1
Large amount of anatomic dead Birth through school-age Fast respiratory rate needed to meet
space in tracheobronchial tree oxygen requirements; at risk for
where gas exchange does not respiratory acidosis if lungs cannot
take place (Kliegman, Behrman, remove carbon dioxide (CO2) quickly
Jenson, & Stanton, 2007) enough
Infants and children breathe Birth until age 6 years Respirations may be inefficient
using diaphragm and (Ball & Bindler, 2006) when crying or with anything that
abdominal muscles restricts breathing such as abdominal
distention; child may retain CO2 as a
result, causing acidosis
Breathing becomes thoracic as 8 to 10 years Respiratory rate lowers to near adult

in the adult levels
Intercostal, scaleni, Birth until approximately Immature respiratory muscles must

sternocleidomastoid, and age 2 years (Swamy & work hard to assist in respiratory
diaphragmatic muscles have Mallikarjun, 2004) effort; nasal flaring may occur;
few type I muscle fibers, which poorly developed respiratory
are used in sustained respiratory muscles hinder expulsion of thick
activity (Macfarlane, 2005; respiratory secretions. Muscles
Swamy & Mallikarjun, 2004) are easily fatigued and can result
in CO2 retention, apnea, and
respiratory failure
Cardiovascular With first breath at birth, Neonates Increased pulmonary blood flow;
System pulmonary vascular resistance low systemic blood pressure
falls
Left atrial pressure greater than Neonates Foramen ovale closes within first
right atrial pressure hour of life
Increased arterial oxygen Neonates Ductus arteriosus closes about 10 to

tension 15 hours after birth; fibroses within
2 to 4 weeks of age; systolic murmurs
may be audible in the first 24 to
48 hours of life because of transition
from fetal circulation
Relatively horizontal position Birth until age 7 years Heart sounds easily audible because
of heart; heart becomes more of thin chest wall; apical pulse heard
vertical as child grows at fourth intercostal space left of
the midclavicular line; apex reaches
the fifth intercostal space at the
midclavicular line by age 7 years;
heart may seem enlarged when
percussed; displacement of the apical
pulse may indicate pneumothorax,
dextrocardia, or diaphragmatic
hernia
Stroke volume somewhat fixed Neonates; infants Poor compliance and reduced
because of less muscular and contractility (Swamy & Mallikarjun,
poorly developed left ventricle 2004)
(Macfarlane, 2005; Swamy &
Mallikarjun, 2004)
Resting cardiac output high—300 Neonates; infants to Cardiac output must be high in
to 400 mL/kg/min at birth and adolescence neonate and infant to meet tissue
200 mL/kg/min within a few oxygen demands; this is done by
months (Macfarlane, 2005), increasing heart rate
decreasing to 100 mL/kg/min
by adolescence (Swamy &
Mallikarjun, 2004)
Cardiac output is heart-rate– Birth to late school-age; Heart rate rapid in children; the
dependent, not stroke-volume– adolescence (Ball & younger the child, the more rapid
dependent (Macfarlane, 2005) Bindler, 2006) the heart rate because of increased
oxygen and energy needs for
growth and higher metabolism. The
provider should be familiar with
age-specific norms for heart rate; the
pulse rises with fever and hypoxia;
tachycardia during sleep is abnormal
Vagal parasympathetic tone Neonates; young infants Prone to episodes of bradycardia

dominant (Macfarlane, 2005)
Electrocardiogram (EKG) Neonates through EKG changes reflect ongoing

readings different from adult’s; young childhood development of myocardium
heart rhythm varies more in (Swamy & Mallikarjun, 2004);
children than adults (Swamy & sinus arrhythmia within normal
Mallikarjun, 2004) limits in children and common in
adolescence
Left ventricular muscle Infancy until school-age Radial pulse may not be palpable
undeveloped until age 6 years until age 6 years; apical pulse should
be taken until then; the younger the
child, the lower the blood pressure
(BP); BP rises as child gets older in
correlation with increased blood
volume and body weight, reaching
adult levels by adolescence
Reduced catecholamine stores; Neonates; infants Poor response to hypotension via

poor response to exogenously vasoconstriction; hypotension
administered catecholamine without tachycardia seen with
(Swamy & Mallikarjun, 2004); hypovolemia in neonates and
baroreceptor reflexes immature infants (Swamy & Mallikarjun, 2004)
Innocent murmurs common in Birth through Innocent murmurs are heard during
children (Biancaniello, 2005); adolescence systole; they cause no cyanosis,
may be present in up to 80% of fatigue, shortness of breath, or
children (Swamy & Mallikarjun, failure to thrive
2004)
Abdomen Weak abdominal musculature; Infants; toddlers Liver and spleen not well protected;
abdomen protuberant in contributes to “pot-bellied”
neonates and prominent in appearance in infants and toddlers
toddlers while standing and flat
when supine
Abdomen larger than chest in Birth until age 4 years Distended or scaphoid abdomen
young children indicative of pathology
Abdomen cylindrical in shape Infants Peristalsis may be visible and may

indicate pathology such as pyloric
stenosis
(continued)
TABLE 1-1
Abdominal contour changes to Preschool-age to Affects provider expectations during
adult shape by adolescence adolescence physical examination
Stomach lies in a transverse Birth until age 2 years Affects normal area to auscultate
plane and palpate during physical
examination
Gastric pH is alkalotic at Birth to age 2 years Affects oral medication absorption;

birth; gastric acid production increases incidence of GER
slowly increases to adult levels
by age 2 years (Swamy &
Mallikarjun, 2004)
Neonate has small stomach Neonates; infants; Need for small feeding amount at
capacity (approximately toddlers birth; increases incidence of GER
60 mL). Stomach capacity
reaches approximately
500 mL by toddler age (Ball &
Bindler, 2006)
Stomach capacity reaches 1000 Adolescents Correlates with increased appetite

to 1500 mL by adolescence
Lower esophageal sphincter Neonates Increases incidence of GER

tone (Ball & Bindler, 2006)
Prolonged gastric emptying Neonates; infants; Affects absorption of nutrients and

time (6 to 8 hours) and transit reaches adult levels by medications, increasing the chance
time through the small approximately 6 to 8 of adverse side effects and toxicities
intestine (Guthrie, 2005) months (Guthrie, 2005)
Length of small intestine Infants; toddlers Child loses proportionately more

proportionately greater water and electrolytes in stool with
with greater surface area for diarrhea
absorption relative to body size
Large intestine proportionately Infants Less water absorbed, explaining soft

shorter with less epithelial stools of infancy
lining (Kliegman, Behrman,
Jenson, & Stanton, 2007)
Pancreatic enzyme (e.g., Birth to age 4 to Varied bioavailability of drugs that

amylase, lipase, trypsin) activity 6 months (Ball & may depend on specific enzymes to
decreased at birth (Ball & Bindler, 2006) aid in drug absorption; enzymes not
Bindler, 2006) present in sufficient quantities to
digest food fully
Hepatic System Liver functionally immature at Birth until age 1 year Bilirubin excreted in low
birth (Macfarlane, 2005; Swamy (Ball & Bindler, 2006) concentrations in newborns;
& Mallikarjun, 2004) prothrombin levels in neonate
only 20% to 40% of adult levels,
which affects clotting; vitamin
storage inadequate, a factor in
young children’s frequent infectious
illnesses; process of gluconeogenesis
immature
Liver occupies a larger part Birth until adolescence Affects normal area for provider
of abdominal cavity than to palpate and percuss; organs are
in adults; palpable at 0.5 to typically nonpalpable by school-age;
2.5 cm below the right costal enlarged liver can indicate right-
margin in infants; 1 to 2 cm sided heart failure
below the right costal margin
in toddlers (Hockenberry &
Wilson, 2007). Liver reaches
adult size and function by
adolescence
Decreased hepatic enzyme Neonates until 3 to Enzyme systems for

function in young children 4 years biotransformation of drugs not
(Swamy & Mallikarjun, 2004); fully developed, which affects
drug enzyme systems mature at drug dosing; infants and children
different rates metabolize drugs more slowly than
adults; can build up toxic levels of
drugs easily
Liver conjugation reactions Neonates Jaundice; long drug half-lives

impaired (Swamy & (infants and children have
Mallikarjun, 2004) short drug half-life) (Swamy &
Mallikarjun, 2004)
Liver synthesizes and stores Neonates until 1 year May become hypoglycemic easily;
glycogen less effectively hypoglycemia in neonate can cause
(Swamy & Mallikarjun, 2004) permanent neurologic damage.
Young children need to eat more
frequently during childhood (e.g.,
a.m. and p.m. snacks)
Maternal iron stores in liver Birth to 6 months Infant requires outside source of
depleted by age 6 months iron (e.g., iron drops, fortified
cereal) beginning at age 6 months
Lower level of plasma albumin Neonates until age 1 Decreased protein binding of
and globulin (Swamy & year drugs in newborns; high levels
Mallikarjun, 2004); endogenous of free drug in bloodstream,
compounds such as bilirubin causing possible toxic level of
and free fatty acids already drug or neonatal coagulopathy;
bound to albumin endogenous compounds (e.g.,
bilirubin) can also displace a
weakly bound drug; high loading
doses of protein-bound drugs may
be needed in neonate. Certain
drugs (e.g., sulfonamides) can
displace bilirubin from albumin-
binding sites, causing kernicterus
in the neonate
Lymphatic Lymph tissue is well-developed Birth to adolescence Potential for airway obstruction with
System at birth and reaches adult size upper respiratory infections, chronic
by age 6 years. It continues to tonsillar or adenoidal swelling, or
grow until age 10 to 12 years, both; large tonsils and adenoids can
when lymph tissue reaches a make intubation difficult
maximum size of approximately
twice the normal adult size, at
which time the tissue rapidly
declines to normal adult size by
the end of adolescence (Ball &
Bindler, 2006)
(continued)
1 0 • S e c t i o n 1 GR O W T H AN D DEV ELO PM ENT
TABLE 1-1
Spleen may be palpable 1 to Infants; toddlers Affects approach to physical
2 cm below the left costal examination; spleen should be
margin (Hockenberry & nonpalpable by preschool-age
Wilson, 2007)
Hematologic Vitamin K–dependent clotting Neonates through early Vitamin K is administered at birth
System factors and platelet function infancy to prevent bleeding disorders in
inefficient newborns
Blood volume is weight- Neonates Overhydration and dehydration

dependent. Total circulating occur more quickly than in an adult;
blood volume (mL of blood per blood loss can cause hypovolemic
kg of body weight) is greater than shock and anemia in infant or young
adult by 25%. Blood volume child more quickly than in an adult
is highest in neonate (80 to
90 mL/kg); in premature infants
approximately 105 mL/kg;
normal adult values are 70 to
80 mL/kg (Bissonnette & Dalens,
2002)
At birth, 70% to 90% of Birth to 4 months HbF has higher affinity for oxygen
hemoglobin is fetal hemoglobin than adult hemoglobin; protects red
(HbF) (Macfarlane, 2005) blood cells from sickling with sickle
cell disease; oxygen saturation curve
is left-shifted for HbF; oxygen not
delivered as readily to tissues; HbF is
replaced by adult hemoglobin (HbA)
by age 4 months
Immunity Infants fight infection Birth to 6 to 8 months After age 6 months, infants are
primarily by passive immunity (Ball & Bindler, 2006) prone to infection and build
acquired transplacentally or until breastfeeding immunity to common illnesses as
(Ball & Bindler, 2006) and by discontinued they are exposed to them
breastfeeding (Hockenberry &
Wilson, 2007)
Humoral and cell-mediated Birth to age 6 years (Ball Frequent infectious illness
immunity not fully developed & Bindler, 2006) in children younger than
approximately 6 years
Reticuloendothelial system Birth until Lymphatic tissue, tonsils, and

active in childhood approximately age 10 adenoids swell rapidly in response
years to mild infections; swollen tissues
can cause airway obstruction
Genitourinary Kidneys proportionately larger Infants; toddlers; Tip of right kidney may be palpated
System than adults; surrounded by less preschoolers because of thin abdominal wall,
fat (Ball & Bindler, 2006) especially during inspiration; child’s
kidneys susceptible to trauma
Ureters relatively short; urinary Birth to age 3 years Bladder descends into pelvis by age
bladder lies between symphysis 3 years; until then affects approach
and umbilicus (Hockenberry & to physical examination
Wilson, 2007)
C HA P T E R 1 A s s e s s m e n t o f He alth an d I lln e s s in Ch ildre n: An Over view • 11
Kidneys are immature Newborns until age Kidneys cannot concentrate and dilute
at birth: increased renal 2 years (Swamy & urine effectively (most pronounced in
vascular resistance; Mallikarjun, 2004) first year of life); young infants cannot
incomplete glomerular and handle large amounts of solute-free
tubular development causes water or concentrated infant formulas;
decreased renal blood flow, prone to dehydration with fluid losses
glomerular filtration rate, and (e.g., diarrhea, vomiting) or decreased
tubular function (Swamy & oral intake; prone to fluid overload;
Mallikarjun, 2004) electrolyte secretion and absorption
suboptimal: infants’ kidneys cannot
conserve or excrete sodium; kidneys
play a role in excreting metabolized
drugs: half-life of drugs excreted
through glomerular filtration;
prolonged dosage adjustments may
be needed. Minimum urine output is
1 to 2 mL/kg/hr
Renal immaturity in premature Premature neonates Decreased creatinine clearance; poor

neonate sodium retention, glucose excretion,
and bicarbonate reabsorption;
ineffective ability to concentrate
and dilute urine; great potential for
fluid overload, insensible losses,
and dehydration; consequent
potential cardiac complications, and
electrolyte imbalances
Testicles enlarge between 9.5 to School-age to Early puberty if testicles enlarge

13.5 years adolescence before 9.5 years
Fluid Balance Children have larger proportion Birth to 2 years Poor adjustment to fluid deficit
of fluid to body weight than or overload; increased potential
adults. Total body water is 80% to for dehydration or hypovolemia
85% of body weight in infants in children younger than 2 years;
(90% in premature infants); total response to fluid loss is tachycardia
body water reaches adult values and vasoconstriction, causing
(65%) by approximately age 3 increased capillary refill time and
years (Swamy & Mallikarjun, mottling; greater fluid volume for
2004). This change is caused by distribution or dilution of a drug;
decrease in extracellualr fluid, dose adjustment may be needed
which is approximately 45%
in a term infant and reaches
adult levels (25%) by age 3 years
(Swamy & Mallikarjun, 2004)
Large body surface area Birth to age 2 years Increased potential for insensible
water loss (e.g., perspiration,
tachypnea, fever); increased risk
for dehydration; metabolism and
heat production influence fluid loss;
allows large amounts of fluid to be
lost via insensible water loss through
perspiration
Musculoskeletal Spine C-shaped at birth Birth until age 3 to Affects infant’s head control
System (Hockenberry & Wilson, 2007) 4 months
Bones not fully ossified until Infants through Types and locations of fractures in
adulthood; bones are soft and adolescence very young children must be fully
easily bent (Ball & Bindler, 2006) evaluated to distinguish between
intentional and unintentional injuries
(continued)
TABLE 1-1
Percentage of cartilage in ribs Birth to puberty Rib fractures uncommon in young
is high; ribs are flexible and children; ribs provide minimal
compliant (Ball & Bindler, 2006) protection to underlying organs and
blood vessels
Lordosis is a normal variation Infants; toddlers Causes appearance of abdominal

in infants and toddlers distention in this age-group
Skeleton grows continuously (at Birth to adolescence Normal growth pattern

varying rate and pace among
children) over a period of 19 to
Skeleton grows faster than Adolescents Hands and feet grow faster than
muscles body
Body growth spurts occur Adolescents: peaks at Provider should expect considerable
during puberty age 12 years for females growth during this time
and 14 years for males
Bow-leggedness because of Infants; toddlers Normal growth pattern

leg muscles bearing weight of
relatively large trunk
Lower muscle mass (Adcock, Neonates Use of intramuscular route for

2006) medication administration limited
Muscles have less tone and Neonates through Increased risk for injury; muscle
coordination during infancy; infancy growth contributes greatly to weight
muscles comprise 25% of weight gain during childhood; walking and
in infants compared to 40% in weight-bearing stimulate growth of
adults (Ball & Bindler, 2006) bone and muscle
Neurologic The neurologic system is Myelination is rapid Nerve impulses do not travel as
System anatomically complete at birth; in the first 2 years of quickly down unmyelinated nerves;
since it is not fully myelinated, life and is completed these impulses are slower and less
it is functionally immature by approximately age predictable. Myelination occurs
7 years (Swamy & cephalocaudally and proximodistally
Mallikarjun, 2004) and corresponding advances in gross
and fine motor function are seen;
more localized stimulus response,
increasing sphincter control,
and better balance, memory, and
comprehension. Most actions in
newborns are primitive reflexes
Blood-brain barrier (BBB) Neonates More permeable BBB allows passage

underdeveloped at birth but of large, lipid-soluble molecules
develops quickly after birth (e.g., bilirubin) and some drugs
(Swamy & Mallikarjun, 2004) (e.g., some antibiotics, barbiturates,
opioids) (Swamy & Mallikarjun,
2004), causing some drugs to
have an increased and variable
central nervous system effect or
unpredictable duration of action
Spinal cord ends at intervertebral Birth to 8 years Necessitates altered approach for
level L3, reaching adult level of lumbar puncture and epidural
L1 to L2 by age 8 years (Swamy anesthesia in children younger than
& Mallikarjun, 2004) 8 years
Cerebral vessels thin-walled and Premature infants Increased risk for intraventricular
fragile (Macfarlane, 2005) hemorrhage
Immature parasympathetic and Neonates; infants Neonates have less ability to control
sympathetic function (Swamy BP; they may respond to pain with
& Mallikarjun, 2004) tachycardia, increased BP
Thermoregulation Body surface area three times Neonates; infants Heat loss is greater in children than
that of an adult; head is adults; susceptible to hypothermia
proportionately larger until and hyperthermia; thermoregulation
age 2 years, creating a greater difficult because of thin epidermis,
surface area for heat loss in little subcutaneous fat, and
infant, especially when the poorly developed sweating and
head is exposed vasoconstriction mechanisms
(Macfarlane, 2005); premature infant
even more prone to hypothermia
because of thin skin and minimal
fat stores; low body temperature
can cause respiratory depression,
acidosis, and decreased cardiac
output (Macfarlane, 2005)
Body heat lost by radiation, Neonates Lower body temperature increases risk
conduction, convection, and for respiratory depression, acidosis,
evaporation and infection; when newborn loses
body heat, body attempts to conserve
heat through acrocyanosis (i.e., hands
and feet turn blue). If infant’s hands
or feet do not become pink when
warmed, provider should consider
congenital heart disease
Thermogenesis by shivering Birth to 6 years Causes need for body heat to

undeveloped (Swamy & be produced in other ways (e.g.,
Mallikarjun, 2004) brown fat thermogenesis), which
causes metabolic acidosis. Oxygen
consumption also increases in cold-
stressed neonate because it is needed
to metabolize brown fat
Sweating and vasodilation Birth until age 2 years Infants do not flush to release
mechanisms not fully developed; body heat with increased body
peripheral vasodilation is temperature or fever; body does not
inefficient because of incomplete cool as fast, making child prone to
myelination febrile seizures
Metabolic System Metabolic rate higher than in Birth through Need more oxygen than adult to
adults adolescence support rapid body growth, work of
breathing; metabolic rate increases
during fever or illness; have difficulty
maintaining homeostasis during
illness; young children prone to
hypoxia and dehydration; have high
heart rates; have high caloric and
fluid requirements to support active
metabolism; certain drugs metabolized
faster in children than adults
Proportion of fat to lean Birth until age 12 years Distribution of fat-soluble drugs
body mass increases with age limited in children; a drug’s lipid or
(Conroy, 2003) water solubility affects the dose for
the infant or child
(continued)
TABLE 1-1
Endocrine Not fully mature until Birth to adolescence Affects bone growth, thyroid
System adolescence with hormonal and function, adrenal cortex, and
physical changes that occur in secretion of sex hormones
puberty
Thelarche normally takes place School-aged children; Affects physical examination;

between 8 to 13 years; pubarche adolescents provider should be aware of
between 8 and 14 years; precocious or delayed puberty;
menarche about 2 years after gynecomastia in adolescent boys
thelarche may be because of pubertal changes,
obesity, or the use of marijuana
or anabolic steroids. Pubic hair
heralds the onset of puberty in boys;
thelarche signifies puberty in girls
• Psychosocial and behavioral stages, with which the

GROWTH AND DEVELOPMENT provider should be familiar. Knowledge of normal
psychosocial developmental stages can be used to
The physical, psychosocial, and cognitive aspects of make an accurate developmental assessment of a child
development in children are interrelated key indica- and to engage the child in the health care encounter
tors of the child’s overall health and must be assessed in an age-appropriate manner (see Chapter 2 for a dis-
at every health care visit to evaluate the child’s growth cussion of pediatric developmental assessment).
and progress toward maturity. Normal growth and de-
velopment occur in a predictable sequence; deviations
from normal may signify an abnormality, making it
essential for the provider to be familiar with normal
COMMUNICATION SKILLS
developmental milestones and children’s growth pat- REQUIRED TO WORK WITH
terns, and to monitor these trends over time. CHILDREN
In this text, infants, children, and adolescents are
arranged into six age groups: neonates, infants, tod- It is essential that all pediatric providers be able to
dlers, preschoolers, school-aged children, and adoles- communicate with children of all ages and at all de-
cents. The corresponding ages are: velopmental levels. This is quite challenging because
• Neonates: birth to 28 days each developmental stage requires vastly different ap-
• Infants: 1 month to 1 year proaches specific to the age and temperament of the
• Toddlers: 1 to 3 years child. The provider must also know when the child
• Preschoolers: 3 to 6 years is developmentally, cognitively, and temperamen-
• School-aged children: 6 to 12 years tally able to provide his or her own answers during
• Adolescents: 12 to 21 years the medical history. In addition, each child must be
For each age group, the pediatric provider should be viewed within the context of his or her family, culture,
knowledgeable about age-appropriate abilities: and social situation (see Chapter 3 for a discussion of
the communication skills needed to work with chil-
• Gross and fine motor abilities, particularly until age 6
dren and families).
years.
• Language and communication abilities. Depending on
the child’s age, temperament, and developmental
level, the child may not be able to verbalize anxiety, OBTAINING THE PEDIATRIC
fear, or pain, making it necessary for the provider to HEALTH HISTORY
make these assessments independently or to rely on
the parent. The reason for the child’s visit dictates the type of histo-
• Cognitive abilities, which change and develop as the ry that the health care provider obtains (see Chapter 6).
child grows. For example, interval histories require only injury- or
illness-specific data. During health maintenance visits, the parent–child relationship. Children are also highly
the provider obtains a very complete history. Data that influenced by the emotional state of their caregiver.
provide information about the child’s growth and de- This can be reflected in the child’s behavior, sleep pat-
velopment, nutrition, daily life, health and safety, envi- terns, appetite, school performance, and peer relation-
ronment, parental knowledge base, and teaching needs ships. In addition, all of these areas should be assessed
are especially important. The complexity of life in the in the context of the family’s culture (see Chapter 4
21st century presents new risks to children that also for a discussion of culture and Chapter 5 for further
require assessment such as obesity; exposure to violent discussion of family assessment).
and sexually explicit media; assessment of television,
computer, and video time; family structure, including
an assessment of all persons living in the home and ROLE OF THE PEDIATRIC
their relationship to the child; parenting style and dis-
ciplinary methods, as well as assessment of depression,
HEALTH CARE PROVIDER
eating disorders, and sexual activity (see Chapter 6 for a
The role of the pediatric health care provider is to
detailed discussion of the pediatric health history).
collaborate and cooperate with the child’s parent or
primary caregiver and to advocate for and protect
the child’s best interests. Children are dependent
THE PEDIATRIC PHYSICAL on the adults in their lives for many years, and the
health care provider can greatly influence the quality
EXAMINATION of care that they receive from their family. If parents
feel supported and validated by the health care pro-
A child’s age and developmental level determine the
vider, they are more likely to feel comfortable asking
provider’s approach to the physical examination. The
questions that will enhance their child’s emotional
approach also depends on the severity of illness or
and physical health. This can be achieved by creat-
injury and whether the child’s primary caregiver is
ing a partnership with the child and family in pro-
present. It is usually recommended that a complete
moting health and preventing illness (Hagan, Shaw,
physical examination be done in an organized, head-
& Duncan, 2008). Bright Futures, a health promotion
to-toe fashion to minimize any omissions of body sys-
and illness prevention initiative, has delineated six
tem assessments. However, this sequence should be
steps for building the provider–child–family partner-
adjusted to the child’s age, temperament, and develop-
ship (Green et al., 2002):
mental level. For example, infants and toddlers dislike
intrusive procedures such as inspection of the throat 1. Model and encourage open, respectful, nonjudgmen-
and ears, and these examinations often elicit crying. tal communication, building trust and empathy.
For this reason, it is wise to first auscultate the young 2. Identify health issues through effective listening
child’s heart, lungs, and abdomen when the child is and by asking open-ended questions.
quiet, and inspect the ears and mouth last. Children 3. Affirm strengths of the child and family, praising
who are school-aged and older are typically able to co- the achievements of the child and family.
operate with a physical examination that proceeds in 4. Identify mutual and shared goals, reinforcing the
a head-to-toe direction (see Chapter 8 for an in-depth notion of a partnership between provider, child,
discussion of physical assessment). and family. Refer the child and family to appropri-
ate community resources as needed.
5. Develop a plan of action based on shared goals.
Goals should be simple, achievable, measurable,
UNDERSTANDING THE and time-specific.
CAREGIVER–CHILD 6. Evaluate the effectiveness of the partnership on an
RELATIONSHIP ongoing basis.
Teaching, supporting, validating, and giving in-
In all pediatric health encounters, whether the child is dividualized care results in a positive health care
well or ill, the provider should appraise the child’s so- experience for the child and family. During the health
cial situation and home environment, paying particu- care encounter, the provider is in a position to have
lar attention to the nature of the child’s relationship a significant impact on the parent’s and child’s con-
with his or her primary caregiver. The child should fidence, competence, and health behaviors through
never be viewed in isolation; the parent or caregiver teaching, role modeling, positive reinforcement, and
is an integral part of the child’s life. The caregiver’s reassurance. The provider actually cares for the en-
responses to and interactions with the child during tire family when assessing and treating a child. Fos-
the health care encounter can provide a wealth of in- tering a trusting, caring, provider–family relationship
formation regarding the child’s emotional health and leads to the healthy development of the child. Having
well-developed pediatric history-taking, assessment, pharyngeal size and soft tissue anatomy in children. Journal of
Applied Physiology, 95(5), 2030–2038.
and physical examination skills is the first step in
Green, M., Palfrey, J. S., Clark, E. M., & Anastasi, J. M. (2002).
delivering excellent care to the child and family. Bright futures: Guidelines for health supervision of infants, children
and adolescents. (2nd ed.). Arlington, VA: National Center for
Education in Maternal and Child Health.
Guthrie, E. W. (2005). Pediatric dosing considerations. US Phar-
macist, 30(12), 5–10.
REFERENCES Hockenberry, M. J., & Wilson, D. (2007). Wong’s nursing care of
Adcock, K. G. (2006). Prescribing principles for children: Founda- infants and children. (8th ed.). St. Louis: Mosby.
tions of a rational approach. Advance for Nurse Practitioners, Kliegman, R. M., Behrman, R. E., Jenson, H. B. & Stanton, B. M. D.
14(3), 30–36. (2007). Nelson textbook of pediatrics. (18th ed.). St. Louis: W. B.
Ball, J. W., & Bindler, R. C. (2006). Child health nursing: Partner- Saunders.
ing with children & families. Upper Saddle River, NJ: Pearson Macfarlane, F. (2006). Pediatric anatomy, physiology and the ba-
Prentice Hall. sics of pediatric anesthesia. Retrieved October 31, 2009, from
Biancaniello, T. (2005). Innocent murmurs. Circulation, 111(3), http://www.frca.co.uk/article.aspx?articleid=100544.
20–22. Pillitteri, A. (2007). Nursing care of the child with a respiratory
Bissonnette, B., & Dalens, B. (2002). Pediatric anesthesia: Principles disorder. In: Pillitteri, A. Maternal and child health nursing:
and practice. New York: McGraw Hill. Care of the childbearing and childrearing family. (5th ed.).
Brady, M. A. (2009). Respiratory disorders. In: Burns, C., Dunn, (pp. 1137–1187). Philadelphia: Lippincott Williams & Wilkins.
A. M., Brady, M. A., Starr, N. B., & Blosser, C. Pediatric primary Swamy, M. N. C., & Mallikarjun, D. (2004). Applied aspects of
care: A handbook for nurse practitioners. (4th ed.). (pp. 767–794). anatomy and physiology of relevance to pediatric anesthesia.
St. Louis: W. B. Saunders. Indian Journal of Anesthesia, 48(5), 333–339.
Conroy, S. (2003). Paediatric pharmacy-drug therapy. Hospital Vernon, P., Brady, M. A., & Barber Starr, N. (2009). Dermatologic
Pharmacist, 10, 49–57. diseases. In: Burns, C., Dunn, A. M., Brady, M. A., Starr, N. B., &
Fregosi, R. F., Quan, S. F., Kaemingk, K. L., Morgan, W. J., Goodwin, Blosser, C. Pediatric primary care: A handbook for nurse practitioners.
J. L., Cabrera, R., et al. (2003). Sleep-disordered breathing, (4th ed.). (pp. 942–1000). St. Louis: W. B. Saunders.
CHAPTER
Assessment of Child
2 Development and
Behavior ELLEN M. CHIOCCA
The developmental assessment is a significant and Cephalocaudal Development

essential part of the health care of a child, as normal Cephalocaudal development refers to physical deve-
growth and development is a key indicator of the child’s lopment that occurs in a head-to-toe direction (Fig. 2-1).
health and well-being. The pediatric health care pro- This is dramatically illustrated when the infant is still
vider must possess a thorough understanding of hu- in utero, and the head is much larger with more com-
man growth and development to conduct an accurate, plex functions than the lower part of the body, which
age-appropriate, developmental assessment. A develop- remains smaller and underdeveloped until later in fetal
mental assessment includes an evaluation of physical life. This disproportion in size persists until the child
growth, neurodevelopmental maturation, and cognitive is 2 years of age, when the chest circumference finally
and psychosocial development. Early identification of equals the head circumference. Cephalocaudal develop-
developmental delays is critical to make appropriate re- ment occurs concurrently with neuronal myelination
ferrals; if untreated, the child is at risk for physical inju- and is exemplified in the achievement of gross motor
ry, poor academic performance, and social difficulties. milestones: head control, shoulder and trunk con-
trol, sitting, standing, crawling, cruising, and walking
(Figs. 2-2 and 2-3); these are followed by complex gross
INFLUENCES ON CHILD motor abilities, including running, jumping, balance,
DEVELOPMENT coordination, hopping, and skipping.
When evaluating a child’s growth and development, it Proximal to Distal Development

is essential to consider both modifiable and nonmodifi- Proximal to distal development occurs in a near-to-far
able influences. Modifiable influences include nutrition, manner. In utero, for example, this is seen in the em-
illness, caregiver quality, provision of developmentally bryonic stage as limb formation proceeds from buds to
appropriate toys and activities, opportunities to de- paddles to plates, progressing finally to digits. Proximal
velop motor abilities, caregiver discipline style, timing to distal development also corresponds to neuronal my-
and quality of education, and the physical and psycho- elination and is seen when a child first demonstrates
social environment. Nonmodifiable influences include shoulder control, then upper extremity control, and
culture, temperament of the child and caregiver, ge- finally fine motor control of the hands, which refines
netics, and the basic principles of human growth and from a palmar grasp to a fine pincer grasp (Fig. 2-4).
development.
Simple to Complex Development
Simple to complex development involves the progres-
PRINCIPLES OF HUMAN GROWTH sion of cognitive abilities and motor skills from simple to
AND DEVELOPMENT complex. Neuronal myelination plays a role in this devel-
To assess growth and development accurately in chil- opment. The gross motor developmental sequence be-
dren, the pediatric health care provider must understand yond walking (including stooping, hopping, jumping,
some basic principles of human growth and develop- skipping, and riding a bicycle) and the progressive deve-
ment, principles that follow well-defined and consistent lopment of fine motor skills (progressing from “raking”
patterns, regardless of child, environment, or culture. to writing and drawing) exemplify this process.
17
FIGURE 2-1. Cephalocaudal development in the infant.
Predictable Sequence of Development

The attainment of developmental milestones (i.e., gross B
and fine motor skills, cognitive abilities, acquisition of
language, social interaction) occurs in an orderly, antici-
pated sequence, following predictable brain growth and
myelination patterns, for all children, regardless of
culture, socioeconomic background, or environment.
For example, all children develop head control before
they stand, grasp objects before they have fine motor
control of their hands, possess receptive language abil-
ities before they can speak, and play alone (“parallel
play”) before they socialize in groups.
Variable Rate of Growth and Development

While development occurs in a predictable sequence,
it occurs at a variable rate among children of the same C
age and in the individual child. For example, in the in-
dividual child, physical growth slows dramatically after FIGURE 2-2. Progression of head control from birth to
the first birthday, but language development blossoms. 4 months of age.
Two children of the same age with similar medical his-
tories may walk at different ages (e.g., 11 months and
15 months): both are within normal limits. critical, sensitive period for the infant–caregiver attach-
ment. Consistent, predictable care is needed from one
Critical Sensitive Periods person (primarily) for the infant to develop trust and to
Critical sensitive periods are developmental periods in feel secure. If this does not occur, the infant will likely
which a child is especially susceptible to particular in- find it difficult to develop healthy, loving attachments
fluences. Critical periods begin and end quickly and are later in life. This condition is known as inhibited reactive
considered to be a time after which a particular phe- attachment disorder and is often seen in children with
nomenon will not appear. Sensitive periods begin and end an early experience in foster care or orphanages where
gradually and involve a time of maximum sensitivity to they may have had inconsistent caregiving or multiple
a specific stimulus. For example, the first year of life is a caregivers (Lubit & Maldonado-Duran, 2006).
C H A P T E R 2 A s s e s s m e n t o f Ch ild De ve lo p m e n t and Behavior • 19
A B
C D
E F
FIGURE 2-3. Development of locomotion. A. Infant pushes up from the prone position. B. Crawling
with abdomen off floor. C. Infant pulls to stand. D. Infant cruises along by holding on to furniture.
E. Infant walks with assistance. F. Infant walks without assistance.
A B
FIGURE 2-4. Progression of fine motor control from (A) palmar grasp to (B) fine pincer grasp.
Language development is another example of a criti- cultural difference, Hispanic children may be at greater
cal, sensitive period. Language is normally acquired in risk for being identified as inattentive or impulsive and
children in the following order: phonology (the sound may be incorrectly diagnosed with attention deficit
of words), semantics (the meaning of words), and final- hyperactivity disorder (ADHD) (Starr, 2007). Health
ly syntax (the rules of grammar). This acquisition se- care providers must be certain to use behavioral or
quence is shaped by factors within the central nervous developmental assessment tools that have been adapt-
system (CNS), and the different stages have different ed for use for specific cultural groups; if one is not
time frames for optimal shaping, making language ac- available, a trained medical interpreter must be sought
quisition a time-dependent process (Ruben, 2005). (see Chapter 4 for a discussion of cultural assessment).
CULTURE DEVELOPMENTAL THEORIES

It is essential for the health care provider to be Knowledge of developmental theories can help the
culturally sensitive when evaluating a child’s growth pediatric health care provider integrate knowledge of
and development. In some cultures, for example, physical, psychosocial, cognitive, and psychosexual
direct eye contact is considered disrespectful; this is growth and development in children and incorporate it
important to know when assessing behavior in the into the developmental assessment. For example, Freud
child. In other cultures, children never speak directly (1938) focused on the psychosexual development of
to an adult, which may make expressive language as- children and adolescents, as well as self-esteem, tem-
sessment difficult. perament, and personal motivation. Erikson (1950)
Differences have been measured in the attain- expanded on Freud’s work and emphasized an indi-
ment of developmental milestones among cultural vidual’s psychosocial development throughout the life
groups, but some of these differences disappear when stages, which he delineated. Piaget (1969) focused on
socioeconomic status is controlled (Kelly, Sacker, a child’s cognitive development and the way in which
Schoon, & Nazroo, 2006). Some differences remain, the child learns about the world as his or her abilities
depending on cultural values such as independence, to reason correspond to cognitive growth.
autonomy, and provision of learning opportunities. Kohlberg (1969) expanded on Piaget’s work, focus-
Children from cultures that value independence and ing on the moral development in children. Because
autonomy achieve feeding, sleeping, and toilet-training Kohlberg’s research just involved boys, Gilligan (1982)
milestones early (Schulze, Harwood, Schoelmerich, & postulated that Kohlberg’s theory would not hold true
Leyendecker, 2002). for girls and developed her theory of moral develop-
Culture is also important to consider when ment in girls. Table 2-1 summarizes these developmen-
assessing behavior. For example, the concept of time tal theories.
for Hispanics is polychronic insofar as several activi- In 1995, Chess and Thomas published their work
ties may be accomplished simultaneously and in an regarding the effect of temperament, in which they
unstructured manner. European-Americans are large- explain how children, as young as infants, have in-
ly monochronic, whereby tasks are accomplished in a nate tendencies to react to their environment in cer-
linear, orderly fashion, one at a time. Because of this tain ways. The temperamental characteristics and
TABLE 2-1
Developmental Theorists
AGE AND ERIKSON PIAGET FREUD KOHLBERG GILLIGAN
DEVELOPMENTAL (PSYCHOSOCIAL (COGNITIVE (PSYCHOSEXUAL (MORAL (MORAL
STAGE DEVELOPMENT) DEVELOPMENT) DEVELOPMENT) DEVELOPMENT) DEVELOPMENT)
Infant (birth to Trust vs. Mistrust: Sensorimotor Oral Stage: Preconventional Preconventional:
1 year) Infant must know (Birth to The source (Birth to Age The goal is
he or she will 2 Years): The of pleasure is 9 Years) individual
receive needed infant learns primarily oral. survival.
physical care; about his or her “Amoral” Stage
care should be environment 1: Punishment
largely rendered through the five and Obedience
by one person to senses; object
allow the infant permanence
to develop trust; develops;
quality of caregiver primitive and
and environment postural reflexes
are critical to the are the first steps
infant developing in cognitive
trust. development.
Toddler (1 to Autonomy vs. Preoperational Anal Stage: Preconventional Preconventional:

3 years) Shame and (2–7 Years): Child’s (Birth to Age The goal is
Doubt: Toddlers Children in interest in the 9 Years) individual
are more in this stage are anal region survival.
control of their egocentric and predominates; Stages 1–2
bodies and see only their child learns that Stage 1:
environment; own perspective; he or she can Punishment
they want to they have a withhold or give; and Obedience:
do things for limited concept power struggles Children obey
themselves of time. may arise with rules to avoid
and be more toilet training. punishment and
independent. to obtain reward;
they have no
understanding
of the reasons
behind why they
must obey rules.
Stage 2:
Instrumental
Relativist
Orientation:
Behavior fits the
child’s own needs;
sharing, loyalty,
and gratitude not
yet seen.
Preschooler Initiative vs. Preoperational Phallic: Child Preconventional Preconventional:

(3–6 years) Guilt: Child (2–7 Years): recognizes (Birth to Age Goal is individual
wants to explore; Child is still differences 9 Years): survival with
creativity egocentric but between two transition to
enhanced when beginning to sexes and is Stages 1–3: conventional
given freedom; see another’s interested Stage 3: “Good stage with change
child develops a point of view; in genitals; girl or boy, nice from selfishness
conscience and demonstrates shows intense girl or boy”; to responsibility
morals; magical concrete, attraction or love a conscience to others.
thinking begins. tangible to the parent of emerges; seeks
thinking and the opposite sex approval; likes
begins to use (Oedipus/Electra conforming to
memory. complex). norms; behavior is
based on avoiding
punishment or
obtaining rewards.
(continued)
TABLE 2-1
Developmental Theorists (Continued)
AGE AND ERIKSON PIAGET FREUD KOHLBERG GILLIGAN
DEVELOPMENTAL (PSYCHOSOCIAL (COGNITIVE (PSYCHOSEXUAL (MORAL (MORAL
STAGE DEVELOPMENT) DEVELOPMENT) DEVELOPMENT) DEVELOPMENT) DEVELOPMENT)
School-aged Industry vs. Concrete Latency: Energy Preconventional Preconventional:

Child Inferiority: Child Operations is directed to (Birth to Age Girls (age 6–18
(6–12 years) wants to produce (7–11 Years): learning and 9 Years): years) interpret
and achieve; Child can play; sexual moral dilemmas
feels inferior classify and impulses are Stages 4–5: in the context
when creativity is organize facts repressed; Stage 4: “Law of human
squelched. and can consider self-esteem and Order” relationships and
another’s is connected Orientation: feelings.
point of view; to sense of Child obeys set
uses inductive industry and rules, respects
reasoning accomplishment; authority, and
(particular to parents are no abides by rules of
general). longer viewed as society.
omnipotent. Conventional
(Age 9–20 Years):
Stage 5: Social
Contract,
Utilitarian
Orientation:
Behavior and
moral code based
on societal norms
as well as the needs
of society; there
is an increased
desire to please
others and be con-
sidered “good.”
Adolescent Identity vs. Formal Genital: Conventional Conventional:

(12–21 years) Role Confusion: Operations: Puberty has (Age 9–20 Years): Girls (age 6–18
Adolescents are They think been reached; Stage 5: Social years) interpret
concerned with abstractly; interest in peer Contract, moral dilemmas
who they are and draw logical relationships Utilitarian in the context
how they look to conclusions; and sexual Orientation: of human
others. can make and relationships Behavior and relationships and
test hypotheses peaks. moral code are feelings.
(deductive based on societal Self-sacrifice
reasoning). norms. defines goodness.
accompanying behaviors described by Chess and and fine motor skills; visuomotor skills), cognitive de-
Thomas are presented in Table 2-2. These tempera- velopment, language development, and socioemotional
ment types help to describe what Chess and Thomas development.
(1995) term the “goodness of fit” between the child Gross motor skills involve the use of large muscles to
and parent, that is, the degree to which the child’s and control the head and shoulders and to sit, stand, bal-
the parents’ temperament and personality mesh. This ance, walk, and run. Fine motor skills involve the use
relates to the assessment of growth and development of small muscles to use the pincer grasp to pick up a
particularly, when parent and child are not a “good raisin, turn the pages of a book, stack blocks, and use
fit,” as this may increase the risk for abuse or neglect. a crayon to draw or a pencil to write.
Cognitive development encompasses intellectual and
adaptive skills. For example, infants first use reflexes
DEVELOPMENTAL DOMAINS but then progress to develop cognitive abilities, such as
achieving object permanence. Cognitive development
When evaluating a child’s growth and development, progresses as toddlers learn to match items, preschoolers
the assessment categories can be divided into physical develop memory, and school-aged children and adole-
development, neurodevelopmental maturation (gross scents develop advanced reasoning abilities.
TABLE 2-2 BOX 2-1

Temperament Characteristics Factors Affecting Speech and
Language Acquisition in Young
TEMPERAMENT Children
CHARACTERISTIC DESCRIPTION
Child abuse and neglect
Activity Amount of physical energy Autism spectrum disorder
in the child relative to quiet
periods Traumatic brain injury
Cerebral palsy
Rhythmicity Level of predictability Fetal drug or alcohol exposure
regarding the child’s
biologic functions (e.g., Hearing impairment
eating, elimination, sleeping Intellectual ability
patterns) Diagnosed language impairment
Approach/withdrawal How a child responds when
presented with a new person Reprinted with permission from Prelock, P. A., Hutchins, T., & Glascoe,
or situation F. P. (2008). Speech-language impairment: how to identify the most
common and least diagnosed disability in childhood. The Medscape
Adaptability How long it takes for the Journal of Medicine. Retrieved June 19, 2008, from http://www.
child to adjust to change medscape.com/viewprogram/14674.
Intensity The amount of energy

released with emotional
responses (e.g., crying;
laughing, excitement)
EVALUATING CHILD
DEVELOPMENT
Mood Overall demeanor displayed
on a day-to-day basis
In 2006, the American Academy of Pediatrics (AAP) pub-
(e.g., happy, sad, positive,
negative) lished a revised policy statement on identifying devel-
opmental delays and disorders in infants and children
Distractibility Ease in which child can be in the primary care, medical home setting (AAP, 2006).
distracted by things going on The AAP uses the term “developmental surveillance”
in the environment
versus “developmental assessment” to connote a con-
Attention span and Child’s ability to stay on task tinuous process. Developmental assessment includes a
persistence and focus thorough history, risk factor identification, physical ex-
amination, and developmental screening (AAP, 2006).
Threshold of How much stimulation a
responsiveness child needs to respond to
stimuli
HISTORY
Reprinted with permission from Chess, T., & Thomas, A. (1995). Before initiating the physical and developmental ex-
Temperament in Clinical Practice. New York: Guilford Press. amination, it is essential to obtain a thorough history
to identify causes and risk factors for developmental
delays. A complete past medical history is completed
Language development acquisition begins with recep- along with a thorough review of systems, family his-
tive abilities, progressing to expressive abilities. A child tory, and social history. Parents are asked to describe
first recognizes the sound of words, then the mean- their child’s gross and fine motor skills, language abili-
ing of words (semantics), and finally the syntax (rules ties, temperament, behavior, and social interactions to
of grammar). Adult articulation abilities are usually guide the provider’s assessments.
achieved by 7 to 8 years of age. Many factors impact
a child’s speech and language abilities; these factors Medical History
are listed in Box 2-1. Bilingual children may reach ex- Prenatal History. The provider determines when
pressive language milestones later as a result of being prenatal care was initiated and if the mother had
exposed to more than one language (American Speech- any illnesses or infections during pregnancy that
Language-Hearing Association [ASLHA], 2008). can cause neurodevelopmental sequelae for the child
Socioemotional development encompasses many ar- (see Chapter 22). It is also essential to determine any
eas of a child’s psychosocial development, including prenatal exposure to alcohol or drugs, especially co-
behavior; temperament; parent–child interaction; so- caine, opioids, methamphetamines, or nicotine.
cial interactions with peers, teachers, and other adults; Prenatal exposure to alcohol can result in low in-
school performance; and psychosexual development. telligence, impaired memory and judgment, and
attention deficits (Rasmussen, Horne, & Witol, 2006). Perinatal History. Information regarding the perina-
Fetal alcohol spectrum disorder (FASD) and fetal alco- tal history is gleaned with questions about the Apgar
hol syndrome (FAS) are direct results of maternal al- score, resuscitation (if needed and for how long), birth
cohol consumption during pregnancy. Fetal alcohol trauma, prematurity, low birth weight, or very low
spectrum disorder is the leading cause of mental retar- birth weight. Neonates who suffer hypoxic–ischemic
dation in the Western world and a common cause of injury are at high risk for cerebral palsy, hearing
developmental delay and behavioral and learning dis- and visual impairments, and developmental delays.
abilities (Caley, Shipkey, Winkelman, Dunlap, & Rivera, Premature, low birth weight, and very low birth weight
2006). Fetal alcohol syndrome results in CNS and neu- infants are at high risk for cerebral palsy; hearing and
robehavioral abnormalities, including microcephaly, visual impairments; and speech, language, and motor
mental retardation, developmental delays, cognitive delays, which affect the developmental assessment
impairment, and ADHD (Chambers & Vaux, 2006). (Blackman, 2007). Preterm infants are also more likely
Some studies have shown that in utero exposure to co- to have learning difficulties, ADHD, and psychologi-
caine adversely affects behavior (Bada, Das, Bauer, Shan- cal and behavioral problems as they reach childhood
karan, Lester, & LaGasse, 2007) and cognitive, motor, (Vanderbilt, Wang, & Parker, 2007).
and language skills (Schiller & Allen, 2005). It also causes
maternal vasoconstriction and resultant hypertension, Neonatal History. The developmental history in-
decreased uterine blood flow, placental abruption, fetal cludes questions about neonatal conditions that
hypoxemia, and premature uterine contractions (Bhu- may affect a child’s developmental status, including
vaneswar, Chang, Epstein, & Stern, 2008), all of which episodes of neonatal apnea, bradycardia, or hypoxia;
can contribute to hypoxic–ischemic events or prema- infections; hyperbilirubinemia; hypoglycemia; or hy-
turity, resulting in neurodevelopmental complications. pothyroidism. A history of poor tone or difficulty with
Prenatal cocaine exposure increases the permeability of sucking and swallowing is also noted, as this can be as-
the fetal blood–brain barrier, leaving the fetus vulnera- sociated with cerebral palsy ( Jones, Morgan, Shelton,
ble to teratogens and infections (Leveno, Cunningham, & Thorgood, 2007). Genetic syndromes are identi-
Alexander, Bloom, Casey, Dashe, et al., 2007). fied, as some syndromes cause developmental delay or
Opioid addiction in pregnant women can cause an mental retardation. It is important to document the
assortment of negative effects on the developing fetus. presence of cyanotic congenital heart defects, as these
Opioid use (i.e., heroin, methadone) during pregnancy defects can cause neurodevelopmental sequelae from
has been shown to cause intrauterine growth restric- repeated hypoxic events. A positive phenylketonuria
tion, decreased birth weight, decreased head circum- (PKU) screen is necessary because if left untreated, PKU
ference, developmental delays, and neonatal seizures leads to mental retardation.
(Belik & Hawes, 2006).
The effects of methamphetamine use in pregnancy Review of Systems. A thorough, detailed review of
are just becoming known. Chang and colleagues systems (ROS) involves determining whether the child
(2004) found that some neonates who were exposed has been diagnosed with an acute or chronic illness
to methamphetamine in utero had smaller brains than or condition that can impact his or her physical or
normal neonates. Neurocognitive assessments were psychosocial growth and development. For example,
conducted on children ages 3 to 16 years whose moth- acute neurologic infections cause serious neurologic
ers ingested methamphetamine during pregnancy sequelae that permanently affect a child’s develop-
and found that the children had poor attention spans mental capabilities (see Chapter 22). Chronic health
and slow verbal memory (Chang, Smith, LoPresti, conditions may also inhibit physical or psychoso-
Yonekura, Kuo, Walot, et al., 2004). cial developmental milestones, depending on the
Cigarette smoking during pregnancy exposes the condition. Chronic illnesses, for example, that require
fetus to nicotine, which may cause prematurity, low long-term treatment (e.g., childhood cancers requir-
birth weight, and the associated neurodevelopmental ing chemotherapy or radiation) can affect a child’s
complications (U.S. Department of Health and Human physical, psychosocial, and cognitive growth and
Services, 2004). development in part because of the necessary long ab-
The provider must inquire about any episodes of sences from school. Some diseases for which children
domestic violence during pregnancy, particularly ab- are immunized can cause serious neurologic compli-
dominal trauma. Women who are physically battered cations; thus, immunization status must be assessed
during pregnancy are at increased risk for antepartum (see Chapter 22). The provider should also inquire
hemorrhage and preterm labor (Peedicayil, Sadowski, about past hospitalizations and surgeries to identify
Jeyaseelan, Shankar, Jain, Suresh, et al., 2004), which potential areas of concern for developmental delays.
can lead to low birth weight in the infant and the neu- Any allergies, particularly seasonal allergies, are impor-
rodevelopmental comorbidities associated with pre- tant to document; some medications used to treat sea-
maturity (see Chapter 22). sonal allergies cause sedation, resulting in poor school
performance. The provider also determines if the child injuries (TBIs), spinal cord injuries, or poisonings often
has ever had any of the following conditions: cause permanent damage to the nervous system, af-
• General: Alteration in growth patterns, short stat- fecting the achievement of developmental milestones
ure, excess height, or asymmetrical growth across all domains. The etiology of some injuries may
• Skin: Café-au-lait lesions (neurofibromatosis), heman- suggest problems with coordination or impulsive be-
giomas, or port wine stains (Sturge-Weber syndrome) havior, which require further investigation. The dates
• Head/Face/Neck: Microcephaly, macrocephaly, hy- of past injuries are obtained and whether the injury was
drocephaly, or craniosynostosis, plagiocephaly, wide severe enough to require medical intervention. The pro-
sutures, bulging fontanelles, altered head control, vider also assesses whether the child has missed school
headaches, migraines, or facial dysmorphism (e.g., or has experienced any changes in social relationships
FAS, FASD) since the injury; this can affect developmental assess-
• Eyes: Poor vision, blurred vision, diplopia, nystag- ment findings. When inquiring about past injuries, the
mus, strabismus, cataracts, or coloboma (associated provider always evaluates whether any caregiver abuse
with CHARGE syndrome) or neglect played a role and whether child protective
• Ears: Low-set ears, pinna deformities, or hearing loss services were or are involved in the family’s life. Child
• Cardiovascular: Congenital heart disease abuse and neglect can lead to delays in achieving de-
• Respiratory: Asthma or cystic fibrosis velopmental milestones and poor school performance
• Gastrointestinal: Crohn’s disease, celiac disease, or (Slade & Wissow, 2007). Depending on the type of
hepatic disease abuse, a child may suffer from depression, behavior
• Genitourinary: Tanner staging, precocious or delayed problems, or developmental delays because of neglect
puberty, ambiguous genitalia, or primary amenorrhea or TBI. Any developmental assessment includes ques-
• Endocrine/Metabolic: Neonatal hypoglycemia, tions about discipline practices, specifically corporal
diabetes, hypothyroidism, hyperthyroidism, glyco- punishment (see Chapter 23 for a discussion of assess-
gen storage diseases, inborn errors of metabolism, ing for child abuse and neglect).
growth hormone deficiency, or congenital adrenal
hyperplasia Medications
• Hematologic/Immunity: Cancers, anemia, or allergies The provider should inquire about any medications the
• Musculoskeletal: Spasticity of extremities, difficulty child is taking on a regular or as-needed basis, includ-
with balance, coordination, or muscle strength; cere- ing over-the-counter medications and complementary
bral palsy, or paralysis or alternative treatments (see Chapter 6). Questions
• Neurologic: Encephalocele, spina bifida occulta, about medications prescribed for seizures, ADHD, or
meningocele, myelomeningocele, hydrocephalus, depression, for example, help to complete the develop-
intraventricular hemorrhage, periventricular leuko- mental history. The indication, dose, and time of last
malacia, hypoxic–ischemic encephalopathy, seizures dose of any medication is noted; some medications
(including type), status epilepticus, tremors, spasms, with neurologic or sedating side effects can alter devel-
parasthesias, ipisilateral or bilateral weakness; in- opmental assessment findings. The provider also deter-
fantile spasms, cerebral palsy, dizziness, history of mines if the child ever received aminoglycosides in the
high fevers, bacterial meningitis, viral meningitis, neonatal period, which can result in hearing loss and
encephalitis, Reye’s syndrome, Duchenne muscular interferes with language acquisition.
dystrophy, Guillain-Barré syndrome, episodes of loss
of consciousness; memory loss, changes in concen- Family History
tration, CNS neoplasm, ataxia, aphasia, head trauma,
Many developmental disorders are genetic and may
irritability, lethargy, chronic fatigue, sleep disorders,
cause developmental delay or mental retardation.
ADHD, dyslexia, learning disabilities, sensory inte-
Conditions about which the provider inquires include
gration disorder, autism, or tics
learning disabilities, speech and language problems,
• Psychosocial: Drug or alcohol addiction, stress,
dyslexia, ADHD, mental retardation, and pervasive de-
emotional lability, irritability, breath-holding spells,
velopmental disorders (e.g., autism). Inherited disorders
behavior disorders, eating disorders, anxiety, depres-
that can cause learning problems or mental retardation
sion, history of suicidal ideation, schizophrenia, hal-
include neurofibromatosis, fragile X syndrome, and
lucinations, bipolar disorder, mood changes, or ag-
Duchenne muscular dystrophy, which also causes gross
gressive behavior
motor muscle weakness and a lack of coordination.
Injuries Social History

Gathering an accurate history of injuries, particularly The child’s home environment, social situation, and
head or musculoskeletal injuries, is especially germane the parenting received greatly impact the child’s world
to the developmental assessment. Traumatic brain and, consequently, development. The social history
assessments are varied, and the focus depends largely van der Ende, & Verhulst, 2004). Adolescents who have
on the child’s age and particular situation. grown up with a mother who is depressed may have
strained family relationships and more difficult peer
Primary Caregiver. The health care provider must relationships, which may result in decreased school
first identify the child’s parent or primary caregiver. attendance and academic difficulties (Hammen, Shih,
This primary relationship greatly impacts the child’s & Brennan, 2004).
growth and development. Some specific characteris-
tics of the parent or primary caregiver, such as young Home Environment. The provider must determine
parental age, low level of education; high parental stress where the child lives, with whom, and whether the
levels, maternal depression, and parental addiction, in- home environment is safe, caring, interactive, and de-
crease a child’s risk for developmental delay. velopmentally enriching or one that leaves the child at
A review of literature over the last 30 years reveals risk for developmental delays. The home environment
that children of adolescent mothers have lower cog- should be evaluated for the presence of toxic chemi-
nitive, vocabulary, and language abilities and are at cals (e.g., lead, mercury, environmental tobacco smoke
increased risk for school failure and grade retention [ETS]) to which the young child may be exposed; these
(Oxford & Spieker, 2006; Qi, Kaiser, Milan, & Hancock, common toxicants have been shown to adversely affect
2006). These poor language, cognitive, and academic child development (Graff, Murphy, Ekvall, & Gagnon,
outcomes are also associated with low level of maternal 2006). For example, a child who lives in an old home
education, immigrant status, low socioeconomic status, with lead pipes or lead-based paint, or who receives
and being from a single-parent family (To, Guttmann, lead-based folk remedies, is at risk for lead poisoning,
Dick, Rosenfield, Parkin, Tassoudji, et al. 2004). Paren- which may result in headaches, irritability, hyperactiv-
tal knowledge deficits regarding normal growth and ity, aggression, difficulty reading, behavior disorders,
development can also affect attainment of develop- developmental delay, and seizures (Centers for Disease
mental milestones. If parents are unaware of normal Control and Prevention [CDC], 2008; Dart & Rumack,
developmental expectations, they may not provide the 2007). Mercury thermometers, disk button batteries,
child with age-appropriate activities or opportunities to fluorescent light bulbs, broken thermostats, and the
achieve these milestones. Similarly, if parents do not consumption of certain seafoods can lead to mercury
know what normal developmental milestones are, they poisoning. Prenatal exposure to mercury is neurotoxic
will be less likely to recognize deviations and to bring (Davidson, Myers, & Weiss, 2004).
their concerns to the health care provider. Childhood exposure to high levels of mercury can
Maternal depression also negatively influences a lead to attention deficits, hearing impairments (Murata,
child’s development and behavior (To et al., 2004). Weihe, Budtz-Jorgensen, Jorgensen, & Grandjean,
Depressed mothers of infants respond to their infant’s 2004), vision impairments, tremors, ataxia, emotional
cues more slowly and often with a blunted affect; these instability (Olson, 2006), irritability, shyness, memory
mothers are also more easily frustrated and respond problems (Agency for Toxic Substances and Disease
less frequently to their infants’ needs. Consequently, Registry, 1999), developmental disabilities (Davidson,
infants of depressed mothers smile less, are less play- Myers, & Weiss, 2004), mental retardation, and loss of
ful, and show more irritability and fussiness ( Johnson IQ points (Trasande, Schechter, Haynes, & Landrigan,
& Flake, 2007). Depressed mothers of toddlers and pre- 2006). Exhaled second-hand smoke or smoke from
schoolers have been shown to have a lower tolerance the burning end of a cigarette, cigar, or pipe emit over
for developmentally normal behaviors, such as crying, 4000 chemicals, 50 of which are carcinogenic (CDC,
tantrums, or the challenges of toilet training; they are 2004). One of these chemicals is nicotine, which is a
more likely to respond in harsh, less nurturing, and neurodevelopmental toxicant; children who are ex-
negative ways. As a result, this age-group is more likely posed to even low levels of ETS have demonstrated
to demonstrate poor social skills, be more withdrawn, deficits in math, reading, and visuospatial reasoning
anxious, and have more temper tantrums ( Johnson skills (Yolton, Dietrich, Auinger, Lanphear, & Hornung,
& Flake, 2007). Preschool-aged children of depressed 2005); they are also more likely to have recurrent mid-
mothers are also more likely to display such behaviors dle ear infections (Yolton et al., 2005), which interfere
as attention seeking, aggression, ADHD, and opposi- with language acquisition.
tional or defiant behaviors, even when prenatal selec- A child’s home must be safe from other risks for
tive serotonin reuptake inhibitor (SSRI) exposure is injury and be amenable to safe exploration to enable
controlled (Oberlander, Reebye, Misri, Papsdorf, Kim, the child to develop motor skills (see Chapter 7).
& Grunau, 2007). School-aged children of depressed The provider must identify the family’s primary house-
mothers have higher rates of anxiety, depression, and hold language; children who hear more than one
behavior disorders, including conduct disorder and language as infants and toddlers often develop expres-
ADHD; they also are at increased risk for poor academ- sive language skills later than normal because of this
ic performance and low self-esteem (Bongers, Koot, exposure (ASLHA, 2008). The amount of screen time
(television, Internet, video games) should be noted. These risk factors are violence (including media vio-
Excessive (greater than 2 hours a day in children age lence), poverty, breakup of the family, lack of responsible
2 years and older) television screen time is linked to adult supervision and role modeling, the availability of
childhood obesity, violent or aggressive behavior, and firearms, and the threat of acquired immunodeficiency
increased risk-taking behaviors, such as substance syndrome. Garbarino (1995) also identified protective or
abuse, sexual activity, and decreased school perfor- mitigating factors to these stressors: resilient tempera-
mance (Christakis & Zimmerman, 2007; AAP, 2001). ment and emotional intelligence in the child, spiritual
The provider should also ask about the child’s involve- orientation, and a variety of social assets and sources
ment in other diversional activities, such as reading, of stability such as a positive, close relationship with at
sports, hobbies, and other creative outlets. least one adult, and additional emotional support from
Parental stress as a result of a recent separation, family, teachers, neighbors, and community. When ob-
divorce, family crises, unemployment, poverty, and taining the social history, the pediatric provider must as-
threats of terrorism or war can adversely affect a child’s sess for the presence of these social mitigating factors.
development and behavior as children readily pick
up on parental behavioral cues and become anxious School Progress. Beginning with preschool-aged
(Schechter & Davis, 2007; Laor, Wolmer, & Cohen, children, the provider must determine whether the
2001). The primary caregiver’s support network must child goes to school or day care and when the child
be identified; these persons may also influence the was enrolled. Some children, for social reasons such
child’s growth and development. Disrupted peer rela- as poverty, homelessness, natural disasters, or recent
tionships, the death of a family member or a pet, or a immigration, may have been out of school for ex-
recent family relocation must be evaluated, especially tended periods of time; some may never have gone
if the child has been acting out, has become withdrawn to school. Children who attend preschool will have
or depressed, or if school performance has declined. more advanced developmental capabilities when en-
Domestic violence causes parental stress and has tering kindergarten than their peers who have had
many adverse effects on children. Mothers in abusive unstructured day care experiences (Magnuson, Ruhm,
relationships are more likely to abuse their chil- & Waldfogel, 2007).
dren, both physically and emotionally (Lutenbacher, The school history for school-aged children and ad-
Cohen, & Conner, 2004). Children, even infants, ex- olescents consists of an assessment of grades and over-
perience negative behavioral outcomes as a result of all school progress, including recent or abrupt declines
being exposed to interpersonal violence between their in school performance, what subjects the child likes
parents. Examples include impaired bonding, exces- and dislikes, whether the child has a best friend, if the
sive crying, and delayed milestone achievement in child is being bullied, the child’s “fit” with the teacher,
infants; anxiety, nightmares, and clinging behaviors and whether the child and family feel supported by
in preschoolers; some may even regress with toileting the teacher, principal, and school. These questions
skills and begin to suck their thumb (Hornor, 2005). are important because children are more likely to skip
School-aged children often suffer somatic complaints, school if they feel unsafe. Children with accelerated
such as headaches or stomachaches, and school per- academic abilities may also want to skip school if they
formance may decline. Adolescents may manifest re- are “bored”; inquiries should be made to the school to
bellious behaviors, such as truancy, dropping out of determine whether the child is a gifted learner. Incon-
school, running away from home, or drug and alcohol sistent school attendance impacts the child’s social,
abuse (Hornor, 2005). emotional, and cognitive abilities and, consequently,
Parents who abuse drugs or alcohol are more likely the developmental assessment.
to abuse or neglect their children than parents who
are not addicted (Davies, 2004). Drug or alcohol in- Immigrant and Refugee Status. Children who have
toxication is also associated with a lack of stable recently come to the industrialized world from a de-
housing and an increased risk of interpersonal vio- veloping country have many threats to their physical
lence (Bhuvaneswar, Chang, Epstein, & Stern, 2008), and psychosocial growth and development. Many of
including domestic violence. Parents who are intox- these children have not met their developmental mile-
icated on a frequent basis are also less likely to pro- stones because of malnutrition, disease, war, or natural
vide their children with developmentally enriching disasters. Malnutrition, in particular, affects physical
experiences (Lambie & Sias, 2005). growth, cognition, and motor and social development
(Neumann, Gewa, & Bwibo, 2004). Poverty also forces
Social Environment. Garbarino (1995) identified sev- families to prioritize, using scant resources for food in-
eral social risk factors that create a “socially toxic” envi- stead of education (Staton & Harding, 2004); children
ronment—that is, one in which a child may not flourish who do not attend school are unable to meet mile-
developmentally and is at increased risk for depression, stones in the areas of language, reading, writing, and
conduct disorders, and other psychosocial problems. mathematical capabilities.
Institutionalization. Children who have spent time in BOX 2-2

orphanages, such as internationally adopted children,
Risk Factors for Developmental
are at high risk for developmental delays across all
domains. Many institutionalized children have been
Delays
confined to cribs, playpens, highchairs, or walkers for Prenatal drug or alcohol exposure
extended periods of time and, therefore, have not had Prematurity
opportunities to develop motor skills. Because institu- Low-birth-weight
tionalized children have had very little individualized
Hypoxic birth injuries
attention or consistent primary caregivers, opportuni-
Perinatal hyperbilirubinemia
ties for face-to-face contact or adult-to-infant verbal-
Perinatal infection
ization are limited, causing speech and language delays
(Narad & Mason, 2004). This lack of attention, indi- Head or neurologic injury
vidual interaction, or a consistent caregiver also con- Chronic otitis media with effusion
tributes to delays in social and emotional development Hearing or vision impairment
in these children, most often demonstrated as poor Inborn metabolic disorder
emotional attachments. Lack of sensory stimulation Genetic disorder with neurodevelopmental component
and age-appropriate toys or play activities also delays Seizure disorders
social and emotional growth (Narad & Mason, 2004). Chronic health condition affecting mobility or activity
When conducting the developmental assessment on a Low level of parental education
previously institutionalized child, the provider should More than three children in family
anticipate these variations and expect delays.
Single parent
Maternal depression
Present History Poor parental social supports
The provider obtains the present history by asking a Parental substance abuse
parent if he or she has any concerns about the child’s Physical, emotional abuse
behavior or developmental capabilities. The parent or Neglect
caregiver is then asked about the child’s developmental
Institutionalization, international adoptees
status, including achievement of major age-appropriate
developmental milestones, current memory abilities,
ability to adapt to new situations, ability to separate
from the primary caregiver, and school performance.
care visits to detect any abnormalities or clues to de-
The provider must be certain that the child does not
velopmental problems (see next section). Next, the
have a current illness or injury that impacts the assess-
provider quietly observes the young child engage in
ment findings, such as fever or pain. Likewise, when a
an age-appropriate activity such as stacking blocks,
child presents with an acute illness or injury, the pro-
completing a puzzle, coloring, reading, or talking to
vider must still include an assessment of any develop-
the parent. The provider then connects with the child
mental red flags or abnormalities; if any are noted, a
verbally in an age-appropriate manner, for example,
follow-up visit is scheduled when the child is well to fa-
by cooing to an infant or asking the school-aged child
cilitate assessment of the present concern. Risk factors
about his or her friends and activities. This puts the
for developmental delay are listed in Box 2-2. Red flags
child at ease and garners more accurate results during
that may herald an existing developmental problem are
the developmental assessment. During this time, the
listed in Box 2-3. Red flags involving tone and motor
examiner notes eye contact, the child’s affect, how the
control indicate the need to follow up or evaluate the
child relates to both the provider and parent or care-
child for cerebral palsy; those involving altered social
giver, and how the child age-appropriately separates or
interaction may indicate child abuse or neglect, autism,
does not separate from the parent. The child’s overall
pervasive developmental disorder, or visual or cogni-
demeanor is also evaluated. The child’s body language
tive deficits; and any red flags that involve language
may indicate that he or she is angry, depressed, or irri-
milestones may indicate hearing loss, autism, or perva-
table. The child may talk excessively; interrupt conver-
sive developmental disorder.
sation; and constantly move, fidget, or get up from the
seat in the exam room; these are possible indicators of
ADHD (American Psychiatric Association [APA], 2000).
PHYSICAL EXAMINATION Any repetitive behaviors are noted, and the quality,
General character, and amount of crying are assessed. A cursory
Before the developmental assessment is conducted, evaluation of receptive and expressive language abili-
the health care provider reviews the physical exami- ties is also included, with a more detailed evaluation in
nation findings from any current or recent health the complete developmental assessment.
BOX 2-3
Developmental Red Flags
3 MONTHS No two-word sentences by age 2 years
Rolling before 3 months Very clingy to mother at 24 months
Persistent fisting by 3 months 3 YEARS
Unable to push up on arms; pushing back with head at
3 months Speech ⬍75% intelligible; does not speak in full
sentences
4–6 MONTHS Incorrect pronoun use
Head lag after 4 months Cannot feed self independently with spoon or fork
Persistent primitive reflexes after 4 months Toeing-in; trips when running
Failure to reach for objects by 5 months 4 YEARS
No smile by 4–6 months
Speech ⬍95% intelligible
Poor or no head control at 6 months
Cannot separate from parent
Stiff arms; crossed, stiff legs; moves one side of the body
more than the other at 6 months Cannot balance on foot for 2 seconds
Cannot copy a circle or hold a pencil correctly
6–12 MONTHS Cannot name two to three colors
No cooing after 6 months Cannot share with friends
Absent stranger anxiety after 7 months Aggression; acting out
W-sitting at 7 months
5 YEARS
Rounded back; poor use of arms; stiff legs, pointed toes;
arched back, stiff extremities (8 months) Excessive fears; night terrors
Cannot bear weight when pulled to stand (8 months) Unable to identify colors
No reciprocal vocalization by 9 months Speech not 100% understandable
Failure to localize sounds by 10 months
AT ANY TIME
12–18 MONTHS Parental concerns
No quadruped crawling; cannot pull to stand; stiff legs, Slow or excessive physical growth
pointed toes; moves one side of the body more than the Child’s gait changes
other at 12 months Child stops walking
No tool use after 12 months Cruelty to animals
Toe walking; moves one side of the body more than the Fire-setting
other; sits with weight bearing to one side; strong hand Persistent sleep disturbances
preference; extremity stiffness at 15 months
Bullying or being bullied
No imitative play after 18 months
Abusive family and/or peer relationships
Hand dominance before 18 months
Difficulty with schoolwork
18–24 MONTHS Pervasive sad mood
No first word (besides “mama”/“dada”) by 18 months Any loss of milestones is always abnormal
Has ⬎10–12 episodes of otitis media
Measurements weight, height or length, and head circumference (age

As part of the physical examination, a measurement 3 years and younger) are measured and plotted on age-
of vital signs is important to detect any physical prob- and gender-appropriate growth charts (see Chapter 8 and
lems that can interfere with a child’s normal growth and Appendix B). Growth measurements are not particularly
development. For example, if the child is febrile, the meaningful in isolation; they should be compared to pre-
developmental assessment will not yield accurate results. vious measurements and should follow the same growth
Tachycardia, tachypnea, or blood pressure abnormali- percentile curve. It is extremely important to recognize
ties may indicate cardiac or chronic respiratory condi- that when a child falls below his or her own previously es-
tions that impede a child’s growth and opportunities tablished growth percentile curve, an investigation is war-
to develop skills. To assess physical growth, the child’s ranted. The physical growth of premature infants must
be followed closely, using the growth curves established Palmar creases should also be inspected, especially in
for premature infants (see Chapter 8). Prolonged periods newborns. A single transverse palmar crease is associ-
of poor growth in premature infants are associated with ated with Down syndrome (Fig. 2-5). Transverse flex-
poor neurodevelopmental outcomes, such as cerebral pal- ion of the palmar crease close to the second and third
sy, learning difficulties, and ADHD (Aylward, 2005). fingers (“hockey stick” palmar crease) is seen in FASD
(Wattendorf & Muenke, 2005).
Integument The hair is also inspected. A low frontal hairline
The skin is inspected for neurocutaneous lesions and thick, markedly arched eyebrows joined at the
associated with chromosomal disorders that cause de- midline are clinical findings in Brachmann-de Lange
velopmental abnormalities or mental retardation. Ex- syndrome (BDLS), which causes cognitive, speech,
amples of lesions for which to look include café-au-lait behavior, and growth abnormalities (Wilson, 2008).
spots (see Chapter 12, Fig. 12-3), axillary freckling, port Absent or abnormal hair whorls may indicate ab-
wine stains (see Chapter 12, Fig. 12-5), ash leaf spots, and normal brain development (Furdon & Clark, 2003);
shagreen patches. More than six café-au-lait spots 5 mm alopecia areata occurs in approximately 6%–9% of chil-
in greatest diameter and axillary freckling are associat- dren with Down syndrome (Dourmishev & Janniger,
ed with neurofibromatosis-1 (von Recklinghausen dis- 2008). Abnormalities of the nails, including hypopla-
ease), a neurocutaneous disorder that causes cognitive sia, anonychia (lack of a fingernail), micronychia, or
and psychomotor problems, learning disabilities, and polynychia, can indicate ischemic injury or terato-
mental retardation (Moe, Benke, & Bernard, 2007). Fa- genic exposure in utero (specifically maternal antiepi-
cial port wine stains are seen in Sturge-Weber disease; leptic drug use); both of these influences often result
intractable seizures are common with this condition in neurodevelopmental injury.
and often cause mental retardation (Moe, Benke, &
Bernard, 2007). Hypomelanotic, macular, oval-shaped Head, Face, Eyes, and Ears
lesions (ash leaf spots) and shagreen patches (firm, The head, face, eyes, and ears are inspected for any ab-
yellow-red or pink nodules) are seen with tuberous normalities. Abnormal head size or shape and facial
sclerosis, an inherited disease that causes seizures and dysmorphisms are frequently signs of chromosomal
mental retardation in up to 50% of those affected disorders or syndromes that cause developmental
(Moe, Benke, & Bernard, 2007). Cutaneous manifes- delays or mental retardation. Inspection of the head
tations of trisomy 21 (Down syndrome) include ex- includes assessment for microcephaly, macrocephaly,
tremely soft skin in early childhood and dry skin in or craniosynostosis (see Chapters 13 and 22). Frontal
later childhood, with xerosis and atopic dermatitis be- bossing or scalp vein dilation indicates increased intra-
ing the main cause (Dourmishev & Janniger, 2008). cranial pressure or hydrocephaly, which can also cause
developmental abnormalities. Symmetry of the head is
another important assessment. Occipital flattening in
an infant is a sign of prolonged supine positioning,
often indicating neglect and decreased opportunities
for the child to attain developmental milestones. The
provider also assesses the child for dysmorphic facial
features which are seen in genetic disorders that can
cause developmental delays or mental retardation, in-
cluding a flat midface, short mandible, a long or ab-
sent philtrum, and micrognathia. A smooth philtrum,
flattened nose bridge, upturned nose, and thin upper
lip, are characteristics of FASD (Wattendorf & Muenke,
2005). Upward slanting palpebral fissures and midface
hypoplasia are seen in Down syndrome (Fig. 2-6) (Elias,
Tsai, & Manchester, 2007).
The provider also assesses for any abnormalities of
the eyes. Cataracts and microphthalmia are seen in
congenital rubella syndrome, which causes learning
disabilities and developmental delay; epicanthal folds
are seen in Down syndrome (see Fig. 2-6), and short
palpebral fissures in FASD. Hypertelorism (wide-spaced
eyes) occurs with cri du chat syndrome; both physical
growth and mental retardation accompany this syn-
drome. Hypotelorism (abnormally close eyes) is seen in
FIGURE 2-5. Palmar crease seen in Down syndrome. children with FASD (Elias, Tsai, & Manchester, 2007).
of the spinal column determines the presence of cysts,

sacral dimples, tufts of hair, or other signs of neural
tube defects (see Chapters 21 and 22 for a discussion of
pediatric musculoskeletal and neurologic assessment,
respectively).
Hearing and Vision

Age-appropriate hearing and vision screening are
conducted, depending on the child’s age and medi-
cal history (see Chapter 9). Abnormalities in hearing
or vision can cause developmental delays, warranting
relevant referrals (see Chapters 14 and 15 for discus-
sions of children at high risk for hearing or visual im-
pairments, respectively).
DEVELOPMENTAL EXAMINATION
The American Academy of Pediatrics (AAP) (2006)
recommends that all infants and young children receive
developmental screening and that this screening is
incorporated into each well-child examination within
FIGURE 2-6. Facial features seen in Down syndrome.
the context of a medical home. Based on the results
of the screening, a full developmental evaluation may
Pinna abnormalities are associated with some chro- be necessary. It is vitally important for the pediatric
mosomal anomalies and syndromes. For example, health care provider to conduct periodic screening to
small, dysplastic pinnae are seen in children with detect any developmental disorders that can impede
Down syndrome. Low-set ears are seen in Noonan school readiness and lead to behavior and emotional
syndrome, which causes learning problems and mild disorders (AAP, 2006). Bright Futures Guidelines for Health
developmental delays (Elias, Tsai, & Manchester, 2007). Supervision of Infants, Children and Adolescents (Hagan,
“Railroad track” ears (outer part of the pinna is unde- Shaw, & Duncan, 2008) provides an ideal template to
veloped, folded over, and parallel to the curve beneath guide this screening.
it) are seen in FASD (Wattendorf & Muenke, 2005).
Otitis media with effusion often leads to conductive Developmental Surveillance, Screening,
hearing loss, which impedes language acquisition. and Evaluation
The AAP (2006) distinguishes the terms developmental
Neuromuscular System surveillance, screening, and evaluation as having sepa-
The examiner notes whether primitive and postural rate and distinct meanings. Developmental surveillance
reflexes are present and whether they are symmetri- occurs within the context of the health maintenance
cal or asymmetrical (see Chapters 11 and 22). Primi- visit. This involves the ongoing process of recognizing
tive reflexes should not persist past age 4 months; if the child’s developmental strengths and weaknesses
they remain, cerebral palsy is suspected. The examiner and social risk factors (see section on Social History),
also observes the child while sitting, standing, walk- as well as readily identifying children at risk for de-
ing, jumping, skipping, hopping, or kicking. In infants velopmental delays. This includes eliciting parental
and toddlers specifically, the examiner determines if concerns, recording the developmental history, ensur-
the child has met normal motor developmental mile- ing that observations made on the child are accurate,
stones, while noting any motor abnormalities that identifying risk and protective factors, and accurately
may indicate cerebral palsy. These motor developmen- documenting all findings (AAP, 2006). The AAP recom-
tal milestones are achieved at different ages among mends that developmental surveillance takes place at
children; the approximate ages at which these mile- all well-child visits throughout the first 5 years of life
stones occur are presented in Table 2-3. Other neuro- and that the timing of these visits is in accord with
muscular assessments include head control, overall the periodicity schedule published by the AAP (2007)
posture and tone, the size and symmetry of muscles, (see Chapter 9 for a discussion of the periodicity sched-
hyper- or hypotonia; and the presence of tremors and ule and relevant assessments during pediatric health
extremity range of motion. Any dactyly is noted, as supervision visits).
this is often a syndromic feature that could involve de- Developmental screening entails the use of a standard-
velopmental delay or mental retardation. Examination ized screening checklist to determine whether the child
32
TABLE 2-3
Major Developmental Milestones: Infancy Through Adolescence
AGE GROSS MOTOR FINE MOTOR COGNITIVE LANGUAGE SOCIAL
0–2 weeks Head lag; turns head Grasps Primitive reflexes present (e.g., suck, Alerts to sound; may Positive parent–infant
slightly from prone position grasp, rooting) blink, cry, or quiet; interaction; fixes and follows
(2 weeks); moves all startles to loud sounds; faces; responds to parents’
extremities; makes crawling undifferentiated voice
movements when prone crying; reacts to voices
2–4 weeks Lifts head off bed; turns head Strong grasp Primitive reflexes present (e.g., stereotyped Alerts to sound; Consoled by voices and being
from side to side in prone repetition of sucking) may blink, cry, held; developing trust in
position (4 weeks) quiet, or startle; caregiver and environment
undifferentiated
crying; reacts to
voices; cooing begins
2 months Holds head up to 45 degrees; Holds rattle briefly; Primitive reflexes present (e.g., stereotyped Vocalizes (different Social smile; stops crying
may have some head control visually pursues it but repetition of sucking); anticipates feedings from crying); enjoys when parent enters the room;
when in upright position will not reach for it; making sounds; recognizes familiar faces
grasp reflex fading locates sounds by (3 months)
turning head; babbles
4 months Rolls from abdomen to back Voluntarily grasps Primitive reflexes disappear by age Turns head toward Pulls clothes or blanket over
(5 months); no head lag objects using raking 4 months; attention shifted to objects sound; responds to face in play; enjoys social
when prone; pushes body motion (5 months); and environment own name; recognizes interaction; self-comforts;
up on own hands; can bear plays with hands; caregivers’ voices; anticipates feeding; begins to
weight on legs bats at objects; brings babbles, laughs, and sleep through night
objects to mouth squeals; vocalizes
consonant sounds
6 months Good head control Uses radial-palmar Object permanence beginning; visual Smiles, laughs, and Becomes excited when familiar
established: no head lag grasp; transfers objects search, not reaching; plays peek-a-boo; squeals; begins persons approach; may
when pulled to sit; rolls from from one hand to the briefly looks for toy that disappears imitating sounds; reach out hands and smile;
back to abdomen; lifts chest other; mouths objects; enjoys hearing own stranger anxiety begins (peaks
and abdomen off flat surface; eats finger foods; can sounds; may begin 7–8 months); shows interest in
sits leaning forward (7 mos.); secure cube on sight to use “mama,” toys; self-comforts by crying,
stands with support and transfer hand- “dada,” and “baba” playing, and thumb-sucking;
to-hand; can pull to (nonspecific); lack may have a security blanket or
obtain an object of vocalization or favorite toy
stopping may indicate
deafness
9 months Sits steadily without support Radial-digital grasp Searches for object seen hidden; Responds to simple Waves bye-bye; plays pat-a-cake
(8–9 months); rolls over (grasp with thumb and purposely drops object so it can be picked verbal commands; and peek-a-boo; shows wants
completely (8 months); finger); inferior pincer up (11 months) stops activity when through gestures and pointing
crawls (9 months); pulls grasp (10 months); hears own name or
self to stand holding bangs objects; feeds self “no-no”; says first
onto furniture; creeps with fingers; starts to words like “dada” and
with abdomen off floor drink from cup; holds “mama” with meaning
(11 months) crayon with fist and
briefly scribbles
12 months Pulls to stand; cruises Fine pincer grasp; Egocentric thinking; searches for Says first word with Becoming ritualistic; wants
holding on to furniture feeds self; uses a cup object where it was last seen; interested meaning (12–18 more autonomy; plays social
or with hands held but rotates a spoon; in cause-and-effect play; associates months); imitates games; imitates others; shows
(10–11 months); walks attempts to build two- one event with simultaneous event vocalizations; says emotions; temper tantrums
independently with wide- block tower; throws (transductive reasoning); short attention 2–10 words besides may begin
based gait (11–15 months) ball overhand; turns span; follows one-step commands; names “dada,” “baba,”
several pages at a time some common objects and “mama”; uses
pointing to “ask”
for something;
understands new word
each week
15 months Walks well independently Builds a tower of Egocentric; will not share toys; sees only Says 3–10 words; Negative; uses “no” even
with wide-based gait; crawls two cubes; scribbles own perspective; interested in pictures understands simple when agreeing to the request;
upstairs; stoops; may run vigorously; drinks commands; uses separation anxiety peaks age
from a cup; feeds self pointing or grunting 15–18 months; imitates during
with fingers to “ask” for something play; imitates housework; plays
ball; listens to a short story
18 months Walks quickly; may run; can Uses spoon and cup; Points to pictures with common objects; Says 20 or more words; Temper tantrums increasingly
walk upstairs with one hand turns pages; builds a knows two or three body parts; begins to uses two-word phrases; evident; security objects
held; can kick ball tower of three to four distinguish you and me; follows simple 25% intelligibility; (blanket); transitional
cubes directions; uses push and pull toys follows directions and object; listens to a short
understands requests; story and looks at pictures;
understands up to fifty shows affection; can remove
words own clothing; may show
readiness for toilet training
(18–24 months)
24 months Gait steadier; goes up and Dresses self in simple Transductive reasoning continues; Vocabulary of approx. Ritualistic, has routines;
down stairs alone with two clothing; turns book egocentric; some sense of time 300 words; two- to negativistic; imitates adults;
feet on each step; kicks ball; pages one at a time; (e.g., “Wait a minute”); says “now”; three-word phrases puts on own clothing; may
jumps crudely builds tower of six follows two-step commands; can name name a friend; enjoys rhyming
cubes; imitates vertical six body parts and singing
or circular strokes;
turns single page
(continued)
33
34
TABLE 2-3
Major Developmental Milestones: Infancy Through Adolescence (Continued)
30 months Jumps with both feet; can Builds tower of eight Follows two-step commands; states first Uses two-word Separates more easily from
briefly balance on one foot; cubes; holds crayon and last name; knows own sex; begins to sentences; uses parent; may be toilet trained
may pedal a tricycle with fingers rather ask questions adjectives and adverbs;
than fist; imitates knows first and last
horizontal strokes; can name; uses pronouns
copy a cross I, me, you but may not
use them correctly;
names a color
3 years Goes upstairs using alternate Feeds self completely; Wants to do things independently; Approximately Less negativistic than toddler;
feet; rides tricycle; balances pours from bottle or asks “why” constantly; progresses from 900-word vocabulary; separates more easily from
5 seconds; may hop; broad pitcher; begins to use autonomy to initiative and continues uses three-and four- parent; may be toilet trained;
jump scissors; dresses self throughout preschool-age; still egocentric word sentences; 75% has beginning self-care
almost completely; but able to share toys; uses “mine”; plays intelligibility; uses skills; interested in gender
buttons/unbuttons rule games; active imagination; animistic pronouns and plurals; role functions; development
easily reached buttons; (e.g., gives lifelike qualities to inanimate constantly talks; asks enhanced by regular
copies a circle; builds objects); many fears (e.g., fear of the dark, many questions; interaction with same-age peers
a bridge of blocks; thunder, monsters); knows several colors may stutter; speech
washes own hands understandable to
parents
4 years Walks down stairs using Copies a square; draws Conscience begins to develop; becomes Approximately Separates from mother easily;
alternate footing; rides person with three capable of classifying and organizing 1500-word vocabulary; selfish, impatient, independent,
tricycle or bicycle with parts; builds tower facts; counts but does not understand defines words; uses and boastful; sibling rivalry;
training wheels; skips and of ten cubes; uses quantity; likes to pretend and dramatize; past tense; tells “tall very imaginative; imaginary
hops on one foot; balances scissors; may tie shoes can relate a story sequentially; follows tales” friends common; engages in
3–5 seconds; can heel-to- three-step commands; plays rule games; cooperative play; likes to talk
toe walk; throws overhand; knows opposite; plays doctor or nurse; about daily activities; tattles;
catches bounced ball imaginary playmates are common; sings songs; occasionally needs
believes that thoughts cause events supervision with dress and
(magical thinking); becoming more able hygiene
to see others’ point of view; names four
colors; asks “why” frequently
5 years Throws and catches a ball Handedness is Still likes to play make-believe; knows Approximately Gets along well with parents;
well; skips and hops on established; ties name, address, and phone number and 2100-word vocabulary; identifies with parent of same
alternate feet; jumps rope; shoelaces; uses scissors days of the week; names coins, four good articulation; asks sex; plays in group; dresses
balances 3–5 seconds; can and pencil well; prints or more colors, and can count to ten; meaning of words; without help
heel-to-toe walk; may ride a few letters, numbers, recognizes many letters; fewer fears; asks correct use of me, I,
two-wheel bicycle or words (e.g., first meanings of words, inquisitive; can tell past tense, and plurals
name); can copy a a story
diamond and triangle;
can draw person with
three to six parts
6 years Can walk a straight line; rides Can copy a diamond; Thinks concretely; reasons inductively; Adult articulation Performs bedtime activities
two-wheel bicycle; may be dexterity increasing; likes to classify and organize facts; patterns forming; without assistance; peers more
involved in team sports builds steps with beginning pattern recognition; fears learning to read important; prefers playing with
blocks; likes to draw from preschool diminish; focuses on same-sex friends
and color; refining here and now; difficulty understanding
ability to print letters the hypothetical; new fears may involve
school failure, bullies, and so on; likes
school; likes chess, checkers, and simple
card games; recognizes all colors; shares;
more cooperative; continuing to develop
a conscience; sees others’ point of view
7–9 years Increased physical Writes cursive at Curious about the meanings of words; Increased ability to Likes school; focus is on sense
capabilities; during school- 8 years old; increasing likes to compete; strict adherence to articulate and describe of industry; strict adherence to
age, learns to ride a bicycle, dexterity; learning to rules; develops principle of conservation thoughts, experiences, rules; feels a sense of inferiority
roller blade, roller skate, ride use keyboard and reversibility; understands mass, and feelings; uses adult if goals not met
a skateboard, run fast, jump, weight, quantities; hierarchies; beginning sentence structure
and swim to learn about how to compute money
10–12 years Increased physical Continues to develop Reads for information and enjoyment; Increased ability to Increasing importance of
capabilities; may become fine motor skills begins to be capable of abstraction and articulate and describe friends and peers; becoming
progressively involved in through writing, deductive reasoning at approximately thoughts, experiences, more independent from
team sports or other athletic drawing, art, crafts, age 11 years; judges acts by intent rather and feelings; uses adult parents; starts to feel peer
activities needle arts, video than consequences sentence structure pressure; becoming more
games, and complex aware of own body; household
puzzles rules still important as part
of socialization; chores and
responsibilities help to increase
child’s sense of accomplishment
12–14 years Rapid physical growth; Continues to refine Increased ability for complex thought; Fully expresses ideas, Less affectionate toward
increasing physical fine motor skills beginning to formulate and test feelings, and thoughts parents; prefers peers;
capabilities may not keep hypotheses; beginning to develop through oral and concerned about body image;
pace with each other; may abstract reasoning written language mood swings; stronger sense of
cause clumsiness in teen, right and wrong
especially boys
15–16 years Increased physical Continues to refine Abstract reasoning continuing to develop Fully expresses ideas, Conflicts about independence;
capabilities; may become fine motor skills but not fully developed; increasing feelings, and thoughts parent–child relationships are
involved in team sports or egocentrism; thinks “it cannot happen through oral and at low point; peers extremely
other athletic activities to me” written language important; interested in sexual
relationships
17–21 years Increased physical Fine motor skills have Thinks abstractly; becomes idealistic; Fully expresses ideas, Importance of peer group
capabilities; increased reached adult levels approaches problem-solving in feelings, and thoughts is decreased; interpersonal
strength; gross motor abilities systematic manner through oral and relationships are deeper;
have reached adult levels written language planning life goals; refining
self-concept
35
is achieving expected developmental milestones. This Elicit Parental Concerns. The parents are asked di-
screening can be conducted by the provider or from rectly about their concerns regarding the child’s de-
a report by the parent. The AAP recommendations velopment, such as: Do you have any concerns about
(2006) suggest developmental screening at the 9-, 18-, John’s speech, behavior, or ability to play like other
and 30-month visits for all infants and toddlers. If the children his age?
developmental screening reveals that the child is behind
in achieving age-appropriate developmental milestones, Obtain the Developmental History. The provid-
a more thorough developmental evaluation is done. er asks the caregiver to provide an update regarding
Developmental evaluation is an in-depth assessment what new skills the child has acquired since the last
that is performed when a child is suspected of having visit. An age-specific checklist assists the parent in
a developmental delay or disorder; it involves the use providing this information. Using a formal, rather
of formal pediatric developmental evaluation tools, than informal, developmental milestone checklist
several of which are available (Table 2-4). The pediatric to complete this assessment is preferred. Informal
health care provider chooses a tool based on its appro- checklists lack reliability, validity, accuracy, and spe-
priateness for the population of children with which cific scoring criteria (Glascoe & Robertshaw, 2007).
he or she works, the age of the child, the purpose of The Ages and Stages Questionnaire (ASQ) and Par-
the developmental assessment (e.g., concerns about ents’ Evaluation of Developmental Status (PEDS) are
language, behavior, or motor abilities), appropriate examples of formal developmental screening tools
psychometric properties, and the provider’s familiarity that guide the provider regarding when to reassure
with the tool. It is important that the health care pro- or teach the parent, additionally screen the child, or
vider is familiar and comfortable in the administration refer the child for intervention services (see Table 2-4)
and interpretation of a particular assessment tool to (Glascoe, 2007).
increase the reliability of the findings.
Most developmental screening and evaluation tools Perform Accurate, Objective Assessments. In
have not been standardized to include premature in- addition to the physical examination described
fants and children born prematurely; for this reason, above, the provider must also evaluate neurodevelop-
the provider must be vigilant in assessing growth and ment and cognitive and psychosocial development,
development in these populations. When assessing including gross and fine motor milestones, cognitive
children who were born prematurely, the provider uses growth and development, receptive and expressive
the infant’s adjusted age as compared to the chrono- language skills, and social-emotional development.
logical age until the child is 2 years old and ensures the Table 2-3 provides an overview of developmental
use of a corrected gestational age up to at least 30–36 milestones, birth through adolescence. Attention
months for children born earlier than 32 weeks’ gesta- should be paid to developmental milestones that are
tion (Vanderbilt, Wang, & Parker, 2007). acquired out of sequence (developmental deviation),
or when one area of development is significantly
Preparation ahead or behind another area (developmental disso-
ciation); both conditions may indicate cerebral palsy
When conducting the developmental examination,
or autism (AAP, 2006).
the evaluator must keep in mind that the younger the
child, the more challenging it is to obtain accurate
findings. This may be because of stranger anxiety or
Identify Risk and Protective Factors. Once the
assessments are complete, the provider identifies risk
a young child’s normally short attention span, high-
and protective factors for developmental delays and
energy level, and easy distractibility. Some children are
disorders. Risk factors are listed in Box 2-1; protective
very shy and may be reluctant to cooperate in an un-
factors are discussed under Assessment of the Social
familiar setting. Depending on the individual child’s
Environment. In addition, the AAP recommends
temperament and medical and social histories, these
screening for autism spectrum disorders at the 18- and
factors may be more or less pronounced.
24-month well-child visit (Gupta, Hyman, & John-
The setting must be informal and relaxed and, to
son, 2007). This can be done by evaluating behavioral
the extent possible, the evaluation must be done by
symptoms, using the criteria for autism spectrum dis-
quiet observation while the child is playing, moving
orders outlined in the Diagnostic and Statistical Manual
around the room, interacting with the caregiver, or us-
of Mental Disorders, 4th edition, revised (DSM-IV-TR)
ing his or her hands to play, scribble, or draw.
or by using one of the autism screening tools listed in
Table 2-4 (Cole, 2008).
Procedure for Developmental Surveillance
Using the AAP (2006) policy recommendations as a Document and Process Findings. All portions of the
guide, the provider begins the developmental surveil- developmental assessment must be accurately docu-
lance by following these steps: mented, with appropriate referrals made as warranted.
TABLE 2-4
Selected Developmental Assessment Tools
AGE
TOOL DOMAINS ASSESSED RANGE NOTES SCORING
Parent Report Communication, gross 4 months to Parent answers simple questions “Yes” answers ⫽ 10 points; “sometimes” ⫽
Ages and Stages Questionnaires motor, fine motor, 5 years about their child’s development; 5 points; “not yet” ⫽ 0; scores are tabulated and
http://www.agesandstages.com problem-solving, and takes 10–15 minutes for parents to evaluated for each domain
personal-social complete; 2–3 minutes for health
care provider; written at 4th–6th
grade literacy level; available in
other languages besides English;
excellent psychometric properties
(Prelock, Hutchins, & Glascoe, 2008)
Child Development Inventories Eight subscales are Birth to Excellent psychometric properties Parent report questionnaire consists of
http://www.pearsonassessments.com/ assessed: social, self-help, 6 years 270 items that address the 8 subscales;
gross motor, fine motor, parent answers question with “yes” or “no”;
expressive language, language 30 questions address parental concerns, each
comprehension, letters, scale is scored by tallying the number of
numbers; also assesses “yes” answers; scores 1.5 below the mean is
parental concerns about borderline; scoring ⬎2 standard deviations
the child’s health, growth, below the mean is delayed
hearing, vision, development,
and behavior; also useful in
determining school readiness
Parent’s Evaluation of Gross and fine motor; self- 0–8 years Ten questions answered by Screening test results do not give quantitative
Developmental Status (PEDS) help; expressive and receptive parent; available in English, results but guide provider via algorithm in
http://www.pedstest.com language; social-emotional Vietnamese, Somali, Arabic, and identifying areas of concern, when to reassure,
development; reading and Spanish; questions written at 5th refer, screen further, or advise/teach parents
math (older children) grade reading level; excellent
psychometric properties (Prelock,
Hutchins, & Glascoe, 2008)
Battelle Developmental Inventory Motor, communication, Birth to 7 yrs The BDI functions as a screening Instrument contains 96 items that assess five
(BDI) personal-social, adaptive, and 11 months or diagnostic assessment tool; domains listed at left; raw scores are converted
http://www.riversidepublishing.com/ cognitive screening test takes 10–30 minutes; to standard scores of possible values of
products/bdi2/index.html complete BDI takes 1–2 hours 0 (normal); 1 (borderline); 1.5 (developmental
problem); 2 (serious developmental delay)
Provider Administered Neurologic processes 3–24 months Screens infants at risk for Uses 10–13 provider-elicited items to make
Bayley Infant Neurodevelopmental (tone; reflexes); neurodevelopmental delay (e.g., assessments; cutoff scores provide three levels of
Screen (BINS) neurodevelopmental skills premature or asphyxiated infants); risk classification: low, medium, and high
http://www.harcourtassessment.com (movement and symmetry); takes 5–10 min to administer;
cognitive and language available in English and Spanish;
skills (object permanence, moderate sensitivity and specificity.
imitation, language)
37
(continued)
38
TABLE 2-4
Selected Developmental Assessment Tools (Continued)
AGE
Brigance Screens Fine and gross motor skills; Birth to Specificity and sensitivity Identifies children who have learning delays,
http://www.curriculumassociates.com receptive and expressive 6 years 70%–82%; available in English disabilities, or giftedness
language; cognitive; academic and Spanish; takes 10–20 minutes
(quantitative, reading); daily to administer
living/self-help; social-
emotional
Denver II Gross and fine motor/ Birth to Modest sensitivity and specificity, The four domains are divided into 125 items
http://www.denverii.com/ adaptive; personal/social; 6 years especially in children under which are arranged in chronological order in
DenverII.html language age 3 years. Should be used for accord with the age; ages are listed at the top
screening purposes only of the page; through the corresponding age, a
vertical line is drawn from top to bottom of the
tool; each intersecting item is scored as fail (F);
pass (P); refused (R); or no opportunity (NO);
if the child fails to pass an item that 25%–90%
of children that age can perform, the score is
caution; a delay is failure to pass an item to the
left of the line; a normal exam is one with no
delays and a maximum of one caution
Early Language and Milestone Auditory receptive, auditory Birth to Takes 1–10 minutes to administer, Scores are presented as percentiles, standard
(ELM) Scale-2 expressive, and visual 36 months depending on child’s age and scores, and age equivalents
http://www.proedinc.com language function evaluation technique. Available in
English only
Peabody Developmental Motor Gross and fine motor Birth to Assessment takes approximately Scores are presented as percentiles, standard
Scales (PDMS-2) development 60 months 45–60 minutes to administer scores. and age equivalents
http://www.wpspublish.com
Parent Report and Provider Cognitive, visual, and 3–36 months Takes 15–20 minutes; some parent A developmental quotient (DQ) is calculated
Administered motor, problem-solving, and report, some assessments made based on child’s chronological age and
Cognitive Adaptive Test/Clinical language skills; purpose is to by provider; high specificity and developmental tasks completed; a DQ ⬍70
Linguistic and Auditory Milestone screen for autism sensitivity (⬎90%); available in indicates delay and requires referral
Scale (CAT-CLAMS) English, Spanish, and Russian
http://www.pbrookes.com
Behavioral Scales Assesses child’s temperament 1 mo to Parent report; takes 4–20 minutes Questionnaires create a temperament profile
The Carey Temperament Scales and behavioral style 12 years to complete, depending on method based on temperament characteristics listed in
http://www.temperament.com of scoring; available in English Table 2-2
only; normed on white middle
class children only
AGE
Child Behavior Checklist Assesses social competence 6–18 years Parent report or self-administered, 118 items are scored on a 3-point scale ranging
http://www.aseba.org and behavior depending on child’s age; excellent from not true to often true; there are an
sensitivity and specificity additional 20 social competency items. Raw
scores are interpreted to create behavioral
profiles
Eyberg Child Behavior Inventory Measures conduct problems 2–16 years Takes 5 minutes to administer; Likert scale questions about disruptive behaviors
http://www.3parinc.com 5 minutes to score; test results at home and in school; data can be obtained
provide data for identifying from parent or teacher
disruptive behavior in children and
adolescents
Pediatric Symptom Checklist Assesses for psychosocial 3–18 years Available in multiple languages; Parent completes a 35-item questionnaire;
http://psc.partners.org/ problems high sensitivity; moderate answers are “never,” “sometimes,” or “often
specificity (Prelock, Hutchins, & present”; items are summed with a possible
Glascoe, 2008) total score of 70; for children ages 3–5 the cutoff
score is ⱖ24; for age 6–18, the cutoff score is
ⱖ28; exceeding these scores requires mental
health referral
Autism Screening Tools Autism screening tool 18–24 Poor sensitivity but excellent Takes 5 minutes to complete; parent interview
Checklist for Autism in Toddlers months specificity; available in English (9 items) and child/provider interview (5 items);
(CHAT) only scored as pass/fail; identifies children at risk for
http://www.autismresearchcentre autism
.com/tests/chat_test.asp
M-CHAT Autism screening tool 16–48 Tool available in English, Spanish, Parent questionnaire (23 items); items are
http://www.dbpeds.org/media/ months Chinese, Japanese, and Turkish scored as pass/fail
mchat.pdf
http://www.firstsigns.org/
downloads/m-chat.pdf
Pervasive Developmental Disorders Autism screening tool 18–48 Takes 10–15 minutes to complete; Parent questionnaire (22 items)
Screening Test-II, Primary Care months 5 minutes to score; available in
Screener (PDDST-II, PCS) English only; moderate-to-high
http://www.harcourtassessment.com sensitivity and specificity
Social Communication Autism screening tool 4⫹ years Takes 5–10 minutes to complete, Parent questionnaire (40 items)
Questionnaire (SCQ) available in English and Spanish;
http://www.wpspublish.com moderate sensitivity and specificity
Adapted from American Academy of Pediatrics. (2001). Committee on Children with Disabilities: Developmental surveillance and screening of infants and young children. Pediatrics, 108(1), 192–195;
American Academy of Pediatrics. (2006). Committee on Children with Disabilities: Identifying infants and young children with developmental disorders in the medical home: An algorithm for develop-
mental surveillance and screening. Pediatrics, 118(1), 405–420; Cole, L. L. (2008). Autism in school-age children. Advance for Nurse Practitioners, 16(3), 38–47.
39
TABLE 2-5
Diagnostic and Laboratory Studies
DIAGNOSTIC STUDY INDICATION
Chromosome analysis To diagnose chromosomal disorders
Complete blood count To diagnose anemia (causes fatigue, which may result in delayed milestone
acquisition); anemia also occurs concurrently with lead poisoning
Electroencephalogram To diagnose seizure disorders; also indicated with microcephaly, regression of

developmental milestones, and mental retardation
Fragile X karyotype Known or suspected mental retardation; family history of fragile X syndrome;
dysmorphic features (Cole, 2008)
Human immunodeficiency virus Obtained when child shows signs of failure to thrive and shows other signs of
(HIV) HIV/AIDS
Lead levels To diagnose lead poisoning, which causes developmental delay and cognitive
dysfunction
Metabolic testing Indicated when newborn screen inconclusive; known or suspected mental
retardation; dysmorphic features, or history of lethargy, cyclic vomiting, and
early seizures (Cole, 2008)
Muscle biopsy To diagnose degenerative neuromuscular disorders (e.g., Duchenne muscular

dystrophy)
Newborn screening To diagnose a variety of metabolic disorders that may cause developmental
delay or mental retardation
Neuroimaging (computed To diagnose atypical findings on neurologic exam; asymmetric motor exam;
tomography scan; magnetic microcephaly; traumatic brain injury, space-occupying lesions, spasticity, and ataxia
resonance imaging; ultrasound)
Wood’s lamp evaluation of skin To screen for hypopigmented macules of tuberous sclerosis (Cole, 2008)
LABORATORY AND IMAGING

DOCUMENTATION OF FINDINGS
ASSESSMENT
Depending on the child’s medical and family history, SAMPLE WRITE-UP:
physical examination, and developmental evaluation,
DEVELOPMENTALLY NORMAL CHILD
certain imaging or laboratory studies may be needed
to complete the assessment. These studies are listed in Subjective Data
Table 2-5. A 12-month-old girl (only child in family) presents for
routine well-child care accompanied by her mother. Birth
history is unremarkable. Mother denies having any con-
cerns about daughter’s developmental abilities, hearing,
SUMMARY or vision. Per mother’s report, child can pull to stand
and cruise, is not yet walking independently, feeds self,
Developmental surveillance is included as part of
says “Mama” and “Dada,” is very attached to security
every well-child visit. When concerns, risk factors, or
blanket, responds to name, and waves “bye-bye.”
red flags are identified with developmental surveil-
lance, a standardized developmental screening tool
is used to pinpoint areas of concern. All children at Objective Data
the 9-, 18-, and 30-month visits should also receive Gross Motor: Per mother’s report; child refused to
developmental screening, even if they are low risk. get off mother’s lap
When developmental screening reveals developmen- Fine Motor: Picked up Cheerios with fine pincer
tal delays or disorders, prompt referrals must be made grasp; drinking from sippy cup
to early intervention services to maximize the child’s Cognitive: Looked for toy that was hidden
developmental potential and minimize long-term Language: Per mother’s report; did not verbalize
sequelae. during visit
Social-emotional: Child and mother interacting Hearing: Turns to name being called
responsively; mother comforts child when fretful Vision: Vision normal per Allen test; named 3 of 7
during visit cards on 3rd attempt
Hearing: Imitating mother while talking to provider; Assessment:
put toy away when asked • Bilateral otitis media with effusion
Vision: Looked for dropped toy • Developmental delay
Assessment: Developmentally normal 12-month- • Speech and language delay
old child • Parental knowledge deficit
• Abuse and neglect
SAMPLE WRITE-UP: CHILD WITH

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RESOURCES Zero to Three
Bright Futures http://www.zerotothree.org
http://www.brightfutures.org/ A multidisciplinary organization that provides developmental
A set of health supervision guidelines that include child screening, evaluation, and diagnosis for children in the first three
developmental assessment for each well-child visit according years of life; also provides information for parents and profession-
to the American Academy of Pediatrics health supervision als on general child development, early language and literacy,
guidelines. social and emotional development, temperament and behavior.
SECTION 2
O B TA I NI NG T H E P E DI ATR I C
H E A LT H H I S T O RY
CHAPTER
Communicating with
3 Children and Families

PATRICIA A. SULLIVAN
this chapter.) The communication process used by the

PROCESS OF COMMUNICATION health care provider to work with the pediatric popula-
tion requires more time and patience than does a typi-
Communication is the exchange of thoughts, ideas, feel- cal health care encounter. Taking additional time and
ings, messages, or information through various means using age-specific and family-oriented communication
(Ball & Bindler, 2006), including speech but also non- techniques facilitates a smooth communication pro-
verbal means such as behavior, body language, or eye cess in the pediatric setting. It is important to include
contact. Developing quality communication skills is es- the child in the communication process of a health
sential to success in working as a health care provider care encounter, and care should be taken to ensure that
because positive communication helps to build trusting this communication is developmentally appropriate.
relationships with patients and their families. Under-
standing the communication process and what leads to
good and bad communication will help a health care UNDERSTANDING FAMILY
provider develop positive communication skills.
Communication is a two-way process: it involves DYNAMICS AND PARENT–CHILD
sending and receiving messages. The sender transmits RELATIONSHIPS
information to the receiver with a specific goal and
meaning, using verbal and nonverbal communication Family dynamics is an important component of the
strategically so that the receiver interprets the message communication process. In pediatrics, important topics
as intended by the sender. The way in which the re- to assess include a child’s birth order, sibling rivalry, and
ceiver interprets the message is largely influenced by family composition, as well as the marital status of the
the verbal and nonverbal delivery used by the sender, parents, step-parents, or foster parents. It is important
as well as the receiver’s past experiences, culture, and to consider which communication efforts will be most
emotional state (Dunn, 2004). effective with the particular child and family, based on
The communication process in the health care the family dynamics. Recommendations for improved
setting is complicated because of heightened physi- family communication are based on this assessment
cal and emotional strain during illness; this process (see Chapter 5 for a discussion of family dynamics).
is even more complicated in the pediatric setting be-
cause it requires an understanding of the communica-
tion techniques needed for each developmental stage PRIVACY AND CONFIDENTIALITY
(e.g., infant, preschooler, school-aged child, adoles- Privacy and confidentiality are key components of com-
cent) when communicating with the child. Commu- munication in health care, as many personal topics are
nication with the parents and family is also necessary. discussed. Children and adolescents often feel vulnerable
(Developmental considerations are covered later in during a time of illness because their privacy is invaded
44
C H A P T E R 3 Co m m un icatin g with Ch ildre n and F amilies • 45
by physical examinations and interviews that necessitate the main contact and decision-maker in a health care
divulging private information. For example, preschoolers encounter and often indicate with whom their infor-
are very modest and become embarrassed easily when mation can be shared. In pediatrics, when children are
asked to disrobe. Adolescents often feel uncomfortable younger than 18 (or 21 in some states), the parents
disclosing information about sexual activity or risk-tak- or guardians are the main decision-makers regarding
ing behaviors. Privacy can be assured by securing an envi- where and with whom information on the child is ob-
ronment that is free from distractions and interruptions. tained and shared, although laws vary from state to
For example, an interview conducted in an environment state (Ball & Bindler, 2006). For instance, if a pediatric
where conversations can be overheard may be less likely patient’s medication is changed, providers are obligat-
to yield truthful information from a patient or his or her ed to discuss this with the parents or guardians, not
family. With adolescents, it is important to allow time the child alone.
during the interview process without the parent present The few circumstances in which the parents’ ulti-
to encourage communication on sensitive topics such mate authority can be overridden include when a child
as sexual behavior, drug and alcohol use, smoking, risk- disagrees with the treatment, when the parent decides
taking behaviors, and nutritional habits (Ball & Bindler, to withhold lifesaving treatment of a child, when there
2006). It is equally important, however, to interview is a conflict of interest such as in the case of an abusive
the parents alone so that they are free to discuss their parent, or when a parent is incapacitated and unable
concerns about their child. Ensuring privacy maximizes to make decisions (Ball & Bindler, 2006). In these cases,
truthful information obtained from both children and a compromise is sought with the provider, parent, and
parents during a health care encounter. child; sometimes an ethics committee helps with the
Confidentiality in health care means that any in- decision-making. Instances in which a minor may be
formation obtained from the patient is not shared the primary decision-maker include when the minor is
with others, with some exceptions. The Health Insur- the parent of a child patient or when an emancipated
ance Portability and Accountability Act (HIPPA) is a minor (i.e., a minor who has been deemed by the court
federal regulation that includes specific guidelines for to be self-supporting) makes his or her own decisions
the health care industry to protect the confidentiality (Ball & Bindler, 2006). Most states have laws that allow
of patient health information (Ball & Bindler, 2006). providers to keep information about sexual behavior,
Each health care facility has its own policies on han- contraception, drug and alcohol use, and sexually
dling confidential records and information. Also, most transmitted disease confidential for their minor-aged
facilities have a HIPPA consent form that patients must patients, even from parents (Ball & Bindler, 2006).
sign, outlining the policies of the institution, clarifying
patients’ rights, and specifying what is considered con-
fidential and what can be shared (e.g., information sent ESTABLISHING EFFECTIVE
to insurance companies for billing, information sent to COMMUNICATION BETWEEN
other health care providers). Being aware of the facili- CHILDREN, CAREGIVERS, AND
ties’ policies and upholding these policies are essential
to protecting the patients’ privacy and confidentiality.
PROVIDERS
Most patients feel comfortable providing informa- Having a thorough understanding of the complexities
tion if they are aware of the hospital’s policies on con- of communication is essential for establishing effective
fidentiality. Explaining these rights at the beginning communication with pediatric patients and their fam-
of a health care encounter facilitates the communica- ilies. Knowledge of the communication process and
tion process. The limitations of confidentiality, insofar communication techniques facilitate the development
as information is shared with the medical team and of communication patterns that are consistent and
recorded in the patient’s record, should be explained at positive. In pediatrics, being aware of developmental
the beginning of every health care encounter. approaches to communicating with the child, having
Other limitations to confidentiality should also be an understanding of family dynamics, and tailoring
explained before the start of an encounter, including communication to the specific needs of the child and
certain topics such as abuse and suicide. Most states family are the keys to successful communication.
have mandatory reporting laws for patients who ver- A recent study on effective and ineffective commu-
balize suicidal ideation, the intent to harm others, or nication strategies in the primary care setting focused
suspected or documented abuse (Ball & Bindler, 2006). on physician–patient encounters (Beck, Daughtridge,
Health care personnel must be knowledgeable about & Sloan, 2002); however, the principles established in
the laws of the state and the policies of the facility in this study are easily extrapolated to encounters between
which they are practicing. all health care providers and patients. A summary of
There are slightly different regulations for confiden- the findings follows:
tiality in the pediatric patient population as compared • Effective communication techniques include assum-
to the adult population. Adult patients generally are ing a friendly demeanor, paying attention during the
4 6 • S e c t i o n 2 O B TAI N I N G T HE PEDI ATRI C HEA LTH HI STO RY
interview, giving positive feedback to patients, and • Providers should avoid interrupting patients or fam-
encouraging the patient to talk. Other behaviors that ily members.
encourage the patient’s openness included clarifying • Providers should listen more than they talk.
and summarizing what the patient said, assuming an When working in pediatrics, all of the provider’s
age-appropriate level at which to talk to patients, and interactions and conversations should be based on a
addressing patients’ emotions, problems, and medi- consideration of the child’s feelings and developmen-
cal reasons for seeking care. tal ability so that the child understands what is being
• Behaviors considered negative communication in- communicated (AAP, 2003).
clude focusing on medical questions, appearing
rushed, allowing interruptions, assuming an all- Listening
knowing attitude, not making eye contact, and turn- One of the most important components of the com-
ing away from the patient when recording the history. munication process is listening. The most effective
These communication techniques are covered in listening is called active listening. Active listening
the next section. necessitates that the provider observes all aspects,
verbal and nonverbal, of the sender’s message (Hock-
enberry & Barrera, 2007). It requires that full attention
COMMUNICATION TECHNIQUES is paid to the person speaking. Distractions should be
eliminated and nonverbal cues, such as eye contact,
Communication techniques are used when obtain-
should be used to relay to the sender that the provider
ing a health history in an outpatient visit or initial
is actively listening. Making judgments about what is
admission to the hospital, during follow-up visits,
being said is a natural response, but the health care
and when relaying important testing and diagnostic
provider needs to maintain objectivity as much as
information. Each health care encounter requires a
possible. This allows the provider to obtain the most
combination of communication techniques that will
factual information available and then complete a
result in effective and positive communication with
nonbiased review of the data during the assessment
patients and their families, especially in pediatric
and planning phases. There are several types of listen-
encounters.
ing that are actually blocks to communication. These
include attentive listening, selective listening, pretend
Building Rapport listening, and ignoring (Cohen, 2003).
Building rapport requires time and the implementa- Attentive listening occurs when receivers focus on
tion of interventions that help to build a trusting re- what the person is saying but actively compare the
lationship. Rapport with pediatric patients and their sender’s experience to their own (Cohen, 2003). In a
families is the base on which good communication is health care encounter, comparing personal experience
built. It means being nonjudgmental and demonstrat- naturally leads to bias and should be avoided.
ing respectful and honest communication. This is not Selective listening occurs when the receivers only
automatic when first meeting a child and family; a hear what interests them, which causes providers to
consistent demonstration of honest communication, miss important details. Some providers use selective
understanding, and respect forms the foundation for listening because their time is limited. However, when
all future communication. Allowing time for ques- patients provide what may seem like unnecessary
tions, answering questions honestly and correctly, re- details, once the communication has ended, these de-
specting patients’ beliefs and ideas, and preparing the tails often positively add to the final review and plan.
environment so that it is conducive to positive com- Pretend listening occurs when providers merely give
munication contribute to building rapport with the the appearance of listening. This type of listening is ob-
child and the family. viously totally ineffective and will not provide enough
Establishing rapport with children helps to ease their necessary information with which to work when for-
anxiety about the visit and makes them feel like they mulating a plan for the patient.
are an important part of the process (Ball & Bindler, Ignoring occurs when providers make no attempt to
2006). Recommendations with which to build rapport listen and do not even give the appearance of listening.
with children follow (Ball & Bindler, 2006): A provider might ignore patients when time is limited,
• Health care providers should place themselves at eye for example, when communicating important test
level with the child. results. Providers may relay the information with an
• Young children should be asked about their favorite adequate explanation and ignore any questions that
cartoon character or favorite toy. patients may have. This may leave patients uncertain
• A calm voice and an unhurried manner should al- or confused about what was said. Another example of
ways be used with children. ignoring occurs when providers finish a progress note
• Adolescents should be included in the conversation while patients are talking. Providers cannot listen ad-
about their care. equately and record notes at the same time.
Specific recommendations for listening to children are provider is being empathic through the verbal and non-
discussed by Howard (2002) and are summarized below: verbal cues given during the communication. The tech-
• Providers should listen with empathy and good eye niques discussed in this section, such as listening, making
contact, responding to the children’s attempts at eye contact, nodding, and interjecting phrases such as “I
communicating. understand,” rephrasing what was said to clarify, and not
• Providers should give children their full attention judging the patient, demonstrate empathy.
and not try to accomplish other tasks while the chil- It is important to distinguish empathy from sympathy.
dren are communicating. Sympathy is sharing similar feelings with another, but
• Providers should ask the children about any emo- empathy is being able to understand another’s feelings
tions that are being assessed during their encounter. (Hockenberry & Barrera, 2007). Empathy is a therapeu-
• Providers should rephrase and summarize what the tic technique whereas sympathy is not. Sympathy might
children have said so the children can confirm that involve the health care provider sharing personal experi-
the providers understand what they are trying to ences, which decreases the time patients have to express
communicate. their thoughts. It also does not allow the provider to re-
main objective and crosses therapeutic boundaries.
Empathy
Empathy is the ability to understand and identify with Encouraging Conversation
another person’s feelings and is often referred to as being Encouraging parents and children to participate in the
able to “put yourself into another person’s shoes” (Hock- health care encounter has been shown to expedite the
enberry & Barrera, 2007). Using empathy in pediatrics re- visit and leave parents feeling satisfied (Hagan, Shaw,
quires stepping into the shoes of the child and having an & Duncan, 2008). Parents who feel rushed, ignored,
understanding of the stages of pediatric development. or left out of the visit generally feel frustrated, accom-
Empathizing does not mean that it is necessary to plishing less than if open dialogue was encouraged
agree with the patient; rather, it means the patient’s (Hagan, Shaw, & Duncan, 2008). Techniques that help
feelings should not be dismissed. Through words and promote communication with the children and par-
actions, health care providers must show that they are ents include using open-ended questions, avoiding
considering what their patients or their patients’ parents questions that elicit a yes-or-no response, including the
are thinking and feeling (Perkins & Fogarty, 2005). Em- parent or child in problem-solving, using encouraging
pathizing requires that health care providers do not give statements to boost the self-esteem of both parents
advice and that they do not share their own thoughts and children, and being nonjudgmental (Hagan,
and feelings. Patients and their families can detect if the Shaw, & Duncan, 2008). Table 3-1 illustrates examples
TABLE 3-1
Techniques to Foster Provider–Patient Communication
Open-ended Questions “What brings you and Julia here today?”
“So when Brendon does that, how does that make you feel?”
“What concerns or questions do you have?”
Encouraging “Go ahead, continue.”

“Tell me more.”
“Is there anything else you want to tell me?”
Including the Parent or Child in “What have you done at home already to alleviate or address the problem?”
Problem-solving (This can be any problem that the child is presenting.)
“What do you think might help?”
“How do you feel about the plan I am proposing for this problem, and do you
have any other ideas about what might work?”
Boosting Parent and Child “That is really great. I think that is a very good idea.”
Self-esteem “Everything checks out well, I think you are taking really good care of yourself;
keep up the good work.”
“You are raising a great kid; keep up the good work.”
“I am glad you have these questions, I can tell that you are really concerned
and are doing a great job parenting.”
Being Nonjudgmental “I see you have a tattoo and a tongue piercing; what was it like to get those?”
of communication that encourage open conversation impersonal terms may support their denial and pre-
with parents and children. vent them from dealing with pertinent issues. This
When communicating with children, it is important may, in turn, lead to ineffectual coping. It may also
for providers to get down to their level, giving them com- prevent parents from seeking care for a problem if they
plete attention (Stein, 2006). This demonstrates a willing- never deal with a problem directly.
ness to communicate and encourages children to talk. Nonverbal communication is the sending and
Children should be allowed to complete their thoughts receiving of wordless messages. Examples include body
and should not be interrupted (Starr, 2004). Interjecting language, facial expressions, eye contact, clothing,
into the child’s attempts to communicate may hinder a hairstyles, and tone of voice and other qualities of
full assessment if the child chooses to not complete what speech. (Stein, 2006). Some studies show that facial
he or she expected to relate before the interruption. expressions of anger, disgust, fear, joy, sadness, and
Use of open-ended questions is an effective technique surprise are universal, whereas other nonverbal com-
to encourage children to talk. Children often feel intimi- munication is culture-specific (Ekman & Friesan, 1975;
dated when talking to a provider and are often unsure Polhemus, 1978). Cultural variances in communica-
of how to respond to questions (Cheek, 2006). Open- tion are addressed in Chapter 4.
ended questions allow for spontaneous answers to ques- Nonverbal communication can be more powerful
tions, and often parents or children answer questions than verbal communication and usually reveals any
more completely (Cheek, 2006). Young children can be emotions felt about the topic being discussed. It has been
offered options, for example: “Some children feel much estimated that nonverbal communication makes up ap-
better after the breathing treatment, but others still feel proximately 65% of the substance of a communication
like they have a hard time catching their breath. Can encounter (Hall, 1966). When there is a discrepancy
you tell me how you feel after a breathing treatment?” between a person’s verbal and nonverbal communica-
Closed-ended questions require a focused, simple tion, the receiver usually interprets the nonverbal cue as
response. For example, “Has Ella been vomiting?” re- what the sender really means to communicate over the
quires a yes-or-no answer. These questions are appro- words that are used (Henman, 2004). It is important to
priate when specific information is being sought for note, however, that the meaning of the nonverbal com-
the health history. munication is easily misinterpreted (Henman, 2004).
Understanding the different types of nonverbal
Verbal and Nonverbal Communication communication and assessing one’s own nonver-
Verbal communication refers to the actual words, either bal communication can promote positive nonverbal
spoken or written, that people use to communicate. interactions with patients through self-awareness. Col-
The words chosen to express thoughts and feelings are leagues, too, can provide positive feedback about non-
powerful and must be chosen carefully. A person’s per- verbal communication when objectively evaluating a
ception of reality can be altered through the sender’s health care encounter.
spoken word (Hockenberry & Barrera, 2007). Being di- Assessment of a patient’s nonverbal cues and know-
rect and honest is always the best approach. ing when to clarify the nonverbal behavior improve
Two examples of verbal communication that may with a thorough understanding of the different non-
block communication include avoidance language and verbal behaviors and their possible meanings. Exam-
distancing language. Avoidance language occurs when the ples of how nonverbal communication can be positive
person speaking uses word choices that avoid describ- and negative are discussed below.
ing what they are trying to communicate, such as when
a person is avoiding strong emotions and feelings about Paralanguage. Paralanguage refers to vocal elements that
a subject (Hockenberry & Barrera, 2007). Examples of are used to communicate such as pitch, rate, inflection,
this include calling “cancer” a “tumor” or using “passed volume, quality, enunciation, flatness, and fullness
on” instead of “dead.” In a health care encounter, the (Henman, 2004). Paralanguage can add enthusiasm or
provider must use very precise language, avoiding am- sadness to a conversation, for example, when a specific
biguous word choices. The provider can restate what tone of voice helps to communicate either good news or
patients say, using precise language, if the children or bad. Paralanguage is an important nonverbal commu-
family members are avoiding direct language to express nication cue, particularly when communicating by tele-
themselves. Using direct and precise language allows phone, as communication cues are limited to the verbal
the child and family to discuss the topic about which message and paralanguage. There is an increased risk of
they have anxiety and promotes therapeutic conversa- misinterpretation of messages with these limited cues.
tion and effective coping patterns.
Distancing language entails the use of impersonal Physical Environment. The environment in which a
language such as “it” or “others” to discuss situations communication takes place can impact the message.
pertaining to oneself or one’s child (Hockenberry Health care personnel do not always have control over
& Barrera, 2007). Allowing children or family to use the environment in which they encounter patients, but it
is important to be aware of the different environmental to intentional gestures and movements. The sender is
factors that affect a health care encounter so that the fully aware of the movements and the message they
environment can be adapted to promote positive results. convey to the receiver. Involuntary body language refers to
Environmental factors to consider include temperature, movements that are usually provoked by emotion such
size of the room for the number of people involved, seat- as facial expressions. Both voluntary and involuntary
ing arrangements, lighting, distractions, noise, and the body language can have positive and negative interpre-
color of the room (see Chapter 6) (Henman, 2004). tations, depending on the nonverbal and verbal com-
Distractions and interruptions can cause patients to munication they accompany. Body language that has
feel frustrated when revealing sensitive information; a positive effect on provider–patient communication
too many interruptions may close off communication includes head nodding, leaning forward, direct body
completely. The health care provider should inform staff orientation, uncrossed arms and legs, and talking to the
to take messages from callers so that every effort can be patient at eye level (Beck et al., 2002). Cultural differ-
made to focus on the child and parent. In pediatrics, ences in body language are addressed in Chapter 4. Ex-
it might also be difficult for parents to focus on giving amples of body language are discussed below:
information if the child wants their attention. Having • Arms or legs crossed or open: Arms that are crossed
a play area for children with age-appropriate activities may indicate that a person is physically uncom-
while interviewing parents helps to alleviate this prob- fortable (e.g., too cold) and may be accompanied
lem and allows parents to focus on the questions being by shivering. It may indicate a standoff position,
asked and communicate more effectively. For example, meaning that the person is closed to communi-
when relaying important news to patients and families, cation. Often closed arms accompany a serious
a conference room may be a more appropriate venue communication encounter and may indicate that
than a patient’s shared hospital room. Hospital confer- a person is in deep thought, which can be either
ence rooms usually maximize environmental aspects positive or negative. When people generally keep
that promote communication. In pediatric areas, there their arms open, it may indicate expansiveness and
are usually activities to keep children occupied. a readiness to communicate. Open arms can also
indicate a friendly, relaxed demeanor.
Physical Appearance. Physical appearance includes • Eye contact: Eye contact can convey friendliness or
clothing, hairstyle, makeup, and hygiene. Physical ap- aggression (Henman, 2004). Making eye contact ini-
pearance is the first thing people notice when forming tially signals a readiness to communicate. Eye contact
an opinion about a person in a face-to-face encounter. can also relay honesty and warmth. If eye contact
In health care, encounters with patients and families is avoided, it may be interpreted as dishonesty, dis-
often take place during a vulnerable time. Maintaining interest, or rudeness, but it could also indicate that
a professional appearance relays confidence and trust; the person is not feeling well. Prolonged eye contact
patients often feel more comfortable with providers may be perceived by the client as hostile or aggres-
who present professionally. Hospitals and health care sive, although it may also indicate that the provider
facilities often have guidelines on hairstyles, jewelry, is deeply interested in what the parent or child is
and attire to ensure a professional appearance. Being saying (Weber & Kelley, 2007). Prolonged eye con-
well-groomed and maintaining a clean and pressed tact can be frightening to a child younger than
uniform or lab coat help convey professionalism. 2 years old if the child is unfamiliar with the provid-
In a pediatric setting, providers can wear child- er (Stein, 2006). Cultural variations in the meaning
friendly lab coats or character pins and use colorful of eye contact are discussed in Chapter 4.
stethoscope covers while still maintaining a profes- • Head tilt: Tilting the head toward the child or par-
sional appearance. These nonverbal cues can have a ent indicates interest in what they are saying (Weber
positive impact on interactions with children who & Kelley, 2007).
“read” these cues as nonthreatening and friendly. • Repetitive movement of extremities: Repetitive move-
The physical appearance of patients often gives ment of the extremities indicates nervousness or stress.
examiners clues about their health status. Ill patients • Sitting behind a desk or standing: Sitting behind a
may present in sleepwear, disheveled and unshowered, desk may convey distance and may send a message
which usually indicates that the patient is too ill to to the child and family that the health care provider
dress or shower. This could also indicate a psychiat- is not approachable. Standing implies that the pro-
ric illness, especially if dress or fashion trend is inap- vider is in a hurry and may not be fully involved
propriate (e.g., wearing a woolen cap in the summer). (Weber & Kelley, 2007; Stein, 2006).
These cues require further questioning before making • Gestures: Gestures can have positive or negative
a judgment. meaning. Head nodding can be affirming to the
client or parent while they are speaking and relaying
Body Language. There are two forms of body language: their concerns to the provider. Pointing while speak-
voluntary and involuntary. Voluntary body language refers ing is considered an aggressive gesture.
Body language is the primary form of communica- customs and in providing culturally competent inter-
tion in children under age 5 (The National Literacy pretations (Lehna, 2005). However, it can be costly to
Trust, 2007). Infants learn to point as an early form of have a variety of interpreters, representing all of the
communication before they are verbal. It is thought different languages, on site.
that infants are born with inherent body language skills Telephone services can provide access to interpret-
on which they build by watching others (The National ers who speak a wide range of languages. This can be
Literacy Trust, 2007). Parentese, which is infant-directed very costly, however. It is also not very personal and
speech, includes exaggerated body language such as can be time-consuming. And because body language is
paralanguage and facial expressions. Infants mimic a significant part of communication, all of this is lost
these sounds and expressions between the ages of 6 when using a telephone interpreter. It is also important
and 15 months, and then by age 3 they acquire body to be sure the interpreter services test their interpreters
language that is similar to that of the adults with whom for language and cultural competence, because these
they have the most contact. A summary of some of the services are not regulated.
positive effects of body language for infants and young Health care facilities that are mandated by law to
children follows (The National Literacy Trust, 2007): have interpreter services often have multilingual pro-
• Body language helps to decrease tension and frustra- viders and use a combination of professional interpret-
tion when the gestures elicit a response. ers available on site and telephone interpreter services
• Body language leads to deeper communication and for patients who speak languages for which they do
improved bonding, which makes the child feel good. not have interpreters, or for emergency situations
• Body language increases brain connections and con- when the on-site interpreters are not available. Many
tributes to early verbalization. facilities use outside interpreter services and schedule
the interpreter before the visit, which offsets the high
When communicating with children, it is important
cost of keeping an interpreter on site at all times.
for providers to remember that tone of voice and pos-
Use of uncertified bilingual support staff such as
ture should reflect openness to communication. Also,
secretaries or medical assistants (Lehna, 2005) can be
the child’s body language should be assessed closely.
problematic because they are not certified, and there
Providers must maintain nonjudgmental body lan-
is no way to ensure that they are competent in the re-
guage when the child is communicating. If emotions
quired language or culture, which may put the provider
or judgment are evident in tone of voice, body move-
and patient at risk for receiving incorrect information.
ments, and facial expressions, the child may be un-
Also, staff may not be available on demand.
comfortable communicating further (Howard, 2002).
Using chance interpreters such as friends or
Facial expressions should convey sincerity and genu-
family poses many ethical dilemmas and violations
ine concern. Facial expressions that convey boredom,
of confidentiality (Lehna, 2005). Using friends or
disdain, judgment, or distraction destroy client trust
family poses the risk that information will be left out
and rapport.
as these individuals do not feel comfortable reveal-
ing news about a terminal diagnosis or other bad
Communicating Through an Interpreter news to the patient who is their friend or relative.
A large population of non–English-speaking people in- The responsibility of having to communicate this
habit the United States today (Lehna, 2005). Federal information can cause acute distress. They may also
and state laws now mandate that health care organiza- not understand medical language and interpret the
tions, which receive federal funding, furnish interpret- communication incorrectly.
ers for non–English-speaking patients (Lehna, 2005). Scenarios that pose ethical dilemmas specifically
However, numerous ethical and legal problems can related to pediatrics include using a child who speaks
arise if the interpreter is not specially trained in inter- English to interpret for the non–English-speaking
preting health care issues. parent. The child may have to interpret information
There are a number of interpreter services available. related to his or her own illness or health care. The child
It is important to be aware of these services and the often is not able to communicate accurate information
pros and cons of each. It is optimal if providers and because of age and the inability to understand the
other health care personnel speak the language of their medical information being discussed. The child may
patients so that they can speak directly to them during become distressed when given the responsibility to
the health care encounter. However, providers should tell his or her parents health-related bad news. Privacy
be tested for language and cultural competence to en- and confidentiality may be breached and, when
sure accuracy of interpretation. communicating sensitive subjects, the child or parent
Professional interpreters, who are available at the may not be truthful or comfortable revealing informa-
health care facility, usually have been tested for their tion if the child interprets.
language skills and trained in the ethics of interpreting If a patient speaks limited English, the provider or
health information. They have been trained in ethnic other health care personnel may try to communicate
with the patient directly. Obtaining true informed a story during an encounter, providers should pay
consent is impossible in this scenario. Also, infor- close attention, document it, and consider what the
mation that is collected is unlikely to be accurate child’s story might mean in the assessment. The child
or complete, and there is no way to ensure that the can also be asked to tell a story about a subject that
patient has understood any of the communication, in- needs to be explored.
cluding teaching and follow-up instructions (Lehna, Children’s drawings can also have messages that the
2005). This is unethical communication, which puts child is afraid to share or may reveal other information
the patient at risk. about the child (Rollins, 2005). When interviewing a
Recommendations for facilitating communication parent, the provider should make art supplies available
with the non–English-speaking child include the fol- to the child so that he or she can draw. The child should
lowing (Ball & Bindler, 2006): be asked about the drawing. When trying to get infor-
• Providers should assess the patient’s language skills mation about a specific topic, the provider can ask the
and the need for an interpreter; if possible, the same child to draw something on a related topic; for exam-
interpreter should be used for each encounter. ple, children can be asked to draw their family or their
• Providers should use a picture board that depicts friends at school. Many pediatric hospitals have art ther-
basic needs, such as bathroom, food, and pain with apists on staff who work with children. They specialize
pictures and words in both English and the child’s in this area and can add to the child’s assessment.
primary language. Sentence completion is a game that can make ob-
• Providers should learn common words in the child’s taining information easier. Providers can tell the child
language to foster trust-building with the child. that they are going to play a game where the provider
• Providers should use a normal tone of voice and starts a sentence and the child finishes it. It is impor-
pitch when communicating with a child. tant to start with questions that help to obtain need-
ed information, For example: “The things I like most
about my family are (...........),” where the child fills in
Communicating Through Play the blank. Pros and cons involves telling children to
Play is considered one of the most important forms relate five things that they like or dislike about certain
of communication techniques to use with children subjects, such as the hospital, their family, their illness,
(Hockenberry & Barrera, 2007). Important assessments or being in 5th grade.
can be made through play, and it also provides a safe
and familiar environment in which the child can
communicate. Using multisensory techniques when Blocks to Communication
talking with children helps to decrease the time needed Barriers to communication in pediatrics include the
to communicate detailed and complex information use of medical terminology, provider gender, the
that is often exchanged in a health care visit and ease child’s health status, and the attitude of the health
their anxiety about this encounter (Cheek, 2006). care provider (Ball & Bindler, 2006). Use of medical
In infant play, mostly nonverbal stimuli such as terminology instead of familiar terms can confuse the
paralanguage, color, and sound are used to capture child and the parents, who may be embarrassed to ask
the infant’s attention. With older infants, making for clarification (Ball & Bindler, 2006). Gender may
eye contact, playing peek-a-boo, and then moving to play a role in blocking communication if the child
touch with pat-a-cake builds trust and allows a smooth attaches the nurturing role or a negative experience
transition in which to start the exam (Hockenberry & to one or the other gender. A child may then react
Barrera, 2007). Puppets can be used with small children negatively to a provider with the same gender as
to demonstrate what the provider plans to do in the a person with whom the child had a negative past
exam. Dolls can be used to show children how to use an experience, despite the provider’s best efforts at age-
inhaler or demonstrate other procedures that can help to appropriate communication (Ball & Bindler, 2006).
ease a child’s anxiety. Allowing older children to touch During a child’s illness, parents often experience a
the provider’s instruments (e.g., stethoscope) or have high level of stress, which may lead to ineffective com-
them listen to the provider’s heart can make children munication. Parents may be unable to communicate
more comfortable by building familiarity with these or process even the most basic instructions during a
objects. Periodically using these techniques throughout child’s illness (Ball & Bindler, 2006). Finally, health
the examination helps to keep children engaged. care providers who appear apathetic and uncaring
Other play techniques that can be used include instead of caring and empathic can block communi-
storytelling, drawing, and sentence completion. Play cation. Patients and families can detect this through
techniques are used when trying to obtain informa- verbal and nonverbal cues and will not be open to
tion from the child. Children often use stories about communication if they feel the provider does not care
imaginary friends or pets to express what they are afraid or is not interested. Other blocks to communication
to reveal (Howard, 2002). If a child spontaneously tells are listed in Table 3-2.
TABLE 3-2
Blocks to Effective Communication in the Health Care Setting
COMMUNICATION BLOCK EXAMPLE
Providing false reassurance “I would not worry. I am sure the lymph node biopsy will be normal.”
Giving unwanted advice “If it were my daughter, I would want her to take the medication.”
Inappropriate use of authority “I really think you should to try my suggestion because I am the health care provider,
and I know what is best.”
Asking leading questions “You don’t drink beer, do you?”
Asking questions that imply blame “Why did you wait so long to bring her to the clinic?”
TODDLERS
AGE AND DEVELOPMENTAL
Toddlers communicate with one- and two-word senten-
CONSIDERATIONS ces. They also use nonverbal language, such as pointing
or pushing the provider’s hand away when being exam-
Effective communication with children requires an ined; they use positive and negative facial expressions
understanding of age and developmental differences. and body movements (Magellan Health Services, 2007).
Communicating with the child so that he or she can Toddlers are in the age group that is least likely to
relate to the topic allows for a comprehensive and respond to friendly efforts by providers to interact with
positive visit and limits the time needed in the visit. them. This is the most challenging age group to ap-
Developmental considerations and recommendations proach (Hagan, Shaw, & Duncan, 2008). Toddlers may
for communication with each age group are discussed cry loudly during an examination as a way of expressing
below (see Table 3-3 for a summary of developmental fear or displeasure at being examined. They respond to
stages and communication). communication directed at them, since they see things
only from their own point of view. Effective communi-
cation with toddlers includes prompt responses to their
INFANTS efforts to communicate. Also, when toddlers speak in
Infants, newborn to 12 months, communicate with one- or two-word sentences, providers should build on
and respond to nonverbal communication. Infants these words to form a complete sentence to acknowl-
coo, grunt, and cry as well as use facial expressions and edge that they understand and to help them build their
body movements to communicate. vocabulary (Hockenberry & Barrera, 2007). Toddlers
Techniques to communicate with infants include should be given concrete, concise directions and only
smiling, picking them up, cuddling, and using a soft one direction at a time. Providers must always warn
soothing voice, especially when trying to calm an agi- toddlers before making a transition in the health care
tated infant (Hockenberry & Barrera, 2007). Using a encounter, especially while examining the child.
high-pitched voice with exaggerated facial expressions
and wide eyes can hold an infant’s attention during
the interview or exam (Magellan Health Services, PRESCHOOLERS
2007). When interacting with infants, the provider Preschool children can speak in full sentences. Provid-
should hold them close and keep close eye contact ers can engage them in conversation about favorite
while talking or singing to them. Infants like looking colors and toys (Hagan, Shaw, & Duncan, 2008). Pre-
at adult faces, and this technique can also keep them schoolers are concrete thinkers with many fears. Magi-
engaged during the health care encounter (Magellan cal thinking plays a major role in how they interpret
Health Services, 2007). what is said to them. They interpret words literally, so
Older infants are generally focused on themselves it is important to communicate effectively with this age
and their parents and experience anxiety when around group and avoid abstractions so these children are not
strangers. Ensuring infants are in direct sight of their unduly stressed. For example the phrase “coughing your
parents or allowing the parent to hold the child dur- head off” could be taken literally and make the child
ing a health care encounter alleviates some of the anx- afraid to cough (Hockenberry & Barrera, 2007). Reassur-
iety and fear the child may be feeling (Hockenberry & ing phrases such as “you are not sick now” may com-
Barrera, 2007). fort preschoolers as they begin to understand concrete
TABLE 3-3
Developmental Considerations When Communicating With Children
Young Infant Smile, use exaggerated facial expressions and an animated high-pitched tone to hold the infant’s
attention and create a positive mood.
Pick infants up and cuddle them.
Use a soothing voice to calm infants.
Hold, rock, and pat infants to comfort them.
Use a quiet, calm voice.
Note a parents’ interpretation of the infants’ nonverbal communication.
Older Infant Establish rapport with parents as well as infants; infants can sense tension and will cry.
The parents should be in the infants’ direct line of vision to minimize stranger anxiety, which peaks at 7
to 8 months.
Allow the parents to hold their children during the visit and during the exam.
Make sure older infants have security objects nearby for comfort.
Toddler Toddlers like to have their parents or a security object nearby during the physical examination.
Respond promptly to their attempts to communicate with you.
Toddlers are the most difficult age group with which to communicate so be creative by using dolls, toys,
or puppets.
If possible, allow toddlers to touch the medical equipment before the physical examination to decrease
fear and anxiety.
Build on their one- or two-word sentences to form a complete sentence so they know you understand
them, and help them build their vocabulary.
Give concise directions and only one direction at a time.
Preschoolers Preschoolers may also like to have a parent or a security object nearby during the physical examination.
Include preschoolers in the encounter by speaking to them and asking them basic questions.
Answer questions with simple, short, concrete explanations.
Preschoolers may also want to handle equipment to lessen fear.
School-aged Include school-aged children in the health care encounter by asking them basic questions and speaking
Children directly to them.
Ask about friends, school, and sports.
Explain procedures and medications in terms that they can understand, and allow them to ask questions.
Use open-ended questions to encourage them to talk.
Adolescent Offer choices to adolescents when possible.

Ask about their favorite music group, friends, and interests.
Listen more than you talk.
Use nonjudgmental listening and responses.
Do not use popular jargon when speaking with adolescents.
Allow private time during the visit without the parent present.
Explain parts of the physical examination and reasons for asking sensitive questions.
Encourage questions.
topics about their health (Hagan, Shaw, & Duncan, related to health promotion allows them to feel a sense
2008). Simple sentences should be used with words that of responsibility for their own health (Hagan, Shaw,
preschoolers will understand. & Duncan, 2008). School-aged children have a basic
understanding of the body and a greater ability to un-
derstand hospitalization and illness than younger chil-
SCHOOL-AGED CHILDREN dren (Ball & Bindler, 2006). They are able to answer
Health information can be retrieved and dispensed direct questions, especially during a sick visit, and take
more easily with the school-aged child (Hagan, Shaw, part in the decision-making process (Hagan, Shaw, &
& Duncan, 2008). Direct conversation with children Duncan, 2008; Ball & Bindler, 2006).
Techniques for communicating with school-aged

children include the following: SUMMARY
• Providers must build rapport with school-aged chil-
Nonjudgmental listening encourages open and hon-
dren, speaking to them directly and allowing them
est communication. Communication in the pediatric
to answer simple questions about their friends,
setting is a dynamic process. Quality communication
school, their favorite subject, clothing, or vacations,
skills take time to develop as a beginning practitio-
for example.
ner, especially in the pediatric setting where there
• Providers must give school-aged children explana-
are many special considerations. Being knowledge-
tions about procedures, diagnoses, medications,
able about pediatric-specific communication tech-
or tests in terms that they can understand. Pro-
niques and developmental considerations leads to
viders must also encourage these children to ask
successful communication encounters with the pe-
questions.
diatric population and their families. Being aware of
• Providers must encourage an open dialogue with the
family dynamics, encouraging parent involvement,
child. For difficult subjects, the following comment and
and always including the child in the health care
question can be used: “Many children your age have
encounter are essential. Having an understanding
questions about (..........); do you have any questions or
of these basic elements and regularly using them in
concerns about this topic?” This allows children to feel
practice are keys to successful communication in the
comfortable talking about a difficult subject.
pediatric setting.
ADOLESCENTS
The health care provider should always speak directly to REFERENCES
adolescents during the health care encounter. Adoles- Ball, J. W., & Bindler, R. C. (2006). Child health nursing. Upper
cents are generally more aware of and concerned about Saddle River, NJ: Pearson Education, Inc.
Beck, R. S., Daughtridge, R., & Sloane, P. D. (2002). Physician-
their bodies. They want to be responsible for their health patient communication in the primary care office: a system-
care needs, and they want to be recognized as adults but atic review. Journal of the American Board of Family Practice, 15,
at the same time feel misunderstood by adults (Hagan, 25–38.
Cheek, B. (2006). Communication with children. Retrieved
Shaw, & Duncan, 2008). Providers must prepare par- October 24, 2009, from http://www.gp-training.net/training/
ents and adolescents before the visit so that they both communication_skills/consultation/children.htm.
know what to expect. Sensitive parts of the health care Cohen, L. (2003). Communication secret: the art of listening.
Retrieved October 24, 2009, from http://www.solo-e.com/
interview with adolescents should always be conduct- library/articles/personal-development/interpersonal-skills/
ed without the parent present. Laws vary from state to communication-secret-the-art-of-listening-321.shtml.
state regarding topics that can be kept confidential from Dunn, A. (2009). Health perception and health management patterns.
In: Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., & Blosser,
the parent (Ball and Bindler, 2006). Adolescents often C. G. (Eds.). Pediatric primary care: A handbook for nurse practitioners.
begin to have sexual encounters and experiment with (4th ed.). (pp. 168–190). Philadelphia: W. B. Saunders.
drugs and alcohol, but they are unlikely to admit to this Ekman, P., & Friesan, W. (1975). Unmasking the face: A guide
recognizing emotions from facial clues. Englewood Cliffs, NJ:
when their parents are present. Topics about sexual be- Prentice Hall.
havior and drug and alcohol use should be discussed Hagan, J. F., Shaw, J. S., & Duncan, P. M. (Eds). (2008). Bright
in private if state law allows confidentiality from the futures: Guidelines for health supervision of infants, children and
adolescents. (3rd ed.). Elk Grove Village, IL: American Academy
parent. Providers must clarify with parents and children of Pediatrics.
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ity limitations before discussing these topics. Henman, L. (2004). It’s not always what you say. Retrieved
October 24, 2009, from http://relationships911.org/experts/
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include the following (Ball & Bindler, 2006): Hockenberry, M. J., & Barrera, P. (2007). Communication and
physical and developmental assessment of the child. In
• Providers must establish trust and rapport. Hockenberry, M. J., & Wilson, D. Wong’s nursing care of infants
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Jellinek, M., Patel, B. P., & Froehle, M. C. (Eds.). Bright fu-
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CHAPTER
Cultural Assessment
4 of Children and
Families ELLEN M. CHIOCCA
INTRODUCTION build a trusting, caring, parent–child–provider relation-

ship. A person’s culture guides every action one makes.
Immigration trends continue to make the United Culture determines how one perceives health and ill-
States culturally and linguistically diverse. In 2008, the ness, approaches health care, and establishes what a
U.S. population consisted of approximately 66% non- person is willing to accept as health care treatment.
Hispanic whites; slightly more than 15% Hispanics/ Similarly, health care providers view the world through
Latino; 13.5% African Americans; and 5.1% Asians and the lens of their own culture; thus, care must be taken
Pacific Islanders (U.S. Department of Health and Human so that providers do not impose their beliefs on others.
Services [USDHHS] Office of Minority Health, 2009). Several related concepts are defined in Table 4-2.
According to projections by the U.S. Census Bureau,
minorities, now approximately one third of the U.S. CHARACTERISTICS OF CULTURE,
population, will become the majority in 2042, and com-
RACE, AND ETHNICITY
prise approximately 54% of the U.S. population by 2050.
By 2023, more than half of all American children will be The terms culture, race, and ethnicity are often used in-
minorities (U.S. Census Bureau, 2009). Since the early terchangeably. However, they all mean very different
1990s, immigration to the United States has been at its things.
highest rate since the early 20th century (1901–1910),
with approximately 1 million people arriving per year. Culture
The largest number of immigrants came from Spanish- Culture is universal, as no people on earth exist with-
speaking countries (41%); 32% arrived from Asian coun- out culture. Culture is:
tries, 18% from Europe and Canada, and 9% from other • Learned: A child learns culture through the process
countries (Martin, 2008). This does not include the large of socialization. The first place this begins is within
number of illegal immigrants in the United States; most the family. Parents and extended family members
of these immigrants are believed to be from Mexico teach a child language, social norms, beliefs, values,
(Martin, 2008). Pediatric health care providers must be and appropriate behavior. This process continues at
aware of these demographic trends and be culturally school and is influenced by peers, the community,
competent to deliver the safest, highest quality care pos- subcultural affiliations (e.g., religion, socioeconom-
sible to children of widely differing groups. ic groups), and the media. Recent immigrants also
learn the rules of a new culture, but transitioning to
a new culture is not always smooth because of lan-
CULTURE guage barriers and experiences of grief and loss.
• Shared: Members of a culture share the social norms,
DEFINITION OF CULTURE beliefs, values, symbols, and language to form a cul-
tural group.
While no universal definition of culture exists, several
• Integrated: Throughout a person’s life, culture influ-
nurse theorists have defined culture; these definitions
ences his or her every action, including health be-
are presented in Table 4-1. Becoming familiar with a
liefs, practices, and behaviors.
particular child’s and family’s culture and incorporating
• Dynamic and ever-changing: Culture allows people
this understanding into the health care visit helps to
to adapt to changes in society and the environment.
56
C H A P T E R 4 Cultural A s s e s s m e n t o f Ch ildre n and F amilies • 57
TABLE 4-1
Definitions of Culture
THEORIST DEFINITION
Giger & Davidhizar (2008) A patterned behavioral response that develops over time through the imprinting of social
and religious structures and intellectual and artistic manifestations. It is shaped by values,
beliefs, norms, and practices that are shared by the same cultural group
Leininger (2001) The learned, shared, and transmitted values, beliefs, norms, and lifeways of a particular
group
Purnell & Paulanka (2008) “The totality of socially transmitted behavioral patterns, arts, beliefs, values, customs,
lifeways, and all other products of human work and thought characteristic of a population
or people that guide their worldview and decision making” (p. 5)
Spector (2009) The non-physical traits such as values, beliefs, practices, habits, attitudes, and customs that
are shared by a group of people and passed from one generation to the next
TABLE 4-2
Definitions of Culture-related Terms
TERM DEFINITION
Acculturation Changing one’s own culture to adapt to the new or dominant culture (Bhugra & Ayonrinde, 2004);
values of the original culture are usually retained in some form
Assimilation Adopting and incorporating traits and aspects of a new culture into one’s own cultural practices
(Spector, 2009)
Bicultural Facility in two or more cultures, including the language, norms, and lifeways of each culture
(Dunn, 2009)
Cultural bias A preference for one’s own cultural values and beliefs
Cultural “[An] awareness of self and one’s own value system; an understanding of the concept of culture
competence and its role as a factor in health and health care; a sensitivity to cultural issues for each patient;
an understanding and ability to use specific methods to deal effectively with cultural issues in
interacting with individual patients, their families, members of the health care team, and the
wider community” (University of Michigan Health System Program for Multicultural Health
[UMHSPMH], 2009)
Culture shock Anxiety, disorientation, confusion, and possible depression felt when a person is placed in a new
and unfamiliar culture (Bhugra & Ayonrinde, 2004)
Ethnicity Identity with a particular group with common characteristics such as language, ancestry, race,
national origin, religion, or kin ties (UMHSPMH, 2009)
Ethnocentrism The belief in the superiority of one’s own racial or ethnic group and culture (Ball & Bindler, 2006);
presents a barrier to delivering culturally sensitive health care
Immigrant Persons who are foreign born and are admitted to the United States as permanent residents to live
and work (Ball & Bindler, 2006)
Lifeways Way of life, custom, and practices of a cultural group (Srivastava, 2007)
Minority A group (e.g., ethnic, religious, racial) that makes up a number that is less than the numerical
majority of the population (Giger & Davidhizar, 2008d)
Multiculturalism An ideology that advocates that society consists of diverse cultural and religious groups and these
groups integrate into society while keeping their identities, taking pride in their heritage and
having a sense of belonging. Multiculturalism “encourages racial and ethnic harmony, cross-cultural
understanding, and discourages ghettoization, hatred, discrimination and violence” (Department of
Canadian Heritage, 2009)
(continued)
TABLE 4-2
Definitions of Culture-related Terms (Continued)
TERM DEFINITION
Norms Learned behaviors within a cultural group that are determined by the cultural values held by that group
Prejudice A negative and often demeaning stereotype applied to all individuals of a certain group (Ball &
Bindler, 2006)
Race A biologic term classifying people who share the same genetically inherited distinguishing physical
characteristics (e.g., skin; hair type, color or texture; bone structure) (UMHSPMH, 2009)
Racism The belief that one racial group is inherently superior or inferior to another, based on genetically
inherited physical characteristics (UMHSPMH, 2009)
Refugee A person who leaves his or her country of birth because of fear of persecution based on race,
religion, nationality, social group membership, or political opinion (U.S. Citizenship and
Immigration Services, 2009)
Stereotype The assumption that all persons belonging to a particular group share the same characteristics
Subculture A smaller cultural group within a larger cultural group
Taboo A strong cultural prohibition against words, actions, or behavior that are considered offensive to the
cultural group
Values Beliefs, attitudes, behaviors, and rules by which peoples’ lives are governed (Giger & Davidhizar,
2008d)
Worldview “A way in which an individual or group looks out on and understands their world about them as a
value, stance, picture, or perspective about life or the world” (Leininger, 2002, p. 83)
Race TABLE 4-3

Race refers to the biologic classification of people who Health Conditions Related
share the same genetically inherited distinguishing to Biologic Variations among
physical characteristics such as skin color; hair type, Cultural Groups
color, or texture; and bone structure. For many years
in the United States, race has influenced the develop- RACIAL GROUP HEALTH ISSUE
ment of social systems and social status, which has re-
African/African American Diabetes
sulted in the unequal treatment of persons belonging Lactose intolerance
to particular groups (Tashiro, 2005). The social systems Sickle cell disease
that have existed based on race have led to disparities
in the health status of people of diverse racial and eth- Asian/Asian American Cleft lip and palate
Lactose intolerance
nic backgrounds (National Center for Cultural Com-
petence [NCCC], 2009; Tashiro, 2005). The health care Caucasian/European Celiac disease
provider must work to ensure that care is delivered ancestry Crohn’s disease
fairly and equally to all people. Biologic variations also Cystic fibrosis
occur among racial groups and can affect the incidence Thalassemia
(Mediterranean origin)
of some diseases and conditions. Examples of some of
these conditions are listed in Table 4-3. Hispanic/Latino Diabetes
Lactose intolerance
Ethnicity Native American/ Alcoholism

Alaskan Native Diabetes
Ethnicity is a term that is often used erroneously to de- Otitis media
scribe race. Whereas race describes biologic identifica-
tion, ethnicity refers to a cultural group’s identification
Source: Ball, J. W., & Bindler, R. C. (2006). Cultural
associated with their common geographical origin, influences. In Ball, J. W., & Bindler, R. C. (Eds.). Child health
language, religion, traditions, values, music, food, and nursing: Partnering with children and families. Saddle River,
other cultural ties (Anderson & McFarlane, 2007). NJ: Prentice Hall.
POVERTY AS A CULTURE mortality rates experienced by minority racial and eth-

Anthropologist Oscar Lewis (1959) coined the phrase, nic groups as compared to the dominant group (USD-
“culture of poverty,” in his book, Five Families: Mexi- HHS, 2000). These disparities are primarily a result of
can Case Studies in the Culture of Poverty. He described decreased access and barriers to health care services.
how the lives of the people he studied were adversely Barriers to health care for minority children include
changed by poverty. In his later work, Lewis also found poverty, lack of health insurance, low level of educa-
that people living in poverty have strong feelings of tion, language barriers for families that do not speak
dependency, marginality, helplessness, and power- English, and provider knowledge deficits about cultur-
lessness; they lack a sense of belonging and possess ally appropriate care (Kataoka-Yahiro & Munet-Vilaro,
strong feelings of inferiority. For people of color, these 2002). Other reasons include lack of transportation and
feelings are exacerbated by racism (Lewis, 1998). Pov- the geographic location of the health care services. En-
erty is also a major contributing factor to the health vironmental factors also play a role. For example, fami-
disparities that exist among certain segments of the lies that live in urban areas may be more vulnerable to
population. For example, in 2005, approximately 8% health or safety hazards such as lead-based paint in old,
of non-Hispanic white families lived below the pov- urban dwellings.
erty level, contrasted with approximately 25% of Afri- The IOM (Smedley, Stith, & Nelson, 2003, p. 3) de-
can Americans and 22% of Hispanics (DeNavas-Walt, fines health care disparities “as racial or ethnic differ-
Proctor, & Smith, 2008). ences in the quality of health care that are not due
The importance of recognizing poverty as a culture is to access-related factors or clinical needs, preferenc-
driven home by the impact that poverty has on a child’s es, and appropriateness of intervention.” Causes of
health. Poverty is one of the main reasons that some health care disparities include provider racism, bias,
children and families are unable to access health care. and discrimination, and patient factors such as mis-
Lack of money, transportation, or insurance; language trust of the health care system and refusal of treatment
barriers, racial bias in health care, culturally insensitive (Baldwin, 2003). Health and health care disparities are
care, parental stress, and knowledge deficits about the inextricably linked; cultural competence on the part
importance of preventive health care all contribute to of the health care provider is necessary to minimize
high rates of illness and injury in poor children (Katao- and ultimately eliminate any differences in quality of
ka-Yahiro & Munet-Vilaro, 2002; USDHHS, 2000). health care.
Poor children of any race or ethnicity are also more
likely to be developmentally delayed, drop out of DEVELOPING CULTURAL
school, and give birth during adolescence (Pearson,
COMPETENCE
2003). It is important for the provider to be mindful
of race, ethnicity, gender, and socioeconomic status as To decrease racial and ethnic disparities in health care,
they affect the health of children, and how these fac- cultural competence is essential for the health care
tors can influence adult health status (American Acad- provider who works with diverse populations. This
emy of Pediatrics [AAP], 2006). A major goal of Healthy can begin with the provider ensuring that the health
People 2010 is to eliminate health disparities among care being provided is culturally appropriate for the
these segments of the population (USDHHS, 2000). specific child and family. Characteristics of culturally
competent care include being able to identify and ap-
preciate differences between cultures, having empa-
thy and tolerance for different views, and having the
knowledge of shared human experiences despite vary-
CULTURAL COMPETENCE ing backgrounds.
Cultural competence is the ability to understand and
HEALTH AND HEALTH CARE effectively respond to the cultural needs of the child and
DISPARITIES family and to demonstrate skill in interacting with those
Recent reports by the Institute of Medicine (IOM) and outside one’s own culture (Spector, 2009; Dunn, 2002).
USDHHS have highlighted racial and ethnic dispari- Subsumed within the concept of cultural competence
ties in health and health care (DeNavas-Walt, Proc- is “cultural sensitivity”; one cannot be culturally com-
tor, & Smith, 2008; Thompson, Mitchell, & Williams, petent without being sensitive to cultural differences
2006). Health and health care disparities exist not only (Dunn, 2002). To develop cultural competence, the pro-
among racial and ethnic minorities but also among vider should begin by examining his or her own values,
other vulnerable populations, such as the poor. These biases, beliefs, prejudices, and stereotypes. The NCCC
disparities are reflected in the higher morbidity and (2009a) has developed a self-assessment tool for health
mortality rates in these groups (Centers for Disease care providers to determine their cultural competence
Control and Prevention [CDC], 2009). Health dispari- (see Additional Resources at the end of the chapter).
ties are defined as increased disease morbidity and Cultural competence also includes the knowledge that
even though the provider’s values and beliefs may dif- • Developing health care goals that are mutually
fer from those of the patient, he or she must accept the acceptable to the client and health care provider:
child and family as the expert on what is right for them. This is not the same thing as getting the child and fam-
The development of cultural competence is an ongoing ily to adhere to the goals and treatment plan set forth
process that is not necessarily sequential. Dunn (2002) by the provider. Cultural beliefs about health and ill-
discussed six elements that demonstrate cultural com- ness may necessitate the use of a “cultural broker” (see
petence in the health care provider: Culture Shock below) to agree on the plan of care.
• Altering one’s worldview: This can be accomplished • Becoming familiar with the core issues of a
by becoming aware of any personal tendencies to- particular culture: This includes having knowledge
ward ethnocentrism, bias, or racism and rejecting regarding beliefs about cultural patterns of communi-
those tendencies, and at the same time, rejecting any cation, including eye contact, personal space, touch,
institutional support of racism or discrimination. and time; family relationships, male and female roles,
• Increasing knowledge about the cultural groups child-rearing practices, who makes the health care
with which the provider regularly works: This can decisions in the family; and beliefs about modesty.
be accomplished by attending cultural events in the Campinha-Bacote (2003) developed the ASKED model
ethnic community, traveling to the countries from for cultural competence. This model views the health care
which clients hail, and reading books about the his- provider as continually striving to become culturally com-
tory of the clients’ countries of origin. Learning to petent by increasing knowledge in the following ways:
speak the language that clients speak is ideal as well,
• Cultural Awareness: This is the first step in achiev-
either by taking formal courses or through immer-
ing cultural competence. This is a process wherein
sion experiences in a foreign country.
health care providers consciously examine their own
• Developing a trusting client–provider relation-
cultural background as well as any biases, beliefs,
ship: This involves making sure that the health care
values, assumptions, and prejudices toward different
provider ensures a welcoming physical environment,
cultural groups.
one in which the child and family feel comfortable
• Cultural Skill: Cultural skill is the ability to gather
and safe. Ways to achieve this include (a) speak-
assessment data in a culturally sensitive, nonjudg-
ing the child’s and family’s language or employing
mental manner.
a bilingual–bicultural staff, (b) displaying pictures,
• Cultural Knowledge: Cultural knowledge is the pro-
posters, or artwork that reflect the cultures and eth-
cess of seeking knowledge of other cultural groups,
nic backgrounds of clients with whom the provider
their worldviews, beliefs, values, biologic variations,
works, and (c) ensuring that magazines, brochures,
language, and perceptions about health and illness.
or printed teaching materials in reception areas or
• Cultural Encounters: This encompasses the number
the clinic room are of interest to and reflect the dif-
of face-to-face encounters with people of various cul-
ferent cultures of children and families served in the
tures to increase cultural competence and decrease
provider’s practice. These materials should also be
stereotyping. Trained medical interpreters should be
written in the clients’ language and at the appropri-
used as necessary.
ate literacy level for the group served.
• Cultural Desire: Cultural desire involves the true
• Becoming familiar with the cultural beliefs about
and sincere motivation on the part of health care
health and illness for a particular group: The pro-
providers to become culturally competent.
vider could start by asking the child or parent what
he or she thinks causes illness and what he or she be- Many excellent resources that are listed at the end
lieves a person should do to stay well. When asking of the chapter can help the health care providers to
a child or parent to explain what an illness means, develop cultural competence.
Johnson and coworkers (1995) suggest asking the
following questions:
• What do you call the problem? CROSS-CULTURAL
• What caused it? COMMUNICATION
• Why did it start?
• What does the illness do to make one ill? Communication is the way in which people share
• How serious is it? information; this information is transmitted both
• What do you expect will happen as a result of this verbally and nonverbally. Cultural differences in com-
illness? munication can be a major influence on the quality of
• How should it be treated? care. Effective cross-cultural communication involves
• What are the main problems that this illness has respect, tolerance, patience, and flexibility. Nonver-
caused? bal communication, such as eye contact and body
• About what are you most afraid with this illness? language, is important, but spoken language barriers
have been shown to have a major effect on health considered; setting goals and planning ahead is rare
care (AAP, 2008). Providers should always strive to (Pearson, 2003). Americans of European ancestry focus
ask clear, culturally appropriate questions, involve ex- more on the future; they are interested in preventive
tended family members in the discussion if requested, medicine and value new medical procedures and drugs
and alter nonverbal communication patterns as need- (Giger & Davidhizar, 2008a).
ed to maintain cultural sensitivity. Accurate, effective Another type of time orientation sees past, present,
communication is essential to elicit an accurate, com- and future as less well defined and more fluid, and
prehensive health history, make accurate diagnoses, the future as less important than the present (Dunn,
and develop health care goals that are acceptable to 2009). For people for whom this time perspective ap-
the family and child. plies, there is no such thing as early or late, so mak-
The Office of Minority Health of the USDHHS ing an appointment for a clinic visit may be difficult.
has developed national standards for effective cross- People from Vietnam (Stauffer, 2008) and some Native
cultural communication in health care (see Additional American cultures value this time perspective (Giger &
Resources at the end of the chapter). Davidhizar, 2008a).
Spatial Distance
NONVERBAL COMMUNICATION The concept of spatial distance or “personal space” is
In addition to language differences, cultural differenc- the amount of physical space between people that is
es regarding nonverbal communication can also create considered an appropriate distance. The distance de-
communication barriers between a child and family pends on the age, gender, social status, social situa-
and the health care provider. Nonverbal communi- tion, and culture of the people involved (Dunn, 2009).
cation differences include eye contact, perception of For example, Hispanic/Latino people normally stand
time, spatial distance, and touch. close to a person when speaking, whereas Americans
of European ancestry prefer more physical space.
Eye Contact
Providers must be aware of the appropriateness of eye Touch
contact when dealing with children and families of var- People use touch as one form of communication. In
ious cultures. For some, maintaining eye contact when some instances, touch can convey closeness and help
speaking is a sign of respect and establishes trust. Af- establish trust and rapport. However, health care provid-
rican Americans and Americans of European ancestry ers must be cognizant of the cultural norms for touch
use direct eye contact when speaking. For others, direct within the specific group with which they are work-
eye contact is avoided and may even be viewed as dis- ing. Before touching the child or adolescent, providers
respectful. Many Native American people are uncom- should always explain what they will be doing to the
fortable with prolonged eye contact (Ball & Bindler, child and the reason for touching. In some instances,
2006), as are Chinese people and Koreans (University touch may even be culturally prohibited. For example,
of Washington Medical Center [UWMC], 2009). when working with an adolescent female Muslim, male
providers are prohibited from touching or examining
Time her, particularly for a pelvic examination (UWMC, 2009).
The concept of time is viewed in some cultures as Vietnamese people consider the head sacred; thus, the
something measurable and is defined as past, pres- provider should avoid touching a child’s head whenever
ent, or future. Some people place more emphasis on possible. If the head needs to be examined, the provider
one type of time orientation. For example, some cul- should also touch the opposite side of the head or shoul-
tures emphasize the past by stressing the importance der to make the child feel protected (UWMC, 2009).
of tradition and the influence of ancestors. Afghans
(Lipson, Iqbal, & Omidian, 2008), Filipinos (Vance,
2008), and Chinese people tend to focus on the past
VERBAL COMMUNICATION
(Giger & Davidhizar, 2008a). Persons who focus on Language
the past may pray to ancestors during illness or other Verbal communication involves both spoken and writ-
times of crisis. Mexicans, Mexican Americans (Gonza- ten language. With spoken language, dialects may dif-
lez, Owen, & Esperat, 2008), and Navajo Indians are fer vastly even among persons from the same culture
primarily oriented to the present (Hanley, 2008). This who speak the same language. Some people may speak
may result in the child or parent being less inclined to a language but not read it well, and vice versa. It is vi-
take preventive measures to treat illness, especially if tally important for providers to ascertain whether they
the child feels well currently or the treatment causes can effectively communicate with the parents or child
undesired side effects. For those living in poverty, time in the same language. In the event that health care pro-
also occurs in the present, and the future is seldom viders speak a language that differs from that of the
parents or child, providers should make every effort group is patriarchal or matriarchal, and who is the head
to secure a trained interpreter to be present during the of the household. The head of the household may be
visit. Children should not be used to interpret during the person to whom the family looks to make impor-
the health care encounter; in some cultures, this role tant decisions for the family, and this may impact treat-
reversal presents an inappropriate situation in addition ment decision-making. Providers should also identify
to issues of confidentiality (see Chapter 6). The AAP behavioral expectations of children for a particular cul-
(2008) has also issued a policy statement opposing the tural group; determine whether children are respected
use of children and adolescents as medical interpret- within the family, and determine whether corporal
ers for family members. When using an interpreter, the punishment is considered acceptable. Often, children
provider should also always remember to speak directly and families who are new to a country experience great
to the child and parents and not to the interpreter. stress because of extra responsibilities, learning a new
language, finding new friends, and fitting in at school.
Tone, Pitch, and Cadence For many refugee families from traditional cultures, the
To provide culturally competent care, health care provid- power balance can shift because of role reversal when
ers should be aware of the cultural differences regarding an adolescent is forced to become the breadwinner, in-
whom to address during the health care encounter and terpreter, or cultural liaison. Some children and ado-
how to address them in terms of tone, pitch, cadence, lescents are forced to switch back and forth between
vocabulary, and the use of silence (Giger & Davidhizar, cultures, adopting American values at school and the
2008b). A child’s parent should always be addressed as values of the family’s culture at home. Peers may tease
“Mr.,” “Mrs.,” or “Ms.”; if they have a title such as “Doc- or taunt the immigrant child about his or her cultur-
tor,” that title should be used. In some Asian cultures al background or about speaking with an accent. The
(e.g., Chinese, Korean, Cambodian, Filipino), the family child may feel pressure to reject the traditional culture
surname is first and then the child’s given name. Asian and adopt the values of the new culture. This can cause
clients may speak in a softer tone of voice and more great stress for children who are less resilient, resulting
slowly than health care providers; clients may perceive in somatic complaints such as headaches or stomach-
providers as loud, especially if providers are deliberately aches, difficulties with schoolwork, anxiety, depression,
speaking loudly when they cannot hear the child or par- and stress-related illnesses. Chapter 5 discusses family
ent or if a language barrier exists (Giger & Davidhizar, assessment in further detail.
2008b). Afghan women speak loudly; Western health
care providers may interpret this as speaking at a high
CHILD-REARING PRACTICES
volume. Afghan men speak more softly (Lipson, Iqbal, &
Omidian, 2008). When speaking to children and families, Providers must be mindful during health assessments
the provider should always keep the child’s and parent’s that child-rearing practices can differ among cultures.
language abilities and level of education in mind; some What one cultural group considers acceptable in child-
simple words also have very different meanings and con- rearing may not be so in another group. Providers must
notations, depending on the culture (Giger & Davidhizar, also avoid making value judgments, while at the same
2008b). The meaning of silence differs among cultures as time assessing for any practices that may be harmful or
well; some view silence as very uncomfortable and will abusive to the child. Specific areas of assessment on which
try to talk to fill the gap; others such as American Indi- to focus include nutrition, toilet training, discipline prac-
ans, and traditional Chinese and Japanese, prefer silence tices, sleeping, emphasis on schoolwork, education, reac-
and view it as a time to reflect and understand (Giger & tion to crying, separation anxiety, and interaction with
Davidhizar, 2008b). See Chapter 3 for further discussion authority figures. Examples of some culturally specific
of communication with children and families. child-rearing practices are listed in Table 4-4.
MODESTY
CROSS-CULTURAL DIFFERENCES In some cultures, people are very modest about be-
ing touched or exposing the body without clothing,
FAMILY RELATIONSHIPS especially with health care providers of the opposite
In the process of providing culturally competent care, sex. Providers must be aware of the populations to
health care providers must become familiar with the which this applies and be sensitive and respectful. For
structure and importance of family for the cultural example, Mexican and Mexican American women are
group with which they are working. This includes iden- very modest, experiencing embarrassment and making
tifying the family structure of the particular cultural it challenging for providers to do a pelvic or external
group, including the presence and influence of the ex- genitalia examination (Giger & Davidhizar, 2008c).
tended family, sex roles, kinship ties (including whether Amish and Muslim women show modesty by covering
or not this is limited to blood ties), whether the cultural their hair and arms. When Muslim girls reach puberty,
TABLE 4-4
Selected Cultural Variations in Child-rearing Practices
ETHNIC GROUP CHILD-REARING PRACTICES
African American • There is a strong emphasis on extended family; these family members may be involved
in discipline.
• Scolding and corporal punishment from the matriarch (typical head of household)
is often followed by forgiveness and offering of food; behavioral change is not often
expected because of a strong belief in fate (Pearson, 2003).
• Children are expected to show respect to authority figures.
Arab American • Male children are preferred.

• The father is the disciplinarian.
• Corporal punishment and shaming are used as methods of discipline.
Asian Indian • Male children are preferred.

• Children are more controlled and protected than American children.
• Discipline is done via threats and occasional spanking.
• Independence is not encouraged.
• There is no fixed schedule of activities for young children.
• Education is highly valued.
Cambodian/Laotian • Discipline is done verbally; corporal punishment is rare.

• Elders are respected, including older siblings.
• Infants are carried for a prolonged period of time and thus walk later than
Western children.
• Infants and young children are not allowed to cry.
Chinese • Male children are preferred.

• Elders are respected.
• Toilet training begins early.
• Children are often taught to suppress displays of emotion.
• Academic excellence and achievement are expected.
• Displays of open affection are rare.
Filipino • Children are adored.

• Parenting is very permissive until school-age, then children are disciplined through
negative feedback.
• Obedience and being polite is expected; children often seem shy or quiet.
Japanese • The mother views the infant as an extension of herself.

• Infants cosleep with adults.
• Crying is discouraged in infants.
• Discipline is done by example with occasional light spanking.
• Elders in the family must be respected.
• Toilet training begins before 1 year.
• There is no open expression of emotion.
• There is a permissive discipline style until school-age at which point the child must
learn behavioral control.
• There is a heavy emphasis on academic achievement.
• Neatness and good manners are rewarded in children.
Korean • Male children are preferred.

• Children are highly valued; parents and children have close relationships.
• Birth order determines the child’s status in the family.
• Elders in the family must be respected.
Mexican/Mexican American • Children are closely protected and highly valued.

• Children are kept physically close to the mother during first year of life.
• Children are strongly attached to the mother.
• Corporal punishment is common.
• Godparents are involved in child-rearing.
• Overweight children are viewed as healthy.
(continued)
TABLE 4-4
Selected Cultural Variations in Child-rearing Practices (Continued)
ETHNIC GROUP CHILD-REARING PRACTICES
Navajo Indian • Male children are preferred.
• A child’s name may not be revealed until the first laugh.
• Infants are kept on cradleboards for protection.
• Children are taught to respect the elderly who pass down tradition and wisdom.
• The grandmother often is the family member who is responsible for toilet training and
discipline.
• Older children are often taught to suppress displays of emotion.
Puerto Rican • Children are highly valued; they are seen as gifts from God.
• Children are expected to be compliant.
• The mother has the primary role in childcare.
• Corporal punishment is common.
Vietnamese • Children are highly valued.

• Discipline may include stern talking, slapping, or occasionally beatings.
• Children are expected to be quiet and compliant.
Source: Engel, J. K. (2006). Beginning the assessment. In Engel, J. K. (Ed.). Mosby's pocket guide to pediatric assessment. (5th ed.). St. Louis:
Mosby Elsevier; Giger, J. N., & Davidhizar, R. (2004). Transcultural nursing: Assessment & intervention. (4th ed.). St. Louis: Mosby-Yearbook;
Spector, R. E. (2004). Cultural diversity in health and illness. (6th ed.). Upper Saddle River, NJ: Pearson Prentice Hall.
they can choose to cover their hair with a head scarf is also referred to as Western medicine. Families who
and wear long-sleeved clothing and long skirts. For hold this belief expect providers to recommend or
Muslims, this practice of modesty is called hijab (Giger prescribe specific interventions, such as medications
& Davidhizar, 2008c). Adolescent girls who practice or surgery. Comfort measures such as rest or heat may
hijab need a female health care provider to perform not be as readily accepted, as the family or child may
breast and pelvic examinations. believe that nothing concrete is being done to alleviate
the problem.
HEALTH BELIEFS AND Holistic or Naturalistic Perspective

PRACTICES The holistic or naturalistic health belief posits that a
child’s illness is a result of the disruption in the bal-
When working with families from diverse back- ance of nature. Infection or illness can take hold in
grounds, the provider must be familiar with the child a child’s body when it is not in balance. This belief
and family’s perspective on health and illness, and is common among Native American, First Nation,
whether they use any traditional healing practices. It and some Eastern cultures. Some Asians believe in the
is particularly important for the provider to be familiar yin/yang theory, the belief that during states of good
with various traditional healing practices to ascertain health, balance is maintained in the body. Many His-
which practices are potentially harmful to children panic, Arab, African American, and some Asian groups
(e.g., lead-based therapies) and to avoid misdiagnosing believe the hot/cold theory of health and illness. Accord-
child abuse (e.g., coining, cupping). ing to this theory, certain illnesses are classified as hot
or cold imbalances in the body and can only be cured
by hot or cold remedies, such as consuming a food,
HEALTH BELIEFS beverage, herb, or medicine classified as the opposite
Scientific or Biomedical Theory of the disease, thereby restoring balance within the
body. Examples of some of these illnesses and remedies
There are three major belief systems about the causes
are listed in Table 4-5.
of illness: scientific, holistic, and magico–religious
(Andrews, Boyle, & Carr, 2007). The scientific or bio-
medical theory of health and illness is based on the Magico–Religious Perspective
belief that physiology explains the functioning of the The third major health belief is the magico–religious
human body. Illness is based on viruses, bacteria, en- perspective. This belief holds that health and illness
vironmental exposures, and bodily trauma. This belief are determined by supernatural forces such as God,
TABLE 4-5
Hot and Cold Conditions and Corresponding Treatment
COLD REMEDIES
USED TO TREAT HOT HOT REMEDIES USED TO
HOT CONDITIONS CONDITIONS COLD CONDITIONS TREAT COLD CONDITIONS
Constipation Food Cancer Food
Diarrhea Barley water Headaches Beef
Fever Bottled milk Joint pain Cheese
Infection Chicken Malaria Chili peppers
Kidney problems Dairy products Menstrual period Chocolate
Rashes Dried fruits Otitis media Eggs
Sore throat Fish Pneumonia Goat’s milk
Fresh fruits Stomach pain Grains
Fresh vegetables Teething Liquor
Goat meat Tuberculosis Oils
Honey Upper respiratory infections Onions
Raisins Peas
Medicines and Herbs Medicine and Herbs

Orange flower water Anise
Sage Aspirin
Milk of magnesia Castor oil
Bicarbonate of soda Cinnamon
Cod-liver oil
Garlic
Ginger root
Iron
Tobacco
Penicillin
Vitamins
Source: Purnell, L. D., & Paulanka, B. J. (Eds.). (2008). Transcultural health care: A culturally competent approach. (2nd ed.) Philadelphia: F. A.
Davis; Wilson, H., & Kneisl, C. (1996). Psychiatric nursing. Reading, MA: Addison-Wesley.
gods, voodoo, witchcraft, spirits, or fate (Ball & Bindler, others use traditional or folk healers when their child
2006). One health belief that exemplifies this perspec- is seriously ill or when they have become dissatisfied
tive is the “evil eye” (mal de ojo) in the Hispanic/Latino with scientific or biomedical approaches that have
community. The evil eye is believed to cause harm or been unable to help their child. The type of healer
illness to a child, especially a newborn, by looking at varies according to the culture (Table 4-7). Traditional
the child with envy. A red bracelet made of thread is or folk healers speak the native language of the cul-
worn as an amulet or charm to protect the infant from tural group, make house calls, and cost much less
the evil eye. than practitioners of Western medicine (Roy, Torrez,
& Dale, 2004). Faith healing and religious rituals are
often part of many folk healing practices, and items
FOLK ILLNESSES such as food substances, charms, talismans, amulets,
Folk illnesses or culture-bound syndromes are those that medals, or religious items are often worn to pro-
are culturally defined. These illnesses often do not have tect individuals against disease or evil spirits (Giger
a corresponding illness from a biomedical or scientific & Davidhizar, 2008d; Gonzalez, Owen, & Esperat,
perspective and may not be perceived as an illness or 2008). Some traditional or folk healing practices may
affliction by another cultural group. Many folk illness- be harmful to a child. For example, one practice used
es have an emotional or spiritual element. Table 4-6 by folk healers in the Hispanic/Latino community
summarizes examples of selected folk illnesses. is greta, which is a lead-based powder used to treat
abdominal and intestinal complaints; this treatment
can cause lead poisoning. This illustrates why, during
HEALTH PRACTICES the health assessment, health care providers should
Traditional Health Practices always ask what, if any, traditional methods of healing
Families may seek the care of traditional or folk are used. Providers must always be nonjudgmental in
healers. For some, these healers are consulted first; the approach and help the family to seek alternatives
TABLE 4-6
Selected Folk Illnesses
ILLNESS DESCRIPTION ETHNIC GROUP CLINICAL IMPLICATIONS
Caida de la mollera This is believed to be caused Hispanic/Latino Treatment is holding the infant
(fallen fontanel) by moving the infant too upside down by the legs and
quickly. Symptoms can include shaking; it may induce head
irritability and failure to thrive. injury similar to shaken baby
syndrome.
Empacho Food lodged in digestive tract; Hispanic/Latino Treatment may include abdominal
(blocked intestines) may be caused by a hot–cold massage to dislodge food;
food imbalance. Symptoms treatment is often done by
include anorexia, vomiting, curandero(a). Treatment by a folk
diarrhea, abdominal pain, and healer may also include azarcon or
distention. greta, a lead-based powder, which is
mixed with water and given to the
child orally; this can result in lead
poisoning in the child.
Falling out This is a sudden collapse and African American– This is a common response to
an inability to see or speak, Caribbean tragic news such as the death of a
but the person can hear and loved one.
understand.
Fright illness Illness is believed to occur Hmong Signs and symptoms can include
(“ceeb” or “cheng”) after an intense emotional fever, crying, cold hands or feet,
experience (e.g., fear, anger) but fear, insomnia, headache, and
has many causes, including loud flailing arms (Moro reflex) [Capps,
sounds, nightmares, falls, and 1999]. It is treated by the child’s
immunizations (Capps, 1999). mother, grandmother, or in most
cases, a traditional Hmong healer.
The treatment is healing massage
(Capps, 1999).
Mal de ojo (“evil eye”) This is an evil or malevolent Hispanic/Latino It is believed that children are
look that can cause the child to particularly vulnerable. It can
become ill. cause fever, rashes, diarrhea,
vomiting, insomnia, crying, and
irritability.
Susto (soul loss or Fright or shock causes the soul Hispanic/Latino A curandera(o) is often used to treat
magical fright) to leave the body; it may cause the illness by performing specific
anorexia, diarrhea, lethargy, rituals. The person suffering from
insomnia, despondency, and susto is allowed to assume the sick
withdrawal. role and is relieved from school or
work.
Voodoo illness (e.g., This is the belief that illness is Afro-Caribbean; Symptoms can include nausea,
hex, fix, witchcraft, caused by a supernatural force. Haitian vomiting, diarrhea, seizures, muscle
spell, black magic) weakness, paralysis, or complaints
that animals are living inside the
body.
Source: Purnell, L. D., & Paulanka, B. J. (Eds.). (2008). Transcultural health care: A culturally competent approach. (2nd ed.). Philadelphia:
F. A. Davis.
to the traditional healing practice if the one used is the World Health Organization (WHO) estimates that
harmful to an infant or child. the majority of people in the developing world use some
type of complementary or alternative medicine (CAM)
(e.g., herbal medicines, acupuncture, energy healing,
Complementary and Alternative Medicine spiritual therapies, meditation) or traditional healer for
Most health care providers in the United States use mod- both episodic and primary health care (WHO, 2009).
ern medical care to treat illness and disease. However, It is important for health care providers to be familiar
TABLE 4-7
Selected Types of Folk Healers and Healing Practices
TYPE OF HEALING USE IN
CULTURAL GROUP PRACTICE/HEALER DESCRIPTION HEALTH PRACTICES CHILDREN CLINICAL IMPLICATIONS
African/African Shamanic Healing/ A Shaman cures illness and Divination, soul Treatment of Child must be developmentally
American; Haitian; Shaman conducts soul retrieval; this retrieval, and hypnosis chronic pain capable of cooperating with
Native American power is derived from the spiritual healing.
supernatural. These healing
powers have been passed down
from the Shaman’s teacher
from generation to generation
(Giger & Davidhizar, 2008d).
Asian Indian Hindus Ayurveda/Ayurvedic This has been practiced in Emphasizes diet and Used to cleanse The herbs, heavy metals,
physician India for centuries; diseases herbal remedies; stresses the body and and minerals used may cause
in Ayurvedic medicine are the body/mind/spirit restore physical toxicity (e.g., lead poisoning),
considered to be psychosomatic connection to disease and psychologic posing a safety concern for use
(Miller & Lass, 2008). prevention and treatment; balance in children.
medication not used
African/African Voodoo (Vodou)/ This is folk medicine based on Use of home remedies Voodoo healers Herbs may not be safe for
American; Haitian Priest or Priestess spirituality. and herbs as suggested are used as general children; those who use the
Shaman (practitioner) by healers or priests caregivers for voodoo healing system may
“Old Granny” Healers (Cosgray, 2008) child and family seek conventional health care
(African American) (Cosgray, 2008). for illness and injury only
Herbalists (Cosgray, 2008).
African/African Witchcraft A hex, evil spell, or bad luck The use of oils, incense, Used to treat Burning of oils, candles,
American Brujos(as) are witches can be placed by one person candles, and amulets are mal de ojo or incense may exacerbate
Hispanic/Latino (Hispanic/Latino) who on another; the motive for this used to repel the evil. respiratory problems in children;
treat hexes, evil spells, is most often hatred or envy worn amulets with small pieces
or bad luck. (Gonzalez, Owen, & Esperat, may present choking hazards in
2008). young children.
Chinese/Chinese Traditional Chinese Acupressure, acupuncture, Coining entails rubbing Coining is used Treatment leaves linear
American; Vietnamese/ Medicine/Physician coining, cupping, herbal the back vigorously to treat fever, (coining) or circular (cupping)
Vietnamese American Herbalist medicine, massage, and with the edge of a coin cough, headache, bruising; moxibustion leaves
Acupuncturist moxibustion (heat treatment) (Ahn, Ngo-Metzger, stiffness, and pain; small burns; health care
restore balance between yin Legedza, Massagli, Brian, cupping is used providers unfamiliar with these
and yang. Clarridge, et al., 2006). to treat pain and practices may confuse the
Cupping entails placing respiratory and bruises and burns with physical
a glass cup on the skin, digestive disorders; abuse.
lighting a candle, and moxibustion
then placing the candle is used to treat
at the base of the cup to mumps or seizures.
create suction.
(continued)
TABLE 4-7
Selected Types of Folk Healers and Healing Practices (Continued)
TYPE OF HEALING USE IN
CULTURAL GROUP PRACTICE/HEALER DESCRIPTION HEALTH PRACTICES CHILDREN CLINICAL IMPLICATIONS
Moxibustion involves
igniting moxa plants
and placing them near
the skin, where small,
approximately 1 cm
craters will remain.
Massage is used to
increase circulation,
joint flexibility, and
increase the body’s
resistance to illness
(Stauffer, 2008; Xu &
Chang, 2008).
Hispanic/Latino Curanderismo Herbs, massage, ritual Use of folk healers This is used to treat The intake of unregulated
• Family folk healers cleansing, or religious rituals Hot and cold foods healing of any herbs may interact with
• Yerbero/a (uses are used to heal physical and Herbs illness in children, other medications and have
herbs) mental illnesses. Massage including folk harmful effects; relying on
• Curandero/curandera Healing rituals often involve Prayers illnesses listed in curanderismo alone in the
• Espiritista other family members. Table 4-6. event of a serious illness
• Brujos(as) are Healers believe that good Families may (e.g., cancer, infectious disease)
witches and are health is maintained by combine may lead to serious health
used after other achieving a balance of hot and curanderismo and consequences.
types of folk cold (Murray, 2007; Graham, Western medicine.

healing has failed 2009).
(Gonzalez, Owen, &
Esperat, 2008).
Native American Herbalist Healing rituals often Ceremonies, herbal This is used to treat Certain herbs may be harmful
Shaman Medicine involve teas, herbs, sweating, therapies, music, healing of any to small children; the process
man or woman and smudging to restore smudging, and illness in children. of smudging, which involves
balance and harmony (Ball & sweatlodge burning sweet grass or sage,
Bindler, 2006). may exacerbate respiratory
disorders in children.
TABLE 4-8
Selected Types of Complementary and Alternative Medicine
HEALING
PRACTICES DESCRIPTION USE IN CHILDREN CLINICAL IMPLICATIONS
Acupuncture Acupuncture originated in To improve immune function, Used mainly for children aged
China and India. The skin control pain, increase circulation 10 years and older; younger
is penetrated with needles and energy flow, control nausea, children may not be able to
placed on acupuncture and promote relaxation (Murray, follow instructions and hold
points; the point is 2007). Massage can be used for still for insertion of needles
massaged to achieve energy children with a fear of needles. (Murray, 2007).
balance.
Aromatherapy Aromatherapy is the use To promote a sense of well-being This should not be used
of candles or essential oils and relaxation for children with asthma;
from flowers, herbs, or trees burning of candles or oils may
to promote healing. exacerbate respiratory distress.
Biofeedback Biofeedback is the Can be used to treat recurrent This is most often used as
measurement of the body’s headaches and other stress- an adjunct to therapy and
autonomic activity to allow related disorders, pain associated not as the primary mode of
voluntary control over with sickle cell crisis, juvenile treatment.
certain physiologic processes rheumatoid arthritis, recurrent
(Allen, 2004). abdominal pain, and other
chronic disorders (Allen, 2004)
Dietary Dietary supplements include Probiotics to treat atopic The provider should always
supplements vitamins, minerals, herbs, dermatitis in children inquire about dietary
botanicals, amino acids, (Schuerman & Vezeau, 2007); supplements when obtaining
enzymes, organ tissues, and echinacea for upper respiratory the health history; potential
metabolites. They may come infections; fish oil for asthma, interactions may occur
in the form of an extract, allergies, hyperlipidemia, bipolar between dietary supplements
concentrate, tablet, capsule, disorder, attention-deficit and prescribed medications;
gel cap, liquid, or powder. hyperactivity disorder, dyslexia, mislabeling, misidentification,
and rheumatoid arthritis; and contamination can cause
lactobacillus for gastrointestinal toxicity (Gardiner, Dvorkin,
ailments (Gardiner, Dvorkin, & Kemper, 2004); safe dosages
& Kemper, 2004); and daily should also be addressed.
multivitamins
Distraction Distraction is used to induce Can include music, pet, play, and The child must be old enough
techniques relaxation. art therapies to be able to cooperate with
therapy.
Massage Massage is used to treat pain Can be used for children with Health care providers should
and emotional stress. musculoskeletal disorders, assess for benefits; any
teething discomfort, sinus pain, fractures contraindicate
and emotional stress; gentle massage; vigorous massage
massage also used in newborns should be used only in
to promote sleep and enhance children aged 12 years and
bonding older (Murray, 2007).
Religious therapies These include prayer, faith Depend on family’s faith and Religion often strongly
healing, laying on hands, severity of child’s condition influences the family’s
anointing, exorcism, and approach to health
pilgrimage. maintenance and treatment of
illness and can give the family
great comfort when a child has
a serious illness. It can cause
harm to a child if it replaces
other therapies (e.g., for
infection, oncologic disorders,
blood loss).
(continued)
TABLE 4-8
Selected Types of Complementary and Alternative Medicine (Continued)
HEALING
PRACTICES DESCRIPTION USE IN CHILDREN CLINICAL IMPLICATIONS
Therapeutic touch Therapeutic touch uses light Used to treat anxiety, asthma, Health care providers should
touch (no deep palpation) fatigue, insomnia, pain, and assess for the health benefits
to balance the patient’s social isolation (Kemper & Kelly, of therapeutic touch (e.g.,
energy field and restore 2004) increased relaxation, decreased
energy imbalances (Kemper anxiety and pain, increased
& Kelly, 2004). sense of well-being) (Kemper &
Kelly, 2004).
Source: National Institutes of Health-National Center for Complementary and Alternative Medicine (NCCAM). (2009). NCCAM facts-at-a-glance
and mission. Retrieved November 1, 2009, from http://nccam.nih.gov/about/ataglance.
with the types of CAM commonly used by the popula- meet the child’s physical, psychologic, or developmen-
tion with which they most commonly work and to be tal needs, and relevant assessments must be made in
familiar with the safety and efficacy of these practices, these areas.
especially when used with infants and young children. Assessment of immigrant and refugee children
In 1998, the National Institutes of Health established presents several challenges to health care providers.
the National Center for Complementary and Alterna- In addition to the likelihood of language and cultural
tive Medicine (NCCAM). This agency was developed to barriers, these children often have unique health care
explore the various types of CAM therapies and study needs. For example, these children may present with
these practices via rigorous, controlled, scientific stud- written proof of having received immunizations,
ies and to disseminate these findings to health care but it is not known if the vaccines were stored at the
providers and the public (NCCAM, 2009). Table 4-8 appropriate temperature before the child received
lists some examples of CAM therapies and traditional them; therefore, their immunity to certain communi-
healing practices and their uses in children. cable diseases could be questioned. In particular, the
provider should determine whether the child has re-
Religious Practices and Spirituality ceived the bacillus Calmette-Guérin (BCG) vaccine, a
Many immigrants originally came to the United States vaccine frequently given in Mexico, the former Soviet
seeking religious freedom. Because of this, many dif- Union, and Southeast Asia to prevent certain forms of
ferent religions are practiced in the United States. tuberculosis. Children arriving from developing coun-
Individual differences must be noted, respected, and tries may also have problems that include unusual in-
incorporated into the health assessment and plan of fectious diseases or nutritional problems with which
care. For example, Hispanic/Latino families may use health care providers in the industrialized world may
prayer for healing, which does not affect the child’s not be familiar. Sensitivity to culture is also particu-
health in any adverse way. Alternatively, Jehovah’s larly important with respect to modesty, the use of tra-
Witnesses are opposed to blood transfusions under all ditional healers, and the presence of extended family
circumstances, including directed donor blood; this members during the health care visit.
may cause the child’s health to deteriorate.
HISTORY AND PHYSICAL
EXAMINATION
ASSESSING IMMIGRANT AND When assessing immigrant and refugee children, it is
REFUGEE CHILDREN important for the provider to obtain a careful, detailed
history. This may take more than one clinic visit,
The children of immigrants present with needs that and a trained medical interpreter is often necessary.
differ from children whose parents do not have the Questions to ask when eliciting a general pediatric
stressors related to leaving the home of one’s birth. health history can be found in Chapter 6; for immi-
People in these groups include not only immigrant grant and refugee children, providers should also pay
families but refugees and those seeking political asy- particular attention to the child’s and family’s social
lum. Children who are adopted from foreign countries situation, including living arrangements, source of in-
are also considered to be in this group. International come, how many people are living in the home, and
adoptees often come from environments that do not parental occupation. Providers must ask if the child is
exposed to secondhand smoke in the home, especially

BOX 4-1
when several adults are living together. The medica-
Assessing Immigrant Victims of
tion history should be obtained in a nonjudgmental
manner with the provider asking about use of herbs,
Violence and Torture
alcohol, or animals to treat illness or promote health. • Has the child or family ever witnessed violence or
The initial physical examination should also be very torture in their country of origin?
thorough. In some cases, this may be the first physical • Has anyone in the child’s family been a victim of
examination the child has ever received. In particular, violence or torture?
providers should note the child’s dentition, any skin • Has the child been the victim of violence or torture?
rashes, signs of malnutrition, or the presence of any in- • Would the child or parent like to be referred to a
fectious disease. Any signs of trauma or torture should special counselor for help and treatment?
be assessed; the two most common forms of torture are
beatings and rape (Green, 2007). Often, these injuries
are carried out using various items such as rubber hoses
or electrical cables (Green, 2007). Physical evidence of among immigrant children. A psychosocial assessment
these injuries includes scars, lacerations, burns, electric should be done to assess whether the child is suffering
shocks, and genital trauma. from culture shock, depression, or posttraumatic stress
Providers should also assess girls for the presence of disorder, especially if the child has been witness to or
female genital mutilation (FGM), which is practiced victim of extreme violence or torture. For survivors of
in some societies for cultural and religious reasons torture, further detailed assessments should be made,
(WHO, 2009) and involves various degrees of cutting, along with relevant referrals (see Box 4-1 and the Sur-
sometimes removing the clitoris and external genitalia vivors of Torture, International web site under Addi-
or stitching the vaginal opening closed (infibulation) tional Resources). Table 4-9 summarizes some risk fac-
(WHO, 2009). Long-term complications of this pro- tors and medical and social problems that can affect
cedure include cysts, abscesses, and keloid formation; immigrant children.
urethral damage that can cause urinary incontinence;
sexual dysfunction; prolonged labor and delivery;
anxiety; and depression (WHO, 2009). Through migra- CULTURE SHOCK
tion, FGM has spread to Western countries. Most girls The process of leaving one’s homeland and coming to
who have undergone FGM come from Africa, Asia, and a new country with different sights, sounds, smells,
the Middle East. U.S. federal law specifically bans this noises, colors, activities, and with a new and unfamil-
practice. If a girl has undergone FGM, providers should iar language can cause disorientation and confusion
assess for physical or psychosocial complications and and sometimes even anxiety and depression. People
make appropriate referrals as necessary. often do not know what behavior is appropriate and
The child’s physical growth and developmental level what is not. It is very important for providers to as-
should also be assessed; significant delays are common sess for signs of culture shock in immigrant or refugee
TABLE 4-9
Assessing Immigrant and Refugee Children
RISK FACTORS LEADING TO
POOR CHILD HEALTH IN
IMMIGRANT AND REFUGEE COMMON MEDICAL SOCIAL PROBLEMS AFFECTING
CHILDREN PROBLEMS CHILD HEALTH
• Poor environmental sanitation • Diarrhea • Poverty
• Lack of clean water • Dehydration • Child labor
• Poor hygiene practices • Malnutrition • Sexual exploitation of children
• Exposure to indoor smoke and fire • Acute respiratory infections • Armed conflict
from solid fuels • Pneumonia • Child soldiers/psychologic trauma
• Lack of immunizations • Burns • Homelessness
• Low level of parental education • Malaria • Lack of formal education (child
• Poor or no prenatal care • Measles and parent)
• No access to health care • HIV/AIDS • Developmental delays
• Perinatal and neonatal morbidity
and mortality
Source: Staton, D. M., & Harding, M. H. (2004). Protecting child health worldwide. Pediatric Annals, 33(10), 647–655.
BOX 4-2
Cultural Assessment
• What is the child or family’s race?
• Where was the child born? Was the child born in a developing country? What are the specific physical and
psychologic health risks in that country?
• What was the family’s immigration experience like (if applicable)?
• Has the child or family spent time as refugees? If so, for how long?
• How long has the family lived in the United States?
• What is the family’s current socioeconomic status?
• What is the child’s ethnicity, and how strong is the family’s ethnic identity?
• Does the family live in a community of people from the same ethnic background?
• What is the child’s or family’s primary language? Do they speak a secondary language?
• Can the child or family read in the primary language?
• Does the child or family speak and read English?
• What is the child’s or family’s educational level?
• What are the family’s cultural values regarding time, personal space, and touch?
• Is there a specific family member who makes important decisions?
• What is the family’s religion and how observant are family members? How do the religious beliefs of family members
affect their daily lives and behavior patterns (e.g., modesty, opposite sex health care providers)?
• What are the health and illness beliefs in the family?
• Does the family visit a traditional healer?
• Does the child or family have any specific food preferences, and are these linked to any cultural or religious rituals?
• Does the adolescent client have any conflict with the parents concerning cultural norms and customs?
• Does the child, adolescent, or family have any concerns about discrimination or institutional racism?
Source: Duderstadt, K. G., & Schapiro, N. A. (2006). Comprehensive information gathering. In Duderstadt, K. G. Pediatric physical examination: An
illustrated handbook. (pp. 33–45). St. Louis: Mosby.
children and families. These signs can include irrita-

bility, sadness, depression, powerlessness, disorienta- SUMMARY
tion, extreme homesickness, change in appetite and
sleep patterns, inability to concentrate, headaches, The need for the health care provider to be culturally
and stomach pains (Ball & Bindler, 2004; Bhugra & competent is well recognized. Increased globalization
Ayonrinde, 2004). People suffering from culture shock contributes to the need for providers to become cultur-
often seek out others who belong to their own culture ally and linguistically competent when working with
as a way of finding something familiar and comfort- children and families of diverse cultures. To convey
ing. A cultural broker may be helpful to assist the child respect, communicate effectively, make the most ac-
and family with cultural transition. Cultural brokers curate assessments, and to decrease health disparities,
are individuals who are bicultural and bilingual and providers must be familiar with the family’s cultural
are willing and able to help people new to a country background and their spoken language. Becoming fa-
adjust to their new life. The use of a cultural broker miliar with the sociocultural background of the child
also facilitates obtaining access to and helps to ensure and family takes the “otherness” out of the health care
the delivery of culturally and linguistically competent encounter, decreases the chance of stereotyping, and
health care (NCCC, 2009b). enriches the experience of health care providers.
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(5th ed.). (pp. 563–591). St. Louis: Mosby-Elsevier. Miller, S. W., & Lass, K. A. (2008). East Indian Hindu Americans.
Department of Canadian Heritage. (2009). Canadians and their In Giger, J. N., & Davidhizar, R. Transcultural nursing: Assess-
government: A resource guide. Retrieved November 1, 2009, ment & intervention. (5th ed.). (pp. 537–562). St. Louis: Mosby-
from http://www.pch.gc.ca/special/gouv-gov/110-eng.cfm. Elsevier.
DeNavas-Walt, C., Proctor, B. D., & Smith, J. C. (2008). Income, Murray, F. A. (2007). CAM for children. Advance for Nurses, 18–21.
poverty and health insurance coverage in the United States: 2007. National Center for Complimentary and Alternative Medicine.
Washington, DC: U.S. Government Printing Office. (2009). NCCAM facts-at-a-glance and mission. Retrieved
Duderstadt, K. G. & Schapiro, N. A. (2006). Comprehensive in- November 1, 2009, from http://nccam.nih.gov/about/
formation gathering. In: Duderstadt, K. G. Pediatric physical ataglance/.
examination: An illustrated handbook. (pp. 33–45). St. Louis: National Center for Cultural Competence. (2009). Home page.
Mosby Elsevier. Retrieved November 1, 2009, from http://www11.george-
Dunn, A. M. (2002). Culture competence and the primary care town.edu/research/gucchd/nccc/index.html.
provider. The Journal of Pediatric Health Care, 16(3), 105–111. National Center for Cultural Competence. (2009a). Cultural
Dunn, A. M. (2009). Cultural perspectives for primary health competence health practitioner assessment. Retrieved
care. In: Burns, C. E., Dunn, A., Brady, M. A., Barber Starr, N., November 1, 2009, from https://www4.georgetown.edu/uis/
& Blosser. C. G. (2009). Pediatric primary health care: A handbook keybridge/keyform/form.cfm?formID=277.
for nurses. (pp. 41–50). St. Louis: Saunders. National Center for Cultural Competence. (2009b). Bridging the
Engel, J. K. (2006). Beginning the assessment. In Engel, J. K. cultural divide in health care settings: The essential role of
Mosby’s guide to pediatric assessment. (5th ed.). (pp. 3–9). St. cultural broker programs. Retrieved November 1, 2009, from
Louis: Mosby Elsevier. http://www.culturalbroker.info/2_role/index.html.
Gardiner, M. D., Dvorkin, L., & Kemper, K. J. (2004). Supplemen- Pearson, L. (2003). Understanding the culture of poverty. Nurse
tal use growing among children and adolescents. Pediatric Practitioner, 28(4), 6.
Annals, 33(4), 227–232. Purnell, L. D., & Paulanka, B. J. (Eds.). (2008). Transcultural health
Giger, J. N., & Davidhizar, R. (2008). Transcultural nursing: Assess- care: A culturally competent approach. (3th ed.) Philadelphia: F.
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Giger, J. N., & Davidhizar, R. (2008a). Time. In: Giger, J. N., & Roy, L. C., Torrez, D., & Dale, J. C. (2004). Ethnicity, traditional
Davidhizar, R. Transcultural nursing: Assessment & intervention. health beliefs and health-seeking behavior; guardians’ atti-
(5th ed.). (pp. 106–128). St. Louis: Mosby-Elsevier. tudes regarding their children’s medical treatment. Journal of
Giger, J. N., & Davidhizar, R. (2008b). Communication. In: Giger, Pediatric Health Care, 18(1), 22–29.
J. N., & Davidhizar, R. Transcultural nursing: Assessment & Schuerman, G., & Vezeau, T. (2007). All bugs aren’t bad: probiotics
intervention. (5th ed.). (pp. 20–46). St. Louis: Mosby-Elsevier. in the treatment of pediatric atopic dermatitis. The American
Giger, J. N., & Davidhizar, R. (2008c). Social Organization. In: Journal for Nurse Practitioners, 11(4), 28–36.
Giger, J. N., & Davidhizar, R. Transcultural nursing: Assessment & Smedley, B. D., Stith, A. Y., & Nelson, A. R. (2003). Unequal
intervention. (5th ed.). (pp. 68–105). St. Louis: Mosby-Elsevier. treatment: Confronting racial and ethnic disparities in health
care. Institute of Medicine Report. Washington, DC: National Complementary and Alternative Medicine
Academy Press. http://www.nccam.nih.gov/
Spector, R. E. (2009). Cultural diversity in health and illness. National Institutes of Health–National Center for
(7th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Complementary and Alternative Medicine (NCCAM).
Srivastava, R. H. (2007). Understanding cultural competence
in health care. In Srivastava, R. H. (Ed.) The healthcare Health Resources and Services Administration (HRSA)
professional’s guide to clinical cultural competence. (pp. 3–27). St. Cultural Competence Resources
Louis: Mosby Elsevier. http://www.hrsa.gov/culturalcompetence/
Staton, D. M., & Harding, M. H. (2004). Protecting child health http://www.hrsa.gov/culturalcompetence/curriculumguide/
worldwide. Pediatric Annals, 33(10), 647–655. chapter1.htm
Stauffer, R. Y. (2008). Vietnamese Americans. In Giger, J. N., & This is a comprehensive listing of cultural competence resources
Davidhizar, R. Transcultural nursing: Assessment & intervention. and web links for health care providers, including information
(5th ed.). (pp. 494–536). St. Louis: Mosby-Elsevier. about cultural brokers.
Tashiro, C. (2005). The meaning of race in health care and National Center for Cultural Competence
research-Part I the impact of history. Pediatric Nursing, 31(3), http://www11.georgetown.edu/research/gucchd/nccc/
208–210. The National Center for Cultural Competence (NCCC)
Thompson, G. E., Mitchell, F., & Williams, M. B. (2006). Examin- at Georgetown University Center for Child and Human
ing the health disparities research plan of the National Institutes Development. Information is available on this web site
of Health: Unfinished business. Washington, DC: The National regarding provider self-assessment of cultural and linguistic
Academies Press. competency. Information is also available on the role of cultural
United States Citizenship and Immigration Services. (2009). brokers in health care delivery and developing cultural broker
Home page. Retrieved November 1, 2009, from http://www. programs. Web access for cultural competency self-assessment
uscis.gov/portal/site/uscis. tool for health care providers: https://www4.georgetown.edu/
United States Department of Health and Human Services. (2000). uis/keybridge/keyform/form.cfm?formID=277
Healthy People 2010. Washington, DC: U.S. Government Print-
ing Office. Survivors of Torture, International
United States Department of Health and Human Services, Office http://www.notorture.org/links.html
of Minority Health. (2009). Minority populations. Retrieved Survivors of Torture, International is an independent nonprofit
November 3, 2009, from http://minorityhealth.hhs.gov/tem- organization dedicated to caring for survivors of politically
plates/browse.aspx?lvl=1&lvlID=5. motivated torture. This organization also includes educating the
University of Michigan Health System. (2009). Program for mul- professional community and the general public about torture
ticultural health. Retrieved November 1, 2009, from http:// and the needs of torture survivors.
www.med.umich.edu/multicultural/ccp/tools.htm#basic.
University of Washington Medical Center. (2009). Culture clues. Therapeutic Touch
Retrieved November 1, 2009, from http://depts.washington. Healing Touch International: http://healingtouch.net/
edu/pfes/CultureClues.htm. Nurse Healers–Professionals Associates International, Inc.
World Health Organization. (2009). Traditional medicine. Re- http://therapeutic-touch.org/
trieved October 31, 2009, from http://www.who.int/media- UNHCR The United Nations Refugee Agency
centre/factsheets/fs134/en/. http://www.unhcr.org/cgi-bin/texis/vtx/home
Vance, A. R. (2008). Filipino Americans. In Giger, J. N., & David- The UNHCR leads and coordinates international assistance to
hizar, R. Transcultural nursing: Assessment & intervention. (5th worldwide refugees, safeguards the rights and well-being of
ed.). (pp. 467–493). St. Louis: Mosby-Elsevier. refugees, and helps refugees to seek asylum and find safe refuge,
Wilson, H., & Kneisl, C. (1996). Psychiatric nursing. (5th ed.) Read- with the option to return home voluntarily, settle locally, or to
ing, MA: Addison-Wesley. resettle in a third country.
Xu, Y., & Chang, K. (2008). Chinese Americans. In: Giger, J. N., &
Davidhizar, R. Transcultural nursing: Assessment & intervention. U.S. Department of Health and Human Services Office of
(5th ed.). (pp. 442–466). St. Louis: Mosby-Elsevier. Minority Health
http://www.omhrc.gov/
The Office of Minority Health home page offers information on
cultural competency and health disparities among minorities.
ADDITIONAL RESOURCES The Universal Declaration of Human Rights
American Public Health Association This document was developed by several world leaders after the
http://www.apha.org/programs/additional/mch/ Second World War. The Universal Declaration of Human Rights
programsResourceCenter.htm consists of 30 articles that outline universal human rights according
This web site provides numerous links for the health care to the General Assembly of the United Nations. This document was
provider regarding children in poverty, minority health, health adopted by the United Nations on December 10, 1948. The full text
inequities, multiculturalism, maternal-child health, health of this can be found at: http://www.un.org/Overview/rights.html
disparities among immigrants. The following link provides The Universal Declaration of
Human Rights translated into hundreds of languages: http://
Amnesty International www.unhchr.ch/udhr/
http://www.amnesty.org/
This is a worldwide organization, the goal of which is to protect University of Michigan Health System Program for
human rights for all people. Multicultural Health
http://www.med.umich.edu/multicultural/ccp/tools.htm#basic
The Boston Healing Landscape Project This is an educational program, the goal of which is to improve
http://www.bmc.org/pediatrics/special/bhlp/ the health status of underserved multicultural populations
This project is affiliated with the Department of Pediatrics at through cultural competency training, cultural health
Boston University School of Medicine. It includes a web-based promotion programs and education for health care systems,
tutorial, focusing on various culturally and religiously based academia, and the community.
practices of Africans, Haitians, Latin Americans, and Chinese.
University of Washington Medical Center
Centers for Disease Control and Prevention (CDC)–Racial http://depts.washington.edu/pfes/cultureclues.html
and Ethnic Approaches to Community Health (REACH) This is a series of handouts called “Culture Clues” that briefly
http://www.cdc.gov/reach2010/index.htm summarize the cultural characteristics of a particular group. It is
REACH is a national program through the CDC that aims to designed to assist the health care provider in learning the basics
eliminate racial and ethnic disparities in health. about a client’s culture quickly and easily.
MEDICAL INTERPRETERS Lewis, O. (1959). Five families: Mexican case studies in the culture of
poverty. New York: Basic Books.
Languageline.com Pipher, M. (2002). The middle of everywhere: The world’s refugees
http://www.languageline.com/ come to our town. New York: Harcourt Press.
This web site provides links to medical interpreters via phone Root, M. P. P., & Kelley, M. (2003). Multiracial child resource book:
to be used during health encounters; document and video Living complex identities. Seattle: Mavin Foundation.
translations are also provided. Thompson, G. (2007). There’s no Jose here: Following the hidden
AT&T language line lives of Mexican immigrants. New York: Nation Books.
http://www.usa.att.com/traveler/access_numbers/view. Wilson, W. J. (1996). When work disappears: The world of the new
jsp?group=language urban poor. New York: Knopf.
This also provides language assistance and interpretation by phone. Wu, F. H. (2002). Yellow: Race in America beyond black and white.
New York: Basic Books.
Memoirs
Chen, D. (1999). The colors of the mountain. New York: Anchor
SUGGESTED READINGS Books.
Reading about other cultures and people’s experiences can Crow Dog, M. (1990). Lakota woman. New York: Grove
assist the provider in achieving the goal of developing cultural Weidenfeld.
competence. The following list of readings is suggested to McBride, J. (1996). The color of water: A black man’s tribute to his
assist the provider in learning about various cultures. Fiction, white mother. New York: Riverhead.
nonfiction, and memoirs are included. Him, C. (2000). When broken glass floats: Growing up under the
Khmer Rouge. New York: W. W. Norton & Company.
Fiction Hirsi Ali, A. (2007). Infidel. New York: Free Press.
Ali, M. (2003). Brick lane. New York: Scribner. Trenka, J. J. The language of blood. St. Paul, MN: Borealis Books.
Dorris, M. (1987). A yellow raft in blue water. New York: Ung, L. (2000). First they killed my father: A daughter of Cambodia
Warner Books. remembers. New York: HarperCollins.
Dubus, A. (1999). House of sand and fog. New York: Random House. Ung, L. (2005). Lucky child. New York: HarperCollins.
Foer, J. S. (2005). Extremely loud and incredibly close. New York: Walls, J. (2005). The glass castle. New York: Simon & Schuster.
Houghton Mifflin.
Hosseni, K. (2003). The kite runner. New York: Riverhead Books. Children’s Books
Lahiri, J. (1999). Interpreter of maladies. New York: Houghton Fox. M., & Staub, L. (1997). Whoever you are. New York: Voyager
Mifflin. Books Harcourt.
Moshiri, F. (2005). Against gravity. New York: Penguin Books. Katz, K. (1999). The colors of us. New York: Henry Holt and
Patchett, A. (2001). Bel canto. New York: HarperCollins. Company.
Walker, A. (1992). Possessing the secret of joy. New York: Simon & Krebs, L., & Cairns, J. (2003). We all went on safari. New York:
Schuster. Scholastic.
Mayer, G., & Mayer, M. (1998). Just a little different. New York:
Nonfiction Golden Books.
Chang, I. (1998). The rape of Nanking: The forgotten holocaust of Miles, M., & Parnall, P. (1971). Annie and the old one. New York:
World War Two. New York: Penguin. Little, Brown and Company.
Chang, I. (2003). The Chinese in America. New York: Penguin. Moore, S. T., & Futran, E. (1998). Somewhere today: A book of peace.
Chideya, F. (1999). The color of our future. New York: William Morton Grove, IL: Albert Whitman & Co.
Morrow and Company. Rappaport, D., & Collier, B. (2001). Martin’s big words. New York:
Fadiman, A. (1997). The spirit catches you and you fall down. New Scholastic.
York: Farrar, Straus and Giroux. Simonds, N., Swartz, L., So, M., & The Children’s Museum,
Gourevitch, P. (1998). We wish to inform you that tomorrow we Boston. (2002). Moonbeams, dumplings & dragonboats. New
will be killed with our families: Stories from Rwanda. New York: York: Gulliver Books; Harcourt, Inc.
Farrar, Straus and Giroux. Sister Susan, Nguyen, T. H., & Nguyen, D. (2001). Each breath a
Kotolowitz, A. (1991). There are no children here. New York: smile: Based on the teachings by Thich Nhat Hanh. Berkeley, CA:
Doubleday. Parallax Press.
CHAPTER
Assessment of the
5 Family GLORIA A. JACOBSON
people who are related. According to Thomlison (2007),

IMPORTANCE OF FAMILY families are composed of people who live with a shared
ASSESSMENT past, feel a measure of emotional connectedness, and
participate together in planning for the future. Mem-
Most children are part of that unique entity called bers may or may not have biologic and legal ties. Wright
“family.” Today, however, if children are asked to draw and Leahey (2009) suggest that “family” is composed of
their family, only some would respond with a traditional whomever members consider to be family.
two-parent family, while many others would include
grandparents and extended family members, stepfamilies,
parents who are either both women or both men. A small
number may draw a residential-living setting resulting PURPOSE OF FAMILY
from the fact that there are no adults to care for them. ASSESSMENT
Regardless of the structure, through birth, adoption,
and sometimes less traditional means, children become The overall purpose of family assessment is to examine
family members—hopefully living among those who are the family’s strengths and weaknesses, to gather infor-
steadfast sources of love, safety, and security. For some mation about the family’s medical history, to assess
children, the family is where they become immersed family functioning and relationships, to determine the
in the values they will carry into adulthood and learn parental knowledge base, and to gain an understand-
how to navigate their own complex worlds. For many ing of the family’s concerns and needs. The assessment
children, time spent with family is filled with happiness also influences which interventions are to follow. Tra-
and security; for others, it is a time of fear, anxiety, and ditionally, assessment has focused on problems and
unpredictability, with time away from home offering re- symptoms with attention to deficits and difficulties
spite from myriad difficulties. (Tedeschi & Kilmer, 2005). Using a problem-centered
Health care providers are in a privileged role to be approach disregards family strengths and resources
able to assess and evaluate the child within the context that may support the family through challenging
of his or her specific family system, however it may be events and times.
configured. A family assessment gives the provider a
unique opportunity to learn about children through
the relationships they have with the people they live
with. The values, beliefs, and attributes of the family
STRENGTH-BASED FAMILY
significantly impact not just the child’s physical health, ASSESSMENT
but also his or her emotional health, well-being, self- An assessment approach that considers family strengths
esteem, confidence, future relationships, expectations, recognizes the family and its members as persons with
and dreams for the future. Health care providers who distinct abilities, wherewithal, life skills, and needs
recognize the value of engaging the family may help that merit consideration (Tedeschi & Kilmer, 2005).
identify problems within the family before they esca- Working within a strength-based framework, health
late into a full-blown crisis. care providers may identify needs for family support
Most providers who work with families view the and resources that are likely to improve the outcomes
family as something broader than simply a grouping of of planned interventions.
76
C H A P T E R 5 A s s e s s m e n t of the F amily • 77
Wells and Stein (2006) identified several fam-

BOX 5-1
ily characteristics that are important for children
Characteristics of Healthy
regardless of the family membership and the man-
ner in which the family has come together. Family
Families
members require basic life necessities that include SAFE, ORGANIZED, AND NURTURING
food, safe housing, clothing, and access to health ENVIRONMENT
care. Children benefit by demonstrated warmth and
• Marital or partner relationship is stable.
affection with developmentally appropriate limit-
• Housing is in good repair with sufficient living and
setting. An environment that assumes respect for all
sleeping space for family members.
and prohibits violence assures children that they are
• Sufficient finances are available for family needs.
safe and secure while teaching them that they, too,
are expected to demonstrate respect and coopera- • Plans to manage emergencies are in place with
family members involved in age and developmentally
tion in the family. Family members all benefit from
appropriate preparation.
stimulation of cognitive development and recogni-
• Predictable routines and expectations are a part of
tion of the importance of fostering moral reasoning.
day-to-day family life.
Children thrive in an environment that encourages
• Secure child care is in place in the absence of parents.
meaningful interpersonal relationships, open com-
munication, cooperative problem-solving, and mo- RECOGNITION OF ADULT AND CHILD
tivation to achieve. Socialization among peers and BOUNDARIES, ROLES, AND RESPONSIBILITIES
with adults assists children to become cooperative
• Parents or designated adults actively assume
members of their community and society. parenting responsibilities.
• A healthy diet is incorporated into family life.
CHARACTERISTICS OF HEALTHY • Parents are able to balance work and home life.
FAMILIES • Parental expectations are appropriate for the child’s
age and developmental level.
Healthy families can be represented by an assort-
• Television time for children is limited.
ment of family structures, cultures, ethnicities, or
• Internet and other isolated activities are monitored
socioeconomic groups. Characteristic of all healthy
by adults.
families are parents or adults in the parenting role
• Reading is encouraged by all family members.
assuring (a) a safe, organized, and nurturing environ-
ment; (b) recognition of adult and child boundaries, • Parents serve as positive role models for a healthy
lifestyle, communication, and responding to
roles, and responsibilities; (c) clarity and continuity
challenges and adversity.
of communication; and (d) respect for others. Spe-
cific descriptors for each area are listed in Box 5-1. CLARITY AND CONTINUITY OF
COMMUNICATION
• Parents regularly communicate philosophy of
FAMILY DEMOGRAPHICS childrearing and parenting style.
It is useful to consider family demographics before • Sibling rivalry is addressed in a loving, age-
considering specific family structures. In 2006, more appropriate manner.
than 73 million children resided in the United States • Family members demonstrate effective coping and
(U.S. Census Bureau, 2003). A total of 69% lived with problem-solving skills.
two parents, 23% lived only with their mother, 5% • Family members have appropriate outlets for
lived only with their father, and another 4% lived with frustration.
neither parent. • Affection is demonstrated among family members.
For many children, grandparents play a significant
role even when a parent is present. A total of 10% of UTMOST RESPECT FOR OTHERS
children who lived with a single mother were grand- • Family members tolerate and respect differences.
children of the householder, compared with 8% who • Discipline is age appropriate, and positive
lived with a single father. When children lived in reinforcement is maximized.
households without either of their parents, 44% lived • Compromise, family meetings, and other strategies
with their grandparents. are engaged to address problems that arise.
In 2002, 16.5 million children lived with a single • Parents spend time together as a couple.
mother, but 1.8 million (11%) lived in a household
• Parents spend time with each child individually.
with their mother and her unmarried partner. Chil-
• Abusive behaviors are absent.
dren who lived with a single father (3.3 million) were
much more likely to be sharing the household with his
unmarried partner (33% or 1.1 million children).
Census data reveal that one in four children live in are employed outside the home, while occasionally
poverty, and noteworthy differences in children’s eco- fathers assume the role of the stay-at-home caretaker of
nomic situations appear when family living arrange- young children. Some parents hold multiple jobs, while
ments are considered. While 30% of all children lived in others commute to jobs in other cities or states.
families with incomes of less than $30,000 a year, only For two-career families, time together is limited,
15% of children in two-parent families fell below that with many parents attending only to what is absolute-
level compared to 65% of children in single-mother ly essential during the work week. For all parents of
families, 45% of children in single-father families, and young school-aged children, the need for before and
61% living in households with neither parent. after school care is often an added stress. For all par-
An important consideration related to the children’s ents employed outside the home, employers may not
well-being involves children’s health insurance cover- understand the need to be home with sick children,
age. For children living in all types of living arrange- to take children to health care appointments, or to be
ments, health insurance coverage increased with fam- available for school activities that may conflict with
ily income. However, children in households receiving parents’ work schedules.
public assistance were more likely to be covered by
health insurance than those who did not. These data,
which like all statistics merit careful scrutiny, provide STEPFAMILIES
information regarding family organization, econom- Stepfamilies often involve children who may be expe-
ics, and access to health care that is useful to consider riencing their third family unit, following the family
when planning a family assessment. unit formed by their biologic parents, then the single-
parent family unit, and now the stepfamily unit. Each
family member moves at his or her own pace, and the
FAMILY STRUCTURE joy experienced by the parents in a new relationship
may be very different from the feelings experienced
Current family structure in North America is highly by the child who may still be mourning the loss of
variable. Some families have one adult or child present the original family. Children of all ages tend to react
while others consist of several persons of all ages, rep- strongly to both divorce and remarriage despite judi-
resenting several generations. Parents of young chil- cious parental planning and preparation for these life-
dren may be in their twenties or in their fifties. Roles changing events.
in some families are flexible and shared, while in other
families each person assumes a prescribed role that is
rarely changed. There are families with minimal re- SINGLE-PARENT FAMILIES
sources who dwell in a spirit of wealth and generosity, Single-parent families occur when individuals choose
while there are families that enjoy an abundance of not to marry or after the divorce or death of a spouse.
material goods but are emotionally impoverished. While families with either a mother or father and two
The capable health care provider, when interacting children represent a range of family arrangements with
with families, may need to assume a variety of roles that three individuals, circumstances can drastically vary.
include resource person, teacher, surrogate, counselor, The parent who has never married takes steps to orga-
teacher, mediator, and researcher to help the family nize the family in a way that meets members’ needs.
move toward health and well-being (Peplau, 1991). This Parents who have experienced divorce face develop-
multiplicity of roles provides multifaceted approaches mental changes and issues that emerge through that
that are the basis of excellence in a provider’s practice. stage of the life cycle, both for themselves and their
Regardless of how a family is structured, it is essential children. Those who have lost a spouse through death
for the health care provider to remember that each fam- face their own adjustments that may or may not be
ily is its own unique entity, with its own culture, tradi- anticipated while being faced with also caring for chil-
tions, resources, needs, disappointments, and dreams dren who are responding to the loss of their parent.
for the future. Every family faces challenges and adver-
sity; the capacity of family members to respond, move
forward, learn, and grow from these experiences results ADOPTIVE FAMILIES
ultimately in growth, satisfaction, and contentment. While about 2% of children in the United States en-
ter a family through adoption (Wells & Stein, 2006),
adoptive families can present very differently. In
TWO-PARENT FAMILIES some families, adopted children join their parents’
While historically viewed as “traditional,” two-parent biologic children. Some families adopt infants, while
families have encountered significant changes in life- others adopt school-aged children. North Ameri-
style and expectations as a result of changes in the can families increasingly adopt infants or children
workforce and parental roles. Increasingly, both parents from other countries. Many adoptive parents find
their anticipation burdened with anxiety related to The American Academy of Pediatrics recognizes that
unexpected alterations in the adoption timeline, a substantial body of literature offers evidence that
changes in government regulations, and other unan- homosexual parents can offer their children the same
ticipated delays in the arrival of the infant or child advantages and expectations for health, adjustment,
they await. While eagerly awaited, adopted children and development as children of heterosexual parents
may bring with them complicated health needs or (American Academy of Pediatrics [AAP], 2002). Despite
family histories that challenge even committed, well- empirical support that children can thrive and flour-
prepared parents. ish with two parents of the same sex, societal pressures
present these families with many challenges.
FOSTER FAMILIES
The nature of foster families implies the care of HOMELESS PARENT FAMILIES
children who are at risk. Children sometimes join a Homeless families frequently have multiple health
foster family for short-term care and at other times, for issues in addition to social problems that occur
lengthy periods of time. These families are presented concomitantly with homelessness. Children or
with the challenge of nurturing a child who may have adolescents may stay with relatives or friends or may
been moved from home to home—each with its own “couch hop” with parents from place to place. Many
family culture. Perhaps the child returns to a home en- families cannot access safe shelters, often leaving
vironment that presents safety or stability concerns to parents and their children on the streets. The Chicago
foster parents committed to the overall well-being of Public School System reports that more than 10,000
the child for whom they are caring. students were classified as homeless for the 2007–
2008 school year (Chicago Public Schools, 2007).
Poor nutrition, disease, violence, substance abuse,
GRANDPARENT-LED FAMILIES sexual abuse, and a child’s overall vulnerability are
Grandparents may find themselves raising grandchil- increasingly troubling to health care providers and
dren or having them in their home at a time when they dangerous for children entering the downward spiral
expected to be free from this kind of responsibility. In of homelessness. The optimal approach is to become
2002, 5.6 million children (8% of all children) were aware of families who are at risk of losing safe and
living in households with a grandparent present. Most secure housing and prevent this from occurring before
(3.7 million) lived in situations where the grandpar- a perilous situation results.
ent was the householder. Of children living in housing
provided by grandparents, 65% had at least one parent
in the household as well (U.S. Census Bureau, 2003). FAMILIES LIVING WITH CHRONIC
While some grandparents find this arrangement en- ILLNESS
joyable or helpful, some find the demands of infant Families dealing with chronic illness need to be able to
or child care difficult to sustain over time. Some may access needed health care, medications, and supplies.
have health issues of their own that require significant These families face insurance difficulties, issues re-
attention, and occasionally a grandparent may be car- garding transportation, and other ongoing financial
ing for another family member whose needs are physi- stress. Adults with chronic health conditions may be
cally, financially, and psychologically demanding. unable to sustain employment or care for their chil-
dren or other family members. Children with chronic
health problems may make it impossible for parents
GAY AND LESBIAN PARENT FAMILIES to maintain employment, may miss school more than
Wells and Stein (2006) reported that 6 to 14 million is acceptable, and may have developmental or psy-
children live with a gay or lesbian parent in the United chologic disabilities related to their chronic medical
States. Gay and lesbian parents represent every race, condition. Families dealing with chronic health issues
culture, religious or ethnic group, and socioeconomic benefit from a strong support network that can be put
affiliation in the United States. Several social and in place by health care providers to help them with
contemporary issues challenge gay and lesbian couples their identified needs.
who have children. Adoption is stressful under any
circumstances, but the process of adoption among
homosexual couples (i.e., gays, lesbians) typically TEEN PARENT FAMILIES
arouses fears related to the contemporary trends of Teen parents present with numerous health issues.
heterosexism, homophobia, and general stigma that While teens sometimes exhibit strong parenting
surround these couples (Herek, 1988, 2000). Even so, skills, their responsibilities related to parenthood are
more than half the states permit gays and lesbians to frequently challenged by conflicting issues that may
adopt (Lobaugh, Clements, Averill, & Olguin, 2006). include peer and social pressures, school, financial
stress, work-related issues, stressful relationships with traditions, beliefs, and standards they will take from
parents, and differences of opinion between teen their family of origin and what they will discard, while
mothers and fathers about their child’s care and fu- also deciding what they will begin for themselves as
ture. Teen parents benefit from supportive family sys- they move through their lives (Wright & Leahey, 2005).
tems that are able to provide positive role modeling Developmental tasks (Carter & McGoldrick, 2005;
and assistance with child care that allows the teen to Wright & Leahey, 2005) during stage one include:
continue and complete his or her education. • Distinguishing the self from the original family
(Wright & Leahey, 2005), which is a process in
which the young adult and parents work toward the
OLDER FIRST-TIME PARENT FAMILIES development of a mutually respectful form of re-
Older first-time parents are faced with new respon- lating. This process varies among ethnic groups in
sibilities that may or may not have been expected. which each has norms and expectations regarding
As they welcome their first child, these parents may attachment to family and also issues regarding
also be faced with other family responsibilities such dependence and independence.
as the care of an elderly parent. Career responsibili- • Developing satisfying and meaningful intimate peer
ties, established routines, health issues, including relationships.
decreased energy, may impact these families. Life- • Establishing oneself in the work world by establishing
style changes that may have been discussed in an- financial goals and career expectations.
ticipation of this significant change may become
greater than expected. Mature adults who have be-
come accustomed to personal leisure time, spon- STAGE TWO: JOINING FAMILIES
taneous dinners or other activities, or vacationing THROUGH MARRIAGE
with other adults may be stunned by the change in When couples marry, each individual brings the families
their everyday lives. Those who find themselves in of origin to the relationship, where at least two but
this situation when they had no plan or intention any number of families might come together. In many
of becoming parents, or perhaps had given up that situations, stepfamilies may also be present, resulting
plan for their lives, may find themselves in a very in additional variables to the dynamics already in
different situation. play. In addition, there is no certainty that the couple
joined in marriage will be heterosexual, as recently
gay marriages and civil unions have been formally
STAGES IN FAMILY recognized and more frequently celebrated by families.
DEVELOPMENT Developmental tasks (Carter & McGoldrick, 2005;
Wright & Leahey, 2005) during stage two include:
Wright and Leahey (2005) urge health care providers • Establishing couple identity, which includes nego-
to use the Calgary Family Assessment Model (CFAM) as tiation of many issues that were previously defined
a framework in which to interact with families as they on an individual basis. Matters to be considered in-
are today, such as two-career families, single-parent clude eating and sleeping patterns, use of space and
households, unmarried couples, homosexual couples, time, sexual contact, traditions, and rules that will
remarried couples (i.e., couples whose members have become those of the family, as well as those that will
been either divorced or widowed and then remarried), be established in the future.
single-parent adoptions, and other configurations. They • Realigning relationships with the extended family to
emphasize the need to avoid language that reinforces include the spouse, which challenges each family of
stereotypes and critically reflects the influence of cul- origin to open itself to new ways of being.
ture, gender, ethnicity, race, and sexual orientation on • Making decisions about parenthood during which
a family’s developmental stages. Diverse families and time couples decide whether or not to have children
lifestyles may result in developmental stages that dif- and if deciding affirmatively, when to conceive. The
fer from the above model. The effective engagement of issue of timing of conception has taken on greater
health care providers with families requires an aware- importance given the trend toward later marriages,
ness of these differences and shifts. the changing roles of women in the workforce, and
the use of contraceptives.
STAGE ONE: LAUNCHING THE SINGLE

YOUNG ADULT STAGE THREE: FAMILIES WITH YOUNG
Each person faces the experience of “leaving home.” It CHILDREN
is a stage that may last for several years, during which Adults now assume caregiving responsibility for a
young adults confront decisions about what values, younger generation. This often occurs at a time when
financial resources are stretched and parents are fo- STAGE FIVE: LAUNCHING CHILDREN
cusing on career development. In two-career families, AND MOVING ON
child responsibilities and household needs can become
Historically, parents always believe they will eventu-
particularly challenging. Developmental tasks (Carter
ally experience an “empty nest.” For many, that de-
& McGoldrick, 2005; Wright & Leahey, 2005) during
parture is taking longer as young adults often return
stage three include:
home, sometimes repeatedly, after leaving. Some
• Adjusting the marital system to make space for the young adults may be reluctant to give up their family’s
child, during which time personal space, intimacy, lifestyle, while others have problems finding employ-
and opportunities for socializing may be significant- ment that can support their very basic financial needs.
ly challenged. Normal changes during this period in- Developmental tasks (Carter & McGoldrick, 2005;
clude adjustments in relationships with the families Wright & Leahey, 2005) for stage five include:
of origin, shifts that occur in relation to the child,
• Renegotiating the family as a dyad, allowing the
changes in stress and social support, and changes in
couple to bond once again.
the couple (Cowan & Cowan, 2003).
• Realigning relationships to include in-laws and grown
• Sharing of child care, financial responsibilities, and
children whereby parents adjust family ties and expec-
household tasks. The contributions of both mothers
tations to include the child’s spouse or partner.
and fathers to a child’s development are important.
• Dealing with disabilities and death of grandparents,
• Realigning relationships with extended families to
a period frequently requiring time dedicated to ill-
include parenting and grandparenting roles, dur-
ness, loss, or death of an elderly parent.
ing which time the couple develops their parent-
ing roles in addition to their marital roles. Members
of each family of origin take on new roles such as
grandmother or uncle. Opportunities for both in-
STAGE SIX: FAMILIES IN LATER LIFE
tergenerational support and conflict are abundant, This stage begins with retirement and lasts until
as expectations regarding childrearing and health the death of both spouses. In North American cul-
practices are expressed within the family. tures, this can last 20 to 30 years. The key emotion-
al process during this time is to accept the shift of
generational roles. Developmental tasks (Carter &
McGoldrick, 2005; Wright & Leahey, 2005) for stage
STAGE FOUR: FAMILIES WITH
six include:
ADOLESCENTS
• Maintaining functioning and interest in the face of
Wright and Leahey (2005) describe this period as one
physiologic decline and exploring new familial and
that can include intense upheaval and transition
social roles. This can challenge both generations,
during which biologic, emotional, and sociocultural
and adjustments are necessary.
changes are rapidly occurring. Developmental tasks
• Making room in the system for the wisdom and
(Carter & McGoldrick, 2005; Wright & Leahey, 2005)
experience of seniors, recognizing that people are
during stage four include:
living longer; it is not unusual for a person in their
• Shifting the parent–child relationships to permit seventies to be caring for both a parent and grand-
adolescents to move in and out of the family system child. Older adults no longer live by stereotypes of
at a time when teenagers vigorously question rules. the past and may be employed, actively engaged in
Initially, parents may respond to their adolescent’s volunteerism, and maintain a very active life.
push for independence by hastily defining rigid • Dealing with the loss of a spouse, siblings, and
rules while recreating an earlier stage of dependency other peers and preparing for death, which is
or by allowing premature independence. Wright for many a time of significant transition and ad-
and Leahey (2005) suggest that parents shift from justment and a time when social support contrib-
the parental role to a “protector” role so that utes to the individual’s and family’s adaptation
adolescents are safe and then to the “preparer” role over time.
so that adolescents are prepared for the challenges
of adulthood.
• Refocusing on midlife marital and career issues. Dur-
ing this time, parents are often forced to examine DIVORCE AND THE
marital and career issues, resulting in what may be a POSTDIVORCE FAMILY LIFE
period of positive growth or painful struggle.
• Beginning a shift toward joint caring for the older Persons living in the United States experience many
generation. During this time parents often feel changes in marital status and living arrangements.
they are being besieged by teenagers seeking more The National Vital Statistics System (NVSS) indicated
freedom and parents seeking more support. that divorce rates for reporting states in the United
States were 3.6 per 1000 in 2005, down from 4.3 per family” as frequently encountered in the media. The
1000 in 1997 (NVSS, 2000). Families experiencing rationale is that “blended family” does not describe
divorce face the same developmental stages as two- family relationships or what occurs when at least one
parent families, but typically do not have the same partner in a marriage brings a child or children from a
resources. Health care providers should be aware that prior relationship.
single-parent divorce status alone influences family Carter and McGoldrick (2005, p. 377) described the
functioning. It is important for providers to focus on family entering remarriage:
the resilience of family members in the postdivorce • Entering into a new relationship with the desired
period. Resilience typically depends on the ability outcome that adults recommit to marriage and form
of parents and their children to establish intimate, a new family with preparedness to deal with its in-
meaningful, and reciprocally helpful and caring herent complexity
relationships that will provide support for members • Conceptualizing and planning the new marriage
when difficulties and challenges appear in their and family, acknowledging one’s fears and those of
lives (Wright & Leahey, 2005). Furthermore, while the new spouse and children about remarriage and
it is noteworthy that 75% of children in divorced forming a stepfamily
families are considered resilient enough to be able
Remarriage and rebuilding the family, necessitates
to move on with their lives, 25% experience more
accepting a different model of family that develop-
lasting adjustment problems (Greene, Anderson,
mentally requires realigning relationships and finan-
Hetherington, Forgatch, & DeGarmo, 2003).
cial arrangements; making room for relationships of
Divorce may occur at any time in the family life
all children with biologic parents, grandparents, and
cycle and with any family regardless of race, age, or
other extended family; and sharing memories and his-
socioeconomic class (Wright & Leahey, 2005). Carter
tories to enhance stepfamily integration.
and McGoldrick (2005) emphasized the importance
The National Stepfamily Resource Center provides a
of the emotional process of transition and atti-
clear outline of the differences between step- and first-
tude essential for attending to the issues that occur
time families (National Stepfamily Resource Center,
through the phases of the divorce family life cycle.
2000). While these may seem obvious, many times ac-
These include:
knowledging the differences is helpful. Box 5-2 high-
1. Deciding to divorce, which requires the individual lights these differences.
to accept the failure to resolve marital tensions and
to accept the part each partner has had in the failure
of the marriage.
2. Planning the break-up of the marital system while
FAMILY ASSESSMENT
supporting viable arrangements for all parties, in-
cluding cooperatively addressing issues related to GENERAL GUIDELINES
custody, visitation, and finances. Wright & Leahey (2005) cited manners, while also hav-
3. Separating while demonstrating a willingness to ing the effect of instilling trust, as a key ingredient to
continue a cooperative coparental relationship and assessment. Suggestions for any encounter with fami-
joint financial support of children while also work- lies include the following:
ing on resolutions of attachment to the spouse, • The health care provider should introduce himself
involving the restructuring of marital and parent– or herself to the patient, family members, or guests
child relationships, adapting to living apart, and re- who are present, using a full name unless safety
aligning relationships with the extended family. concerns deem that disclosure unwise.
4. Finalizing a divorce, which requires more work on • Initially, a formal approach is assumed with patients
overcoming hurt and guilt, while retrieving hopes, and family members. Family members should be
dreams, and expectations from the marriage. asked how they want to be addressed.
5. Defining “postdivorce custodial” or “noncustodial” • All children should be included in introductions and
roles. Parents are faced with maintaining the care of greetings. How children should address the health
their children while supporting the other parent’s care provider should be clarified.
relationship with the children. Parents must main- • The health care provider should position himself or
tain visitation arrangements and financial resourc- herself so that he or she is at eye level rather than
es, rebuild their social networks, and establish ways standing above or over patients.
to continue effective parenting. • The health care provider should explain his or her
Carter and McGoldrick (2005) provide a develop- role and the time period during which he or she will
mental outline for the remarried family that results in be involved with them.
children becoming part of yet another family system. • The provider should explain things before they
The National Stepfamily Resource Center encourages happen—including procedures or staff changes.
the use of “stepfamily” rather than the term “blended • All commitments should be honored.
BOX 5-2
Differences in Stepfamilies from First-Time Families
STEPFAMILIES RESULTING FROM A LOSS
• Adults grieve the loss of a partner, a marriage relationship, loss of dreams, and losses related to death or divorce.
• Children grieve the loss of a parent (even if visits are regular), loss or lessened availability of remaining parent when
courtship and remarriage occur, loss of stability, changes that happen because of divorce or death, and loss of their
fantasy of their family the way they want it to be.
PARENT–CHILD RELATIONSHIP WITH A LONGER HISTORY THAN THE NEW COUPLES’ RELATIONSHIP
• Incoming marriage partner may feel like an intruder or outsider.
• New adult partners may have difficulty “being allowed in.”
• Stepparents are not a part of the family’s history or “memory book,” which can only be accomplished as people
share time and activities.
BIOLOGIC PARENT IS IN ANOTHER PLACE

• Children need to be allowed to save memories of their other parent.
• Children whose parent is living away must have easy access to them.
• Children need permission from a parent and stepparent to love the other biologic parent.
• Children need permission of both biologic parents to like the stepparents.
• Forcing children to choose among parents places the children in a no-win emotional dilemma.
CHILDREN AS MEMBERS OF TWO HOUSEHOLDS

• Parent and stepparent need to discuss household rules for the behavior of children and consequences for broken
rules.
• Once rules are clear, they should be communicated to the children by the biologic parent.
STEPPARENTS MAY BE ASKED TO ASSUME A PARENTAL ROLE BEFORE EMOTIONAL TIES WITH THE
STEPCHILD HAVE BEEN ESTABLISHED
• Biologic parents grow into their roles; stepparents are often expected to adjust instantly as though parenting were an
inborn skill.
• The bonding process typically makes parents more tolerant of their children’s personalities and behaviors. The reverse
is also true.
THERE IS NO LEGAL RELATIONSHIP BETWEEN STEPPARENTS AND STEPCHILDREN

• Stepparents often have feelings of responsibility with no authority.
• Stepparents may need written authority for certain matters (such as to authorize emergency medical care) through a
limited power of attorney.
It is most beneficial when the provider and family group that you can affirm. Affirmation that is gen-
engage in the assessment process with the understand- uinely offered is extremely empowering as well as
ing that optimal outcomes occur when the provider trust-building.
and all family members participate as active part- There are innumerable approaches to creating
ners. The term process is essential to acknowledge, as nurturing and growth in a family. There are many
the assessment is more than the completion of a tool parenting styles that produce healthy children who
or checklist (U.S. Department of Health and Human become productive members of society. That path
Services, 2007). may be very different from the one the provider
In situations in which angry exchanges occur, it might choose, but none is superior to another. The
is often useful to step back and take the time to view provider who is for the family is actively aware of
the situation from the eyes of the family. It is likely ethnic and religious backgrounds, different values,
also that each family member will have a different and different beliefs; is open to different ideas; and
viewpoint, just as each person’s experience in a fam- is likely to partner successfully with families, result-
ily is different. It is also useful to take the time to ing in satisfactory outcomes that allow families to
find something about the family member or family reach their goals and expectations.
TYPES OF FAMILY ASSESSMENT result in the provider determining the need for a com-
Many families are never engaged in a formal family as- prehensive family assessment as described by the U.S.
sessment process. For all families, though, it is beneficial Department of Health and Human Services Adminis-
when the health care provider practices within the tration for Children web site (2007). Comprehensive
context of a family perspective. Many children appear family assessment is always indicated when there is
for well-child appointments or time-limited acute con- need to involve the child welfare system, with review
ditions during which the provider assesses the prob- and updates indicated when there are changes regard-
lem and intervenes accordingly. It is assumed and ing matters such as child placement, reunification
expected that providers working in a pediatric setting decisions, court reviews, and termination of parental
are competent in assessing growth and development rights. The web site noted above provides excellent
of infants, children, and adolescents, as well as in information for providers whose roles involve assess-
recognizing developmental issues encountered by ments of this nature.
families at different stages.
An important consideration is that many capable
A BRIEF FAMILY ASSESSMENT
parents may experience a time in their child’s devel-
opment where they find themselves in difficulty; for Health care providers in all practice settings are chal-
example, managing bedtime or eating habits. Some lenged by time constraints and patient care issues
families do well through infancy and toddlerhood that necessitate a brief family assessment unless
and find themselves challenged when children enter issues or needs emerge that indicate a more in-
school. Some families do not particularly enjoy infant depth consideration of the family is needed. Within
care but excel with their toddler or adolescent. The a 10- to 15-minute assessment there is opportunity
point to establish in the relationship with the family for purposeful conversation, structural assessment,
is that providers can intervene in helpful ways, prefer- therapeutic inquiry, and partnership with the family
ably before a crisis occurs. that leads to opportunities to affirm and commend
family and individual strengths. Skilled providers are
able to integrate the tasks of necessary patient care
with engaging, purposeful conversation. In any set-
SENSITIVE ISSUES ting there is opportunity to explore with the family
It is helpful for health care providers to consider their ideas regarding what is needed to address the
issues that may be sensitive for family members. presenting problem. Through such conversation,
What has become normalized through everyday there is also opportunity to recognize the family’s
work experiences may not be so for the family. For skill in managing the health issues they have en-
example, there may be a family in which each of countered. All families can be included throughout
the three young children has a different father. Per- this type of communication. It is important to note
haps a parent has been reported for abuse or neglect. that a critical part of the interview is listening! The
Occasionally, families are sensitive regarding health- family is the expert in identifying its needs and in
related matters if they feel responsible for them. suggesting approaches for addressing them. The pro-
Perhaps a parent is responsible for injuring a child, vider who is attentive to all methods and levels of
albeit accidentally. Sometimes families are sensitive communication recognizes important messages fam-
about social issues, such as a parent in prison or a ily members share.
family member who has been negatively presented Structural assessment of the family can be ap-
in the media. For others, financial concerns may proached through a simple genogram and by identi-
limit their ability to purchase essential medications fying external support information. Family members
or other necessities. Without genuinely and authenti- can be asked two or three purposeful questions. Infor-
cally engaging with the family, it will not be possible mation can be gleaned not just from verbal responses
to know the diseases, situations, or conditions that but from all that is perceived as the basis for iden-
families may perceive as carrying a stigma. tifying strengths and affirming the family’s dignity
and capacity to deal with the circumstance currently
confronting it. Providers can clearly state their belief
in the family’s capacity to embrace the challenges it
INDICATIONS FOR A COMPREHENSIVE faces, while also assuring family members that there
FAMILY ASSESSMENT will be support from health professionals who can best
Initial interactions with the family may result in the assist them with needs that emerge. The knowledge
provider determining the need to explore an aspect of that a trusted professional believes in the family can
the family further that relates to a presenting health be extremely empowering—particularly when that
issue; for example, exploring a family’s reluctance to professional also assists as teacher, resource person,
attend to a school-aged child’s postoperative dressing coach, or in other capacities that foster the health of
change. Another communication with the family may the family.
There may be occasions that lead providers to

BOX 5-3
doubt the family members and their abilities. At
Potential Questions Regarding
times, that may be a valid response. Nonetheless, pro-
viders must take a moment to suspend assumptions
Internal Structure
and disbelief and recall the individual patient and 1. How many people are in your immediate family?
family triumphs, both anticipated and unexpected, Who are they, and how are they related?
that have occurred in the health care provider’s ca- 2. Which family members live at home? How many of
reer. Perhaps that next triumph is right around the these are children, and what ages are they? Do any
corner, waiting for a provider to facilitate and guide nonfamily members live in the home?
the journey. 3. Has anyone recently moved in or out? If so, how has
this move impacted the family?
4. Who takes responsibility for administering medication
THE CALGARY FAMILY ASSESSMENT when someone in the household is ill (e.g., flu
MODEL medicine, antibiotics, diabetes medications)?
The CFAM includes three major categories (Wright 5. Does everyone share household tasks equally in your
family? Some families have specific roles for certain
& Leahey, 2005): (a) structural, (b) developmental,
people. How are the roles divided in your home?
and (c) functional. Each category contains several
6. Is there any marital discord in the family? What are
subcategories, and it is important for the health care
the issues over which the parents disagree? How are
provider to decide which subcategories are relevant.
these disagreements handled?
The provider may move among categories, synthesizing
7. How are problems solved in the family? Is one member
relevant information into an integrated assessment.
of the family delegated as the problem-solver?
The provider who is familiar with CFAM can use it
8. If someone in the family was troubled, ill, or
as an organizing framework to help families address
depressed, to whom would they be likely to speak? A
problems or issues. trusted friend, another relative, or someone from the
religious community to which you belong?
Structural Assessment
The provider considering the family’s structure ex-
amines who is in the family, the connection among
members, and the family context. Internal structure
BOX 5-4
includes family composition, gender, sexual orien-
tation, rank order, subsystems, and boundaries. It is
Potential Questions Regarding
important to note changes in the family’s composi- External Structure
tion, whether transient or permanent. It is critical 1. Do both parents of the family live at home? If not,
that the provider ask questions for a specific purpose where do they live?
while also noting that it is helpful to begin with 2. How often do the children have contact with the
questions of a less intrusive nature. Box 5-3 suggests parent or parents who do not live at home?
questions that may be useful in exploring family 3. How often is there contact with the extended family
structure (Wright & Leahey, 2009). (e.g., aunts, uncles, grandparents)?
External structure includes the extended family and 4. Is their any ongoing conflict with the extended
larger systems. Ties to extended family members can be family or in-laws?
highly influential, and it is important to explore how 5. Are there steprelatives in the family?
significant the extended family is to this particular
6. Which relatives are closest emotionally to the
family. Larger systems include social service agencies immediate family?
and personnel with whom the family has meaning-
7. Who is the most helpful when problems arise? How
ful contact. Box 5-4 suggests questions that may be are these problems solved within the family?
helpful to the assessment of external family structures
8. Who generally makes all of the important decisions
(Wright & Leahey, 2009). in the family? Does everyone of a certain age have a
Context is the complete situation that is relevant chance to voice an opinion?
for the family and includes ethnicity, race, social 9. Do one or both parents work? If both, who is
class, spirituality, religion, and environment. Box 5-5 responsible for child care in their absence? Do older
suggests questions that address these areas (Wright & children look after younger children?
Leahey, 2009). 10. Have there been any incidents of child abuse or
violence in the home?
Constructing a Genogram 11. Are there any agencies involved with your family? If
A genogram, a diagram of the family constellation, can so, which ones and why? What has been the most
simply communicate an abundance of information. useful help you have received from these agencies?
It provides data about relationships, health, religion,
square or circle, which signify a male or female child,

BOX 5-5
respectively. If a family member has died, the year of
Potential Questions Regarding death is noted above. Figure 5-1 shows a blank geno-
Context gram, and Figure 5-2 shows the symbols that are used
1. Would you tell me about your Chinese practices in a genogram.
regarding illness? An example of a nuclear and extended family is
2. How does coming to the United States from Mexico presented in Figure 5-3 for the Stone family. Alex, age
influence your beliefs about when to see a health 44, is married to Eva, age 43. They married in 1993.
professional? They have three children: Anne, age 13 in grade 7;
3. What does health mean to you? Marie, age 7 in grade 2; and Joey, age 4 in preschool.
4. Could you help me to understand what I need to Alex’s mother Jill has arthritis. Both of Eva’s parents are
know to be most helpful to you? deceased. Her father died in 1990 of a “heart problem”
5. How many times have you moved in the past 5 years? and her mother in 1996 of problems related to diabe-
6. How many schools have your children attended? tes. Alex has an older sister who is depressed. Eva has
7. How does your insurance situation affect your use
an older brother and sister.
of health care?
8. Are you involved with a temple, mosque, church, Family Developmental Assessment
etc.? Would talking to anyone from this place be a While health care providers working with children are
support for you in dealing with your illness? typically familiar with stages of child development,
9. Are your spiritual beliefs a source of stress or systematic consideration of family development and
support for you? family life cycle may not be an active component of
10. What community services does your family use? interventions of the provider. Societal changes require
11. On a scale of 1 to 10, with 10 being most a rethinking of traditionally accepted assumptions
comfortable, how comfortable are you in your regarding normality and what family means in the
neighborhood? North American culture. All families represent complex
systems that experience ongoing growth, transitions,
and changes.
occupation, ethnicity, and migration. Because the geno- Family Functional Assessment
gram focuses on the biologic family, some criticize its in- Functional assessment addresses how individuals behave
adequacy in recognizing the importance of the family’s in relation to one another in everyday living. Instrumen-
interaction with those outside their family. tal functioning refers to activities of daily living, such as
Nevertheless, genograms facilitate an understanding meal preparation, caring for a family member’s health
of family constellations and patterns that occur among needs, getting children off to school, doing laundry,
family members and across generations. and going to work. The expressive aspects of function-
The skeleton of the genogram is a family tree de- ing include nine categories (Wright & Leahey, 2005), as
picting the family structure. It is most helpful to in- follows: (a) emotional communication, (b) verbal com-
clude three generations. Family members are situated munication, (c) nonverbal communication, (d) circular
in horizontal rows that signify generational lines. communication, (e) problem-solving, (f ) roles, (g) influ-
Children are denoted by vertical lines and are rank- ence and power, (h) beliefs, and (i) alliances and coali-
ordered from left to right, beginning with the eldest tion. Families having difficulty with instrumental issues
child. The person’s name and age are noted inside the almost always have challenges in areas of expressive
Grandparents
Aunts and Uncles
Parents
Children
FIGURE 5-1. Blank genogram.

Male Female
M 1974
Children: Birth
order (beginning
with oldest on left)
Marriage (M)
or common law (CL)
husband on left,
wife on right
Miscarriage
Abortion
1978
or (give) Adoption
Twins:
Death
(give date)
Circle members of current household
S1983 D1986
Marital separations Family assessment

(give date) Divorce (give date)
FIGURE 5-2. Symbols that are generally used in genograms.
1996 1990
Diabetes Heart Problem
Joe Jill Steven Sara
Arthritis
Depressed
Alex M 1993 Eva

44 43
Anne Marie Joey

13 7 4
Grade 7 Grade 2 Pre-school

FIGURE 5-3. Sample genogram of the Stone family.
functioning. The primary focus of the functional assess- Cowan, P. A., & Cowan, C. P. (2003). Normal family transi-
ment is on the “here and now.” Thus, while past behav- tions, normal family process, and healthy child develop-
ment. In Walsh, F. (Ed.). Normal family processes: Growing
iors and future goals are considered, the commitment of diversity and complexity. (3rd ed.). (pp. 424–459). New York:
the provider is to the present. Guilford Press.
Greene, R. J., Anderson, E. R., Hetherington, E. M., Forgatch,
M. S., & DeGarmo, D. S. (2003). Risk and resilience after divorce.
In Walsh, F. (Ed.). Normal family processes: Growing diversity and
SUMMARY complexity. (3rd ed.). (pp. 96–120). New York: Guilford Press.
Harniss, M. K., Epstein, M. H., Ryser, G., & Pearson, N. (1999).
The behavioral and emotional rating scale: convergent valid-
While CFAM may seem detailed, complex, and lengthy, ity. Journal of Psychoeducational Assessment, 17, 4–14.
its inclusive and thorough approach need not be over- Herek, G. (1988). Heterosexual attitudes toward lesbian and gay
men: Correlates and gender differences. Journal of Sex Research,
whelming if the provider uses it as a guide to learn 25(4), 451–477.
from the family so as to have the information that will Herek, G. (2000). The psychology of sexual prejudice. Current Di-
optimally guide the care that follows. The provider rections in Psychological Science, 9(1), 19–22.
Lobaugh, E. R., Clements, P. T., Averill, J. B., & Olguin, D. L.
may elect to use the three main categories to obtain (2006). Gay-male couples who adopt: challenging historical
an overview of family strengths and needs. Based on and contemporary social trends toward becoming a family.
the findings of that overview, the provider may elect Perspectives in Psychiatric Care, 42(3), 184–195.
National Stepfamily Resource Center. (2000). Stepfamily fact sheet.
to do a more detailed assessment of selected areas prior Retrieved August 3, 2007, from http://www.stepfamilies.info/
to considering approaches to address identified needs. faqs/factsheet.php.
Regardless of the approach and depth of inquiry, it is National Vital Statistics Center. (2000). Births, marriages, divorces,
and deaths: Provisional data for March 1999. 48(4). Retrieved
essential that the provider is comfortable with the in- July 23, 2007, from http://www.cdc.gov/nchs/data/nvsr/nvsr
formation that has been obtained and that it is then 49/nvsr49_06.pdf.
used to draw all the relevant information together into National Vital Statistics Center. (2006). Births, marriages, divorces,
and deaths: Provisional data for March 2005. 54(20). Retrieved
an integrated body of information. August 3, 2007, from http://www.cdc.gov/nchs/data/nvsr/nvsr
While historical data may be important, it is im- 54/nvsr54_20.pdf.
portant that it be integrated only insofar as it serves Peplau, H. E. (1991). Interpersonal relations in nursing: A conceptual
framework for psychodynamic nursing. New York: Springer.
to explain a current situation or the way the family is Tedeschi, R. G., & Kilmer, R. P. (2005). Assessing strengths, resil-
currently functioning. It is critical to remember that ience, and growth to guide clinical interventions. Professional
the assessment is not a fixed truth with a guarantee Psychology: Research and Practice, 36(3), 230–237.
Thomlison, B. (2007). Family assessment handbook: An introductory
of accuracy. Both the health care provider and family guide to family assessment and intervention. (2nd ed.). Belmont,
members have individual perspectives that have been CA: Thomson Higher Education.
gained through mutual inquiry and consideration. U.S. Census Bureau. (2003). Children’s living arrangements and
characteristics: March 2002. Retrieved July 27, 2007, from
http://www.census.gov/prod/2003pubs/p20–547.pdf.
U.S. Department of Health & Human Services. (2007). Comprehensive
REFERENCES family assessment. Retrieved August 3, 2007, from http://www.
The American Academy of Pediatrics. (2002). Coparent or sec- acf.hhs.gov/programs/cb/pubs/family_assessment/fa2.htm.
ond parent adoption by same-sex parents. Pediatrics, 109(2), Wells, R. D., & Stein, M. T. Special families. (2006). In Dixon, S. D.,
339–340. & Stein, M. T. (Eds): Encounters with children: Pediatric behavior
Carter, B., & McGoldrick, M. (Eds.). (2005). The expanded family life and development. (4th ed.). (pp. 622–647). Philadelphia, PA:
cycle: individual, family and social perspectives. (3rd ed.). Boston, Mosby/Elsevier.
MA: Allyn & Bacon. Wright, L. M., & Leahey, M. (2009). Nurses and families: A guide to
Chicago Public Schools. Chicago Public Schools drive. Retrieved family assessment and intervention. (4th ed.). Philadelphia, PA:
July 27, 2007, from http://www.cps.edu/Pages/home/aspx. F. A. Davis Company.
CHAPTER
Obtaining the
6 Pediatric Health
History ELLEN M. CHIOCCA
the historian, in most cases the child’s parent or guard-

HOW TO CONDUCT A ian. This involves assessing the quality of the historian’s
PEDIATRIC HISTORY INTERVIEW responses to questions with respect to clarity, consis-
tency, or vagueness of the information provided. The
Obtaining an accurate and complete pediatric health provider should also assess the historian’s anxiety level.
history is critically important when providing health A reliable historian provides clear, consistent informa-
care to children. The health care provider not only re- tion. It is important to assess whether or not the histori-
lies on objective data gleaned from the physical exam, an fully understands the questions being asked. For this
laboratory results, and other diagnostic tests, but also reason, the provider should avoid using medical termi-
on subjective data collected from the health history to nology or jargon, as this may be confusing. If the histo-
identify health risks, educational needs, and knowledge rian does not speak English, a trained interpreter should
deficits. In addition, these data enable the provider to be provided. Using the child to translate questions and
make an accurate diagnosis and provide appropriate responses into English should be avoided; in some cul-
management. The depth of the pediatric health his- tures, when a child assumes such a responsibility, the
tory depends on the reason for the child’s health visit. role reversal is deemed inappropriate and conveys dis-
respect to the parent (Hockenberry & Wilson, 2007).
Also, a young child is unlikely to have the maturity and
COMMUNICATION vocabulary to interpret the interview correctly. This can
Communicating well and establishing rapport with the lead to inaccuracies, which could result in misdiagnoses
parent or primary caregiver and the child are crucial and potential legal liabilities (Lehna, 2005).
during the health history interview (see Chapter 3).
This not only lays the foundation for a trusting rela- Developmental Considerations
tionship but also conveys to the parent and child that Whether or not a child participates in providing his
they are important. If trust is established during this in- or her own history depends on the child’s chrono-
terview, the child is likely to be more cooperative dur- logic age, developmental level, and temperament.
ing the physical examination, and more accurate data When developmentally appropriate, all pediatric cli-
are likely to be obtained. When interviewing the child ents, preschool-aged and older, should participate in
and parent, the provider must ask questions in a non- the interview process, giving the provider an oppor-
judgmental, unhurried manner, avoiding interruptions tunity to assess the child’s language abilities, social
whenever possible. The provider should sit down when skills, and knowledge of health and illness (Instone,
taking the history, thereby conveying to the child and 2002). It also allows the provider to note the child’s
parent that the provider has time for them and is in- cognitive abilities and intellectual skills and provides
terested in what they have to say. Maintaining privacy a cursory view of the child or teen’s overall behavior
and confidentiality during the interview is also essen- and temperament. In addition, it conveys to the child
tial and further facilitates the establishment of trust. that he or she is important and that the health care
provider is interested in hearing about his or her life
Reliability and Accuracy of the History and concerns. It also prepares the child for being a
During the health history interview, it is important for lifelong, active participant in his or her own health
the provider to determine the reliability and accuracy of care (see Chapter 3 for an in-depth discussion of the
89
developmental aspects of communicating with chil- and interests. Then the provider can proceed to more
dren and adolescents). sensitive issues (Instone, 2002). The adolescent should
be reassured that what is discussed with the provider is
Infants and Young Children. For infants and preverbal confidential, unless intervention is necessary to avoid
children, the primary source of historical information harm to the teen or others.
is the parent or primary caregiver. For older infants and
toddlers, it is important that the parent remains with-
in eyesight of the child to minimize stranger anxiety. PHYSICAL SURROUNDINGS
Parents can then concentrate on answering questions Facilitation of history-taking includes providing an
rather than tending to a crying child (Fig. 6-1). Some appropriate physical environment. A comfortable
preschoolers can answer questions during the history, and welcoming environment helps the health care
depending on their language abilities, developmental provider obtain the most complete health history
level, and temperament. These questions may involve possible. There should be a place for everyone in the
play, toys, likes, dislikes, friends, and school. Young room to sit and an examination table on which the
children who are very shy should not be forced to par- child may lie down. Examination rooms should also
ticipate in the interview, and children should not be be clean, well lit, and child safety-proofed, ensuring
overwhelmed with too many questions. The health that any equipment, needles, or medications are
care provider should remember to use simple terms kept out of reach. The exam room should be kept
and avoid medical jargon. at a comfortable temperature, and there should be
minimal noise that could distract the health care
School-aged Children and Adolescents. Children provider, parent, or child. Age-appropriate toys and
who are school-aged and older can provide their own books in both the waiting and examination rooms
health history with verification from the parent or provide welcome diversions for children and help to
caregiver as needed. Beginning the encounter with the occupy the child so the parent can concentrate on
parent in the room is important to make the child feel giving a proper history. This also allows the provider
comfortable and secure. Older school-aged children an opportunity to assess the child’s attention span,
and adolescents have a heightened need for privacy; ability to play independently, and overall behavior.
for this reason, the parent should be asked to leave Additionally, this allows the provider to observe
the room for certain portions of the history, such as parent–child interactions (Bickley, 2007).
questions that deal with drug or alcohol use, sexual The examination rooms should be decorated in an
activity, depression, and risk-taking behaviors. The age-appropriate manner. Pediatric clinics that function
pre-teen or adolescent client is more likely to give ac- as “teen clinics” during off-peak hours should have
curate answers without the parent present. Before this rooms set aside in which adolescents will feel comfort-
portion of the health history is obtained, however, it able and relaxed. Motifs that employ popular cartoon
is important for the health care provider to establish a characters are appropriate for very young children but
rapport with the child by asking questions about his may be off-putting to an adolescent.
or her life that are not emotionally charged, such as
those concerning school, friends, activities, hobbies,
TYPES OF PEDIATRIC HEALTH

HISTORIES
Before the provider can obtain the health data, the
reason for the child’s health care visit must be deter-
mined; the type of health history that is necessary is
dictated by the purpose of the visit. Types of pediatric
health histories include:
• Initial (comprehensive) health history: An initial
client visit requires a comprehensive health history,
which creates a database of information for the child
who is new to the provider’s practice. The data col-
lected in this history focus not just on past or cur-
rent illnesses, but also on wellness, health patterns,
health knowledge, and activities of daily living
(ADLs). The content of this history creates a baseline
FIGURE 6-1. Keeping a younger child on the caregiver’s lap
during the interview helps to minimize stranger anxiety and against which all future changes in the child’s health
increases the child’s sense of security. status are measured.
C H A P T E R 6 O btain in g th e Pe diatric Health Histor y • 91
• Interval (well-child) health history: Subsequent For every health care encounter, the child’s past
well-child visits require an interval history; that is, medical history (PMH) must be obtained and reviewed
a history that updates the client’s health status since as this provides important information about all as-
the last office visit. pects of the child’s general health. The pediatric PMH
• Focused (episodic) health history: This history is includes the prenatal and birth histories, the immuni-
problem-centered, focusing on the present illness or zation history, and a history of growth and develop-
problem. A focused health history is all that is neces- ment (see the section on Past Medical History below).
sary when the child presents with an acute problem This information can be used to make a diagnosis in
or the exacerbation of a chronic condition. the child. It may also provide information about the
• Follow-up health history: When the child returns teaching needs of parents. In addition, a pediatric PMH
to the office after an illness or injury, a follow-up includes a comprehensive review of systems (ROS), the
history is done to assess whether the problem is the components of which can be reviewed in Table 6-1.
same, better, or worse. The provider must assess the child’s family medi-
• Emergency health history: An emergency health cal history, as it helps to determine the health sta-
history involves the quick collection of data in an tus of family members and may help to narrow the
acute situation. While this history resembles a fo- differential diagnoses. All pediatric health histories
cused history, it needs to be done rapidly, usually must include an up-to-date allergy history. In addi-
with simultaneous interventions, such as the admin- tion, a list of current daily and as-needed medications
istration of medications or respiratory treatments. should be elicited, including the dose, the frequency
When obtaining a pediatric health history, it is of the drug, and an indication for its use. A list of
important to remember that these various histories herbal remedies must also be obtained. The provider
are not mutually exclusive. For example, if the pro- should determine if the child’s immunizations are up-
vider notices that a child appears ill during a yearly to-date or if there have been any reactions to past
well-child visit, it is important to obtain a focused immunizations.
history regarding the current illness. Similarly, if a
child presents for an acute visit, but appears to the
provider to be underweight and has not reached ap- INITIAL HEALTH HISTORY
propriate developmental milestones, questions must
The initial health history is a comprehensive health his-
be directed to these problems as well as the present-
tory, one that makes up the child’s baseline database.
ing illness.
An initial health history is conducted on all pediatric
Several components of the health history are com-
clients when they are seen for the first time. Because
mon to all types of pediatric health histories. This
taking the initial health history is time-consuming, a
includes relevant biographical information such as the
full hour should be allotted for the visit, which also
child’s name, nickname, age, date of birth, gender,
includes the physical exam. The initial health history
race, ethnicity, religion, and the child and family’s pri-
begins by obtaining general biographical information,
mary spoken language. The parent or primary caregiver’s
recording the source of this information, and assessing
name, address, and phone numbers (i.e., home, work,
the reliability of the informant. The reason for seeking
cell phone) should also be recorded. An emergency
health care is documented; it is usually the first visit by
contact, with an address and phone number, should
the infant, child, or adolescent. A detailed PMH should
be obtained as well.
be obtained, which needs to be updated each time the
The provider should always record the source of
child is seen.
historical information and assess the reliability of
the informant and that person’s relationship to the
child. The chief complaint or the reason for seeking Past Medical History
health care is recorded no matter what type of health Prenatal, Birth, and Neonatal History. The depth
history is obtained. This should be brief and stated of this history-taking depends on the child’s age.
in the parent or child’s own words (not paraphrased The younger the child, the more important this in-
by the provider). The reason for seeking health care formation is, as prenatal, birth, and neonatal events
is elicited by asking open-ended questions such as, are crucial to a child’s future physical and psychoso-
“What brings you here today?” cial growth and development and may explain any
The provider should treat all concerns seriously neurologic or developmental problems. The provider
and listen carefully for “hidden agendas.” Sometimes should obtain as much detail as possible in these areas
the chief complaint of the child is very different from in children 3 years of age and younger and in older
the concerns of the parent or caregiver (Weber & children who have ongoing problems because of a
Kelley, 2007). Also, adolescent clients and their par- birth injury (see Chapter 11 for a thorough discussion
ents may differ greatly in what they see as the chief of the components of prenatal, birth, and neonatal
complaint. health histories).
TABLE 6-1
Pediatric Review of Systems
General Overall state of health; recent weight loss or gain (compare to growth charts); obesity; delays
in physical, psychosocial, or language development; fatigue; weakness; malaise; difficulty
performing activities of daily living; or chronic pain
Integument General skin texture, birthmarks, or pigmentation; skin color changes: jaundice, cyanosis,
mottling, pallor, bruising, or petechiae; rashes or lesions (location and description); excessive
skin dryness; pruritus; hives; atopic dermatitis; contact dermatitis; seborrhea; acne; changes in
moles; changes in body hair: excessive hair growth or loss or hair color change; nail disorders; or
pediculosis
Head Head size and shape (including fontanels), microcephaly, macrocephaly, head injuries,
headaches, or dizziness
Eyes Visual problems: blurred vision, double vision, bumping into objects, sitting very close to the
television, inability to see blackboard, holding book very close to face, squinting, rubbing eyes,
photophobia, use of glasses or contact lenses; date of last eye exam and results; strabismus;
dizziness; eye drainage or infections; excessive tearing; or eyelid edema
Ears Ear infections (e.g., otitis media, otitis externa), ear pain, ear drainage, surgery (e.g.,
myringotomy with tympanostomy tubes), delayed speech, evidence of hearing loss, date of last
hearing exam and result, or tinnitus
Nose Frequent rhinorrhea, upper respiratory infections, sinusitis, allergic rhinitis, stuffy nose, nasal
congestion, allergies, mouth breathing, snoring, obstructive sleep apnea, epistaxis, allergic salute,
allergic crease, dark circles under eyes, or altered sense of smell
Mouth/Throat Tooth eruption/loss pattern, number of teeth, teething (infants), dental care, use of fluoride,
dental caries, age of first dental visit, date of last visit to dentist, frequency of dental visits, tooth
pain, history of dental trauma, sores in mouth or tongue, history of oral candidal infections,
gum bleeding, mouth breathing, tonsillar enlargement or infections, history of tonsillectomy,
postnasal drip, cleft lip/palate, sore throats, streptococcal infections, difficulty chewing or
swallowing, hoarseness, or voice and cry irregularities
Neck Limitation of movement, pain, stiffness, torticollis, thyroid enlargement, or lymphadenopathy
Chest Pain, newborn breast enlargement, female thelarche, male gynecomastia, breast lesions,
discharge, or enlarged axillary nodes
Lymphatic System Frequent infections, fevers, pain, swelling, tenderness of any lymph nodes, hepatosplenomegaly,
chills, night sweats, or pallor
Respiratory System Frequent respiratory infections, dyspnea (shortness of breath), apnea, stridor, croup, pneumonia,
cystic fibrosis, asthma, wheezing, chronic cough, sputum production, reduced exercise
tolerance, dyspnea at rest or on exertion, cyanosis, or tuberculosis; date of last chest radiograph
and skin reaction from tuberculosis skin testing; or history of smoking or secondhand smoke
exposure
Cardiovascular Murmurs, congenital heart defects, poor infant feeding, slow or decreased weight gain, chest
System pain, cyanosis, tachypnea, tachycardia, hypertension, edema, cold extremities, dizziness,
palpitations, fainting spells, exercise intolerance, dyspnea on exertion, fatigue, diaphoresis,
rheumatic fever, anemia, or recent blood transfusion
Gastrointestinal Appetite, food intolerances, dietary history, abdominal pain, ulcers, nausea, vomiting, reflux,
System recent changes in bowel patterns, gastrointestinal infections, diarrhea, belching, flatulence,
constipation, type and frequency of stools, use of laxatives, blood in stools, jaundice, anal
itching, fissures, or pinworms
Genitourinary Dysuria, frequency, urgency, burning, hesitancy, enuresis, urinary tract infections, discharge,
System pyuria, polyuria, oliguria, hematuria, character of stream, or flank pain; history of epispadias
or hypospadias and date of surgery; history of cryptorchidism (include age of child and if
orchiopexy performed, include date of surgery); hernia, hydrocele, swelling of scrotum when
crying, performance of testicular self-exam in adolescent males, sexually transmitted infections,
or sexual activity
TABLE 6-1
Pediatric Review of Systems
Gynecologic System Age of menarche, date of last menstrual period, length of menses, frequency of cycle,
dysmenorrhea, history of heavy menstrual bleeding, vaginal discharge, abnormal vaginal bleeding,
sexual activity, type of contraception, date of last Pap smear, or obstetric history, if applicable
Musculoskeletal Usual activity level, history of weakness, clumsiness, ataxia, lack of coordination, unusual
System movements, joint or muscle pain, cramps or inflammation; swelling, sprains, fractures, mobility
problems, back or joint stiffness, abnormal gait, limps, or spinal curvatures
Neurologic System General affect and mood, ataxia, tremors, tics, dizziness, syncope, tingling, sensory changes,
paresthesias, unusual movements, seizures, loss of consciousness, memory loss, headaches,
aphasia or other speech problems, fears, nightmares, or unusual habits
Endocrine System Disturbances in growth, polyuria, polyphagia, polydypsia, thyroid disease, obesity, type 1 or 2
diabetes, excessive sweating, salty taste to skin, intolerance to temperature changes, signs of early
or delayed puberty, or abnormal hair distribution
Hematologic System Anemia, pallor, lymphadenopathy, bleeding disorders, bruising, petechiae, bleeding gums, blood
transfusions, toxic drug exposure, radiation, or chemotherapy
Psychosocial Developmental delays, behavior changes, tantrums, breath-holding spells, bedwetting, school
Development failure, social withdrawal, irritability, sleep pattern disturbances, depression, substance abuse,
eating disorders, or psychiatric disorders
Table 6-2 summarizes the components of these the child contracted any childhood infectious diseases
histories. The prenatal, birth, and neonatal histories and any complications that resulted should be noted.
are obtained at the child’s initial visit and do not need
to be updated because the information does not change. Allergies. All allergies to medications, food, animals,
In some cases, information may come from the medi- and insect bites; environmental allergies; and a his-
cal records from the hospital or birthing center where tory of eczema, allergic rhinitis, contact dermatitis, or
the child was born, if the mother or primary caregiver latex sensitivity should be noted. The type of allergic
does not know the answers to the medical questions in reaction the child has experienced in the past should
the histories. be recorded (e.g., rash, hives, itching, respiratory dis-
tress), including any anaphylactic reactions. It may be
Acute and Chronic Illnesses. This component of helpful to ask the parent to describe what they believe
the history comprises the child’s current health status. is an allergic reaction to distinguish it from a side ef-
The health care provider should inquire about com- fect of a medication. It is important to have accurate
mon childhood illnesses such as respiratory infections, information concerning allergies to any drugs before
ear infections, diarrhea, vomiting, and dehydration. prescribing medications.
The provider should also ask about chronic illnesses,
including congenital anomalies, genetic disorders, Medications. The provider should ask about all
cancer, rheumatic fever, heart disease, hypertension, current prescribed or over-the-counter (OTC) medi-
obesity, diabetes, sickle cell disease, cystic fibrosis, cations that the child is taking, for example, anti-
asthma, allergies, eczema, seizure disorders, neurologic pyretics, topical medications, and cough and cold
infections, tuberculosis, renal disease, depression, and preparations, especially those containing acetamino-
anxiety disorders, among others. The age of onset, the phen, to avoid unsafe dosing. The name, dose, and
treatment, when the treatment was initiated, and any frequency of the drug should be recorded for each
complications should be determined for all illnesses. medication along with the parent’s report of the
Also, the provider should ask about frequent visits to indication for the drug. Multivitamins, herbal rem-
the emergency room for treatment of minor illnesses edies, and the use of complementary and alternative
so that, if necessary, the family can be referred to a medical (CAM) therapies such as traditional healers,
primary care provider. acupuncture, or massage should be included in this
assessment.
Childhood Infectious Diseases. The provider should
determine if the child has had measles, mumps, rubella, Hospitalizations. The date, the child’s age, and the
varicella, pertussis, streptococcal infections, or has reason for any hospitalization as well as the name of the
recently been exposed to these illnesses. The age at which hospital and duration of the stay should be recorded.
TABLE 6-2
Components of Prenatal, Birth, and Neonatal Histories
Prenatal History • Maternal age
• Month at which prenatal care began
• Pregnancy planned?
• Methods of contraception
• Number of previous pregnancies and outcomes
• Mother’s health before and during pregnancy (e.g., illnesses such as rubella, varicella, urinary tract
infections, hepatitis, sexually transmitted infections; HIV status)
• Stresses during pregnancy (e.g., injuries, family problems, crises)
• Onset of fetal movement
• Medications taken during pregnancy (e.g., prescription, OTC) or alternative/complementary
therapies (e.g., hormones, antibiotics, vitamins, fertility drugs)
• Length of pregnancy
• Pregnancy-related conditions (e.g., abnormal vaginal bleeding, placental previa, edema, excessive
weight gain, hypertension, pre-eclampsia, proteinuria)
• Radiation exposure
• Assessment of mother’s diet during pregnancy
• Certain fish (e.g., shark, swordfish, king mackerel, tilefish), which should not be consumed during
pregnancy
• Illegal drug use, including type, frequency, and route
• Alcohol use, including amount and frequency
• Tobacco use, including type, frequency, and packs per day
• Infections transmitted by house pets (e.g., tinea infections)
• Family genetic history
Birth History • Duration of pregnancy

• Length of labor
• Place of delivery
• Amount/type of anesthesia/analgesics used during labor
• Type of delivery (e.g., NSVD, induction, forceps, breech, C-section [primary, repeat or emergency
C-section for fetal distress], VBAC)
• Problems associated with labor and delivery (e.g., nuchal cord, neonatal seizures, intraventricular
hemorrhage, fever)
• Condition of infant at birth (e.g., onset of cry/APGAR scores)
• Respiratory problems after delivery (e.g., oxygen requirements, if any; resuscitation efforts,
intubation, ICU admission)
• Mother’s physical and mental condition postpartum
Neonatal History • Gestational age

• Birth weight, length, head circumference
• Problems in the nursery (e.g., hypothermia, fever, hypoglycemia, poor feeder, oxygen
requirements, respiratory distress, apnea, cyanosis, seizures, excess sleeping)
• Jaundice-physiologic, ABO/Rh incompatibility, sepsis
• Congenital anomalies (e.g., cardiac, cleft lip/palate, imperforate anus, diaphragmatic hernia)
• Feeding problems/lethargy
• Sleep patterns
• Number of days in hospital and whether discharged with mother
• Discharge weight
• Illness (especially fever) within first 2 months of life
• Degree of bonding (ask and observe)
C-section, cesarean section; HIV, human immunodeficiency virus; ICU, intensive care unit; NSVD, normal spontaneous vaginal delivery;
OTC, over-the-counter; VBAC, vaginal birth after C-section.
Records of the hospitalization should be obtained as for and the frequency of hospitalizations to determine
needed. The provider should inquire about the child’s whether child neglect is a factor.
psychologic reaction to any hospitalizations. It should
also be noted whether the child received any blood Surgeries. The date of any surgical procedure should
transfusions and if there were any reactions to the be recorded, as well as the child’s age at the time of
transfusions. The provider should evaluate the reasons surgery, the reason for surgery, the type of surgical
procedure, and whether there were any complica- Screening Procedures. The health care provider
tions. If the child had a same-day surgical procedure, should determine if the child has had the recommended
it should be noted whether the child was able to go age-appropriate routine screening tests such as newborn
home the same day or needed to be admitted to the screening, vision and hearing screening, blood pressure
hospital for complications (e.g., a child who has a measurement, hemoglobin or hematocrit screening for
tonsillectomy but is unable to be discharged as a result iron deficiency anemia, lead or tuberculosis screening,
of dehydration secondary to inadequate oral intake or or urinalysis. Condition-specific screening tests such as
postoperative bleeding). A note on the child’s course sickle cell anemia, human immunodeficiency virus, cho-
of recovery of inpatient surgical procedures should be lesterol, or other metabolic or genetic screenings should
included, and whether the child needs any ongoing also be noted. The dates of each exam and the results
treatments after the surgery (e.g., chemotherapy or should be recorded (see Chapter 9 for a discussion of
radiation after surgery for cancer). recommended screening procedures for children).
Injuries/Ingestions. The date of any injury should be Family Medical History

documented in addition to the age of the child when Obtaining the child’s family health history is necessary
injured, the type and extent of injury, and whether the to determine the health status of immediate family
injury necessitated a visit to an emergency room or members and to identify and document any inherited
other type of treatment center. Sequelae to any injuries disorders that the child may have. The ages and current
should be noted. Specific inquiries should be made about health status of immediate family members should be re-
motor vehicle collisions, falls, head injuries, injuries recorded in the chart. Any consanguinity should be noted.
quiring sutures or surgery, ingestions, choking episodes, The provider should ask about common communicable
burns, or fractures, and whether the child’s injuries are diseases and illnesses related to unhealthy lifestyle be-
fully resolved. An assessment also includes determining haviors such as smoking or other chemical use. When
whether the injuries were unintentional or intentional working with families from developing countries, it is
and whether any injuries to the child were the result important to inquire about family travel to areas with
of inadequate parental supervision, abuse, or neglect. poor environmental sanitation so that parasitic illnesses
These assessments help providers to identify parental and specific communicable diseases endemic to that par-
teaching needs or to make a decision about reporting ticular area of the world are considered. Specific illnesses
intentional injuries to Child Protective Services. and conditions about which the provider should inquire
include arthritis, asthma, allergies, eczema, heart disease,
Immunizations. The child’s immunization history hypertension, stroke, obesity, hyperlipidemia, diabetes,
should include which immunizations the child re- cancer, blood disorders (e.g., hemophilia and sickle cell
ceived and at what age the child received them. The disease or trait), tuberculosis, lead poisoning, cystic fibro-
child’s official immunization record should be reviewed sis, alcoholism, drug abuse, depression or other mental
rather than relying on the parent’s recollections. Par- illnesses, seizure disorders, kidney disease, learning dis-
ents should also be questioned about any untoward re- abilities, mental retardation, and congenital anomalies.
actions the child may have had after being immunized. The use of a genogram is helpful to clarify the family his-
If the child’s immunization record evidences a delay, tory (see Chapter 5 for information about constructing a
the parents should be asked about the circumstances genogram and questions used in data collection).
that led to the delay. Lack of insurance, transportation
difficulties, or illness are common reasons for parents to Review of Systems
postpone immunizations. Religious beliefs and health The ROS establishes the past and present health status
care neglect may also be factors (see Chapter 9 for the of each body system. This assessment comprises a his-
pediatric immunization schedule recommended by the tory, not current physical findings. The provider must
Centers for Disease Control [CDC] for the following re- ask questions in terms that the parent or child can un-
quired immunizations [CDC, 2009a]): derstand to be sure that the history is accurate. Positive
• Hepatitis B (HepB) responses to questions require more thorough question-
• Diphtheria, tetanus, acellular pertussis (DTaP; Tdap) ing about that particular body system. Questions should
• Tetanus, diphtheria (Td) be general (e.g., “Has Antonio been mostly healthy?” or
• Haemophilus influenzae type b (Hib) “Has Lana ever had problems with her ears?”). The order
• Inactivated poliovirus (IPV) in which these questions are asked is roughly head-to-
• Measles, mumps, rubella (MMR) toe. It is important to tailor the ROS to the child’s age and
• Varicella (Varivax) developmental level because certain health problems are
• Meningococcal vaccine (MCV4; MPSV4) common to certain age groups. For example, questions
• Pneumococcal vaccine (PCV) regarding the timing of menarche would not be appro-
• Influenza priate until a girl reaches school age (see Table 6-2 for a
• Hepatitis A summary of the components of a pediatric ROS).
Pain Assessment Health supervision interview guidelines provide devel-

In 2001, the Joint Commission on Accreditation of opmentally appropriate interview questions, among
Healthcare Organizations ( JCAHO) established stan- them Bright Futures: Guidelines for Health Supervision
dards requiring that all patients, including infants and of Infants, Children and Adolescents (Hagan, Shaw, &
children, be assessed for pain ( JCAHO, 2001). During Duncan, 2008).
the health history, the provider should ask about a
history of chronic or current pain. Open-ended ques- Nutrition. This is an important area to assess dur-
tions can be used, such as “Has your child experienced ing both well and illness visits. Pediatric nutritional
pain in the last few months?” or “Is your child in pain assessment must be tailored to the child’s age. The infor-
now?” Positive responses require a detailed assessment mation obtained during this assessment helps the pro-
that is appropriate to the child’s age and developmental vider diagnose any nutritional problems and identify
level. This assessment should include a pain intensity any teaching needs. The best approach to nutritional
measure. For younger children, the Wong-Baker FACES assessment is to begin with general questions, progress-
Pain Rating Scale (Hockenberry & Wilson, 2007) could ing to questions based on age and developmental level.
be used (Fig. 6-2). For older children and adolescents, a First, the provider should ask parents to describe the
descriptor or numeric pain rating is appropriate. child’s appetite and to give a 24-hour dietary recall. The
provider should then determine if this recall represents
Functional Assessment the type of food the family and child typically eat. The
provider should inquire about whether the child is on
A thorough assessment of the child’s health during
any special diet or if there are any cultural or religious
the initial health history and in health supervision
influences affecting the child’s diet. The provider must
visits includes asking about specific areas that are im-
determine if the child has any food intolerances or al-
portant to a child’s functioning and ADLs. This may
lergies and, if so, the parents should be asked to describe
entail organizing this assessment around “pattern ar-
what reactions, if any, the child has had. Any recent
eas” as described by Gordon (2002), including health
weight loss or gain should be explored. The provider
beliefs and behavior, nutrition, elimination, activ-
should ask the parent if the television is typically on
ity, sleep, role relationships, coping, self-perception,
during meals. It should be pointed out that mealtime
cognitive/perceptual behavior, sexuality, and values/
television decreases quality time with the family and
beliefs. For this discussion, patterns are subsumed in
increases food consumption; caloric intake is difficult
the following assessment categories: nutrition, physi-
to control when there are distractions like television
cal activity, elimination patterns, safety status, sleep
(Dennison & Boyer, 2004). The provider should ask
patterns, social situation, sexual history, growth and
the parents if they have any overall concerns related
development, and spiritual assessment. All of these
to nutrition or diet of their child. Once answers to the
areas are assessed as part of the initial health history
general questions are recorded, the provider can pro-
and then updated with each interval history dur-
ceed to a nutritional assessment that is specific to the
ing subsequent well-child health maintenance visits.
child’s age and developmental level.
Wong-Baker FACES Pain Rating Scale Infants. The younger the child, the more detailed
the nutrition history should be. The provider should
ask if the infant is breast- or bottle-fed and how fre-
quently. The provider should note whether breast-fed
infants are supplemented with formula. For infants
0 1 2 3 4 5 who are taking formula, the provider should determine
NO HURT HURTS HURTS HURTS HURTS HURTS
LITTLE BIT LITTLE MORE EVEN MORE WHOLE LOT WORST the type of formula and how many ounces of formula
Alternate a day are taken. The age at which the infant is weaned
coding 0 2 4 6 8 10
should be noted. Introduction of the cup in infants
Instructions: Explain to the person that each face is for a person older than 6 months should be assessed; the bottle
who feels happy because he has no pain (hurt) or sad because he should be discontinued by 1 year of age. The provider
has some or a lot of pain. Face 0 is very happy because he should ask the parent if the infant takes the bottle to
doesn’t hurt at all. Face 1 hurts just a little bit. Face 2 hurts a little
more. Face 3 hurts even more. Face 4 hurts a whole lot. Face 5 bed and whether the bottle is propped, a practice that
hurts as much as you can imagine, although you don’t have to be can lead to tooth decay, obesity, choking, and otitis
crying to feel this bad. Ask the person to choose the face that best media. It should be determined when the parents
describes how he is feeling. introduce solid food, noting the type of solid food that
FIGURE 6-2. The FACES Pain Rating Scale can be used is fed to the child, including whether cereal is added to
in children as young as 3 years old to quantify their pain. the bottle. Any allergic reactions to solid foods should
(Source: Hockenberry, M. J., & Wilson, D. [2007]. Wong’s
nursing care of infants and children. [8th ed.]. [p. 120]. be investigated and recorded. Any “spitting up” or
St. Louis: Mosby, with permission.) vomiting should be noted, including a description of
the character and frequency of the vomiting. Periods Adolescents. Providers should ask adolescent cli-
of prolonged crying should be noted as well. Provid- ents to describe typical meals and snacks and the
ers should also ask if parents clean their infant’s teeth frequency with which they consume fast food and
after meals. soda. With the parent out of the room, providers
should ask adolescent clients if they are satisfied with
Toddlers. The provider should ask if the toddler their body image or if they view themselves as fat.
drinks cow’s milk and, if so, what type (e.g., whole Providers should inquire about dieting, binging, purg-
vs. skim) and how many ounces a day. Physiologic ing, or taking laxatives or diet pills to control weight
anorexia is normal in this age group; parents often (see Chapter 10 for an in-depth discussion of pediatric
report that the toddler is picky, eats small amounts, nutritional assessment).
and eats the same types of foods over and over (“food
jags”). The provider should ask the parents about the Physical Activity. Because childhood obesity has be-
types of food the toddler likes or dislikes, noting the come so prevalent, once a child is walking well, the
nutritional value of the food the child usually eats, provider should ask the parent at each well-child visit
including a typical meal. Specific inquiries should how much physical activity the child gets each day, in-
be made about the number of servings of fruits, veg- cluding typical play activities, involvement in sports,
etables, and protein the child eats each day. The pro- and walking to and from school. The provider should
vider should also ask how often the toddler eats fast ask about the number of hours the child spends each
food and what snacks are provided. It is important to day watching television, playing video games, or us-
identify any foods that the toddler eats that would pre- ing the computer. Any limitations to physical activity
sent a choking hazard, such as grapes, nuts, hot dogs, should be noted, as well as whether the child requires
popcorn, gum, hard candy, and raw vegetables. The any special equipment to assist mobility.
health care provider should ask parents to describe the
toddler’s mealtime behavior and how they deal with Elimination. Elimination is an area where the assess-
any undesired behaviors that occur at the table. ment data are very specific to the child’s age.
It should be ascertained whether or not the tod-
dler is still taking a bottle and whether the toddler Newborns and Infants. For newborns, the provider
also takes a bottle to bed. Toddlers should be drinking should ask about number of wet diapers a day (six
out of a regular cup and at mealtime only. The use of to eight are normal), and whether the male infant
a no-spill sippy cup should be assessed because these urinates in a straight stream. If the urinary stream
cups have valves in the lids to prevent spillage, which aims downward rather than straight, this may indi-
require the toddler to suck on the cup to get the liq- cate hypospadias, which requires surgical repair. The
uid out. This mimics a bottle and as such, is undesir- provider should ask the parent about the number and
able, especially if a toddler carries a cup around full of character of daily stools.
a sweetened drink during the day. The provider should In the first few weeks of life, breast-fed infants typi-
assess the amount of juice the child consumes in a day cally stool after each feeding. The stools of breast-fed
and whether the juice consumption is at mealtime, infants are pale yellow, soft, and without much odor.
throughout the day, or both. It is important to ask Formula-fed babies pass stools less frequently than
parents if the toddler drinks soda regularly, and if so, breast-fed babies, usually two to four stools a day in the
how much. The pattern of tooth eruption in the child first month of life (Dunn, 2009), then one to two stools
should also be noted, as well as what dental hygiene a day as the infant grows and the gastrocolic reflex be-
practices are used. comes less active. The stools of formula-fed babies are
also dark in color, firm in texture, and have a distinct
Preschoolers and School-aged Children. The pro- odor. The stools of both breast-fed and formula-fed in-
vider should ask the child and parent to describe a typi- fants become firmer, darker, and less frequent as solid
cal meal, the child’s favorite food, and a typical snack. foods are introduced (Dunn, 2009). Daily stool patterns
Specific inquiries should be made about the number vary from infant to infant, with one stool a day to one
of servings of fruits, vegetables, and protein a day. The stool every 2 or 3 days considered within normal limits.
provider should inquire about fast food consumption,
frequency of junk food snacks, and about the amount of Toddlers and Preschoolers. Because renal function
milk, juice, and soda consumed in a day. The provider is fully developed by age 2 years, the child’s kidneys
should note if the child obtains junk food snacks from are able to concentrate and dilute urine. Depending
vending machines at school. Dental hygiene practices on the child’s fluid intake, fluid losses (e.g., diarrhea),
should also be assessed; a child should see the dentist body temperature, and the environmental tempera-
for the first semiannual cleaning and dental visit by age ture, the number of voids a day varies. Toddlers and
3 years. The pattern of tooth loss in the school-aged preschoolers urinate 8 to 14 times a day (Dunn, 2009).
child should also be assessed. In this age group, the number of stools a day varies,
according to the child’s diet, usually one to three Adolescents. With adolescents, questions about
stools a day, but one stool every 3 to 4 days is within elimination patterns should continue to focus on
normal limits (Dunn, 2009). When assessing for con- the number of voids and stools a day, which varies
stipation, it is important for the provider to know according to the teen’s diet and fluid intake. It is also
how the parent defines constipation. Constipation important to ask about urinary frequency or urgency,
is defined as hard, painful stool passed infrequently which may indicate either urinary tract or sexually
(every 3 to 5 days) with difficulty (Klish, 2004). Not transmitted infections. Polyuria in this age group can
having a stool each day does not constitute consti- be a sign of type 1 diabetes. Frequent or chronic diar-
pation. Similarly, if the parent reports episodes of rhea may indicate laxative use.
diarrhea, the provider should be sure to clarify what
the parent means by diarrhea. Diarrhea is stool that Safety. The leading cause of death in American
is frequent, watery in consistency, and often leaves children over 1 year of age is unintentional inju-
water rings in the diaper or underclothes. Diarrhea is ries (CDC, 2009b). Therefore, assessing the safety of
not the same as loose stools that may be the result of the environment of an infant, child, or adolescent
increased dietary fiber or sweetened drink intake. In is extremely important, and the areas of assessment
this age group, the provider should ask about toilet vary according to age and developmental level. The
training efforts, which should begin when the child is type of home environment must be determined be-
no younger than 18 to 24 months of age or when the fore the provider can pose general questions about
child expresses interest (Fig. 6-3). Providers should ask the child’s safety; for example, different risks exist
parents about their attitudes about toilet training. For for children living in urban as compared to rural
many people, this is an extremely frustrating task and settings. The provider should begin by asking gen-
can lead to harsh or impulsive discipline. It is impor- eral questions such as: “Is the hot water heater set-
tant to determine if the child has dry naps or sleeps ting less than 120° F?” “Does the family home have
through the night without urinating. The age at which working smoke and carbon monoxide detectors?”
daytime and nighttime bowel and bladder control are “Does the family have a firearm, and if so, is the
achieved should be assessed and recorded. gun locked and unloaded and is the ammunition
kept separately?” “Does the family have a swimming
School-aged Children. School-aged children should pool?” The provider can then progress to questions
be fully toilet trained. The provider should continue that are age-specific, such as: “Does the child ride
to ask about the number of voids a day (usually five to in a car seat or wear a seatbelt?” “Are poisons and
six, depending on fluid intake) and whether the child cleaning supplies stored in a high, locked cabinet?”
remains dry through the night (nocturnal enuresis is “Does the child wear a bike helmet?” (See Chapter 7
within normal limits until age 6 years). The provider for an in-depth discussion of assessing the safety of
should inquire about urinary frequency or urgency, a child’s environment, according to age and devel-
which may indicate a urinary tract infection, and about opmental level.)
polyuria, which may be a sign of type 1 diabetes. The
frequency of stools should be assessed (normal ranges Sleep. Sleep patterns should be assessed at every
from one to three a day, to one stool every 2 to 3 days), well-child visit and as needed when a child is seen for
as should the presence of constipation or encopresis. an illness or other complaint. A developmental ap-
proach is necessary when obtaining a pediatric sleep
assessment. For example, infants should be placed in
the supine position for naps and at bedtime because
of the association of sudden infant death syndrome
(SIDS) with a prone sleep position (AAP, 2005). To
avoid upper body gross motor developmental delays,
infants should be placed prone while awake (“tummy
time”) to develop these muscle groups (Fig. 6-4). The
provider should be sure to emphasize to the parent
that the infant must be awake when placed in the
prone position. The provider should also be sure to
inform the parents that co-sleeping during the first
year of life is also associated with an increased inci-
dence of SIDS (AAP, 2005).
Sleep patterns vary according to the child’s age, with
younger children requiring naps during the day to en-
FIGURE 6-3. Assessment of elimination patterns in toddlers sure that sleep requirements are met. Sleep problems
includes inquiring about toilet training progress. are common in preschoolers, so it is important for the
TABLE 6-3
Sleep Needs of Infants and
Children
Birth to Approximately 16.5 hours a day, half
6 Weeks of which is daytime sleep; sleeps 2 to
4 hours at a time
1 Month 15.5 hours a day; may sleep 4 to 6 hours

at a time
3 Months 15 hours a day; bulk of sleep shifts to

nighttime hours
4 Months Begins to nap at regular times during day;

may sleep 7 to 8 hours at a stretch
FIGURE 6-4. Parents should be taught the importance of 6 Months 14.25 hours a day, including two naps
placing their infants prone while they are awake to facilitate
the infant’s development of gross motor abilities such as 9 Months 14 hours a day, including two naps
reaching, scooting, and crawling.
12 Months 13.75 hours, including one to two
naps a day. The morning nap is given
provider to inquire about nightmares and night terrors up between 12 to 24 months of age.
The afternoon nap persists until
in this age group (Burns, 2009). Table 6-3 summarizes approximately age 4 to 5 years.
the sleep requirements for children, birth through
adolescence, and Table 6-4 briefly summarizes the im- 18 Months 13.5 hours a day, including one nap
portant questions to ask in a pediatric sleep patterns
2 Years 11 to 12 hours at night, one nap a day
assessment. lasting 1 to 2 hours
The child’s medical history should also be taken
into account when evaluating sleep patterns in in- 3 Years 12 hours a day total, including one
fants, children, or adolescents. Ear infections, chronic 1-hour nap during the day
pain, certain respiratory disorders or infections, neu- 4 Years 11.5 to 12 hours of sleep a day; many
rologic problems, obesity, and the side effects of some 4-year-olds stop naps, needing an earlier
medications (e.g., bronchodilators), drug or caffeine bedtime to get required sleep
use, and depression can all affect sleep (Burns, 2009).
5 Years 11 hours with most children stopping
Recent parental separation or divorce, maternal de- naps at this age
pression, a recent move from the family home, or
other family stresses can also interfere with the child’s 6 Years 10.5 to 11 hours a day
quality of sleep.
7 Years 10.5 to 11 hours a day
During the sleep assessment portion of the history,
the provider should ask the parent if he or she has any 8 Years 10.25 to 10.75 hours a day
concerns about the child’s usual sleep patterns. The
9 Years 10 hours a day
provider should assess the child for common pediat-
ric sleep problems such as sleep refusal, nightmares, or 10–12 Years 9.25 to 10 hours a day
trained night feeding. Parents should be taught that in-
fants begin to sleep through the night at 4 to 6 months Adolescents 8 to 9 hours a day
of age (Burns, 2009) and that waking at night after that
time should not be handled by feeding the infant. Source: Howard, B. J., & Wong, J. (2001). Sleep disorders. Pediatrics
in Review, 22(10), 327–342.
The provider should determine whether or not the
parent sees the child’s sleep patterns as a problem. For
example, some parents find co-sleeping disruptive, while
provider about the child’s daily environment. This infor-
others consider it the norm. A sleep problem is one that
mation explains why a child may have a particular prob-
interferes with the child’s health and well-being and is
lem, for example, developmental delay, behavioral issues,
disruptive to the family (Burns, 2009) (see Table 6-5 for
obesity, poor school performance, frequent injuries, or
a summary of common sleep problems in children).
depression. These problems can potentially be attributed
to the current family situation, parental knowledge defi-
Social History cits, socioeconomic status, or possibly abuse or neglect.
Eliciting the social history of a pediatric client is ex- With the answers to these questions, the provider is bet-
tremely important because these data tell the health care ter equipped to address these problems.
1 0 0 • S e c t i o n 2 O B TAI N I N G T HE PEDI ATRI C HEA LTH HI STO RY
TABLE 6-4
Assessment of Sleep Patterns in Children by Age Group
AGE RELEVANT ASSESSMENTS
Infant (Birth to 1 year) • Sleep position (should be supine until child rolling over independently, approximately
age 6 months)
• What time does the infant go to bed? What are the nighttime sleep intervals? What is
the longest interval?
• What is the hour of bedtime and the hour of rising in the morning?
• How many daytime naps? How long do they last?
• Where does the infant sleep?
• Does the infant co-sleep with parents?
• Does infant sleep through the night (after 4 to 6 months of age)?
• How do parents deal with night waking after age 4 months? Do they feed the child? Do
they bring the child to bed with them?
• Is there any soft bedding, quilts, pillows, bumper pads, stuffed animals, or sheepskin
in crib?
• Are there any bedtime rituals (e.g., bath, story, song)?
• How does baby fall asleep? Is infant placed in crib while still awake or rocked to sleep?
• Does the child self-comfort or are security objects needed?
• Is infant placed in bed with a bottle of milk or juice?
Toddler (1 to 3 years) • What are the bedtime rituals? How is the toddler’s behavior at bedtime? Is the child
rocked to sleep?
• Where does the toddler sleep?
• Does the toddler cosleep with the parent?
• Is child placed in bed with a bottle of juice or milk?
• How long does the toddler sleep at night? Does the toddler nap during the day?
• Does the toddler have a problem falling or staying asleep?
• Does child sleep through the night?
• What is the parent’s reaction to night waking?
Preschooler (3 to 6 years) • What are the bedtime rituals? How is the child’s behavior at bedtime?
• Where does the child sleep?
• Does the child cosleep with the parent?
• How long are the sleep intervals?
• Does child have difficulty falling or staying asleep? If child awakens, how do parents
respond? Can child self-comfort back to sleep?
• Does the child still nap (most children give up naps by age 5 years)?
• Does the child experience any sleep problems such as nightmares, night terrors, or
bedwetting?
School age (6 to 12 years) • What are the bedtime rituals? How is the child’s behavior at bedtime?
• Where does the child sleep?
• Does the child cosleep with the parent?
• Does the child need to be awakened in the morning?
• What are the sleep intervals overnight?
• Does child sleep through the night?
• What is the parent’s reaction to awakenings?
• Does the child experience nightmares/night terrors or bedwetting?
Adolescent (12 to 18 years) • What are the hour of bedtime and the hour of rising in the morning?
• Does the teen need to be awakened in the morning?
• Does the adolescent have difficulty falling asleep or staying asleep?
• Does the adolescent sleep excessively (may indicate depression)?
TABLE 6-5
Common Pediatric Sleep Problems
SLEEP PROBLEM AGE GROUP CLINICAL FINDINGS ASSESSMENTS
Sleep refusal Toddler/preschooler Child refuses to settle once put to bed. Do parents maintain a consistent sleep routine? Are security
objects used? Do parents reinforce calling out or crying behaviors?
Night waking Any age Child needs help during night to return back Do parents put the child to bed while he or she is still awake so that
to sleep. the child becomes accustomed to falling asleep independently?
Do parents rock the child to sleep in their arms and then transfer
the child to the bed? Do parents reinforce calling out or crying
behaviors? Are security objects used?
Trained night feeder Infants Infant older than 4 months awakens Do parents put the child to bed with a bottle? Have parents tried
predictably, wanting to be fed. to end this bedtime ritual either by gradually discontinuing night
feedings or by discontinuing night feedings completely?
Delayed sleep phase Any age Child goes to bed late and awakens late. Have the parents tried awakening the child 15 minutes earlier
each day until appropriate bedtimes and waking times result?
Advanced sleep phase Any age Child goes to bed early and awakens early. Have the parents tried putting the child to bed later so that
awakening will occur later?
Unpredictable Any age Child goes to bed and awakens at random Have the parents maintained a predictable family schedule and
schedule times. consistent expectations for bedtime?
Nightmares Most common in Child awakens crying and fearful with memory Do the parents comfort and reassure child? Is a nightlight or
preschoolers; occur of dream, which usually occurs in the latter closet light used to help the child who is afraid of the dark?
from 18 months half of night; child is slow to return to sleep.
through adolescence
Night terrors and Most common in Child begins screaming or crying but is not fully Do the parents try to protect the child from injury? Do parents
sleepwalking preschoolers; occur awake; child usually has no memory of event; help the child to lie down and return to sleep? Do parents of
from 18 months night terrors usually occur in first third of the sleepwalkers use gates at the top of stairs?
through adolescence night; sleepwalkers arise and walk about without
being fully awake.
Insomnia/ School age and older Child is unable to sleep or excessive sleeping, Do parents ensure that the child has no stimulating activities at
hypersomnia which may be related to depression. bedtime that interfere with sleep such as caffeine consumption;
rough play; or violent and upsetting television, movies, or other
media? Has the child been medically evaluated for hypersomnia
to rule out medical conditions such as severe anemia,
hypothyroidism, or depression?
Obstructive sleep Preschoolers and older Child sleeps restlessly, with snoring, periods of Has the child been referred for sleep studies, allergy consults, or a
apnea respiratory distress, or apnea while sleeping and possible adenoidectomy?
exhibits daytime fatigue.
101
Adapted from: Burns, C. E., Dunn, A. M., Brady, M., Starr, N. B., & Blosser, C. G. (Eds.). (2009). Pediatric primary care: A handbook for nurse practitioners. (4th ed.). (p. 313). Philadelphia: W. B. Saunders.
Universal Assessments. A pediatric social history is the family’s economic status such as a divorce or
mostly age-dependent, but some questions are universal. death in the family, parental job loss, or if the family
The provider should ask the less threatening questions has recently moved to a new dwelling. Assessment of
first to establish rapport with the child and family, then the child’s and family’s adjustment to these changes
progress to the more sensitive, personal questions. is important because stress may cause alterations in
sleep patterns, recurrent abdominal pain, depression,
Family. To begin, the child’s primary caregiver should drug or alcohol use in older children, or other physical
be identified. The provider should note if the caregiver or psychologic manifestations of stress and grief. The
is the child’s biologic parent. The provider should then provider should ask what the family does for fun and
ask if the primary caregiver has any concerns about the if they do things together as a family.
child’s health, welfare, safety, and physical or psychoso-
cial growth and development. The provider should obtain Immigrant Status. The social history includes an
information about the child’s family composition, not- assessment of immigrant status, and if the child has
ing which family members live at home (e.g., extended special health care needs as a result. International
family, siblings, step-siblings, including their ages and adoptees also fall into this category. Newly arrived
sex) and whether the family includes both biologic par- immigrant children often have nutritional deficits,
ents. The provider should determine the parents’ marital dental decay, and immunization delays. They may suf-
status, noting if they have a stable relationship and if fer from communicable diseases not often seen in the
both parents are involved in the child’s care. The pro- United States. Children in families who come to the
vider should note whether the child is adopted, and if it United States seeking refuge from persecution because
is a domestic adoption, whether the child’s birth mother of race, religion, nationality, or politics may not only
or family is involved in the child’s life. It should be noted have physical problems, but may suffer from depres-
whether the child lives in a single-parent household, sion, nightmares, and posttraumatic stress disorder as
and if the parent feels that he or she has adequate child well. When asking these questions, the provider should
care, finances, and emotional support. It is important be nonjudgmental and culturally sensitive, using an
for the provider to assess whether the child’s primary interpreter when necessary. It should be ascertained
caregiver is able to provide daily care (e.g., Is the primary what language the child and family speaks. Also, it is
caregiver a teenager, homeless, or addicted to drugs or important to note whether the family and child have
alcohol? Does the caregiver have mental health issues?). any religious beliefs or practices that may impact the
Exposure to secondhand cigarette smoke should be child’s health (see Chapter 4).
assessed. The provider should ask about any episodes of
domestic violence in the home, if any guns are kept in Emergency Room Use. For children of all ages, the
the home, and if the child is exposed to violent televi- provider should also note the frequency of visits to the
sion or other media. emergency room or urgent care facilities for frequent
illnesses or injuries. This may indicate knowledge defi-
Home Environment. Assessment of the home envi- cits, medical neglect, or lack of age-appropriate super-
ronment is another important part of the social history. vision. Consistent immunization delays should also be
The type of home in which the family lives should noted, as this may also indicate medical neglect.
be noted (e.g., single-family home, apartment), and
whether the primary caregiver believes that the size of Age-Specific Assessments. Additional data that
the home is adequate, safe, warm, and well lit. The pro- comprise the social history should be tailored to the
vider should ask the parent about family pets (e.g., what child’s age group.
type, how many). Some kinds of animals (e.g., snakes,
pit bulls) may be dangerous around small children, and Infants, Toddlers, and Preschoolers. For infants,
the provider may need to ascertain whether the home toddlers, and preschoolers, the provider should ask
environment is safe for the child. The provider should if the child has a security object, and if so, the age
ask the parent if the neighborhood is safe (e.g., Is there of the child should be noted. The provider should
a safe area in which the child can play? Is it safe for the inquire about any habits such as nail-biting, thumb-
child to walk to school? Is there any gang activity or sucking, pica, repeated rocking, or head banging, and
other type of violence nearby?). if the parent expresses any concern over any of the
child’s habits or overall behavior. It is important to ask
Economic Status. The family’s economic status about the child’s temperament, whether he or she is
should be assessed, including financial resources or fussy or easily consoled. Providers should ask parents
agencies used such as Women, Infants, and Children of toddlers and preschoolers if the child has temper
(WIC), food stamps, or Medicaid. Family stressors tantrums or breath-holding spells, and how the par-
should also be noted, such as if the family has recently ent handles these tantrums. The provider should ask
experienced any major life changes that could impact about what type of discipline the parent employs, such
C H A P T E R 6 O btain in g th e Pe diatric H ealth Histor y • 103
as “time-outs” or corporal punishment. Parents should Growth and Development

be discouraged from spanking and taught about other Assessment of growth and development is an essen-
methods of discipline. Providers should ask parents tial part of the pediatric health history and should be
about any power struggles concerning toilet training done at every health care visit, whether the child is
and remind parents that toilet training should not be well or ill. It is extremely important to determine if
started too soon. The provider should inquire about the child has achieved age-appropriate physical and
whether the child is enrolled in day care or preschool developmental milestones and to identify any areas
and if the parent is satisfied with the arrangement. It of concern, such as developmental delays, neurolog-
is important to ask how the child copes with separa- ic problems, or neglect. The provider should begin
tion from the primary caregiver when it is time to go the history by asking the parents if they have any
to school or daycare. concerns about the child’s growth or development.
A complete history of a child’s growth and develop-
School-aged Children. Children in this age group ment entails determining achievement of develop-
can provide some information for the history. A mental milestones in the areas of physical growth,
social history for a school-aged child includes infor- gross and fine motor development, cognitive abili-
mation about the child’s school progress, interaction ties, language development, social interaction, be-
with family members, peer relationships, friendships, havior, and temperament. Past milestones and cur-
violent media exposure, and computer/video game rent abilities should be assessed, which requires
or television watching. The provider should ask knowledge of physical, psychosocial, and language
the child about particular hobbies or involvement milestones relevant to the child’s age group.
in sports or other types of activities. The provider
• Gross motor milestones can be assessed by asking
should ask the parent to describe the child’s tem-
about infant head control, rolling over, sitting and
perament and to relate any concerns about the child’s
standing without support, crawling, walking, and
behavior or habits. It is important to note how much
dressing.
time the school-aged child spends alone after school
• Fine motor milestones can be assessed by exploring
unsupervised.
areas such as reaching for objects, achievement of a
pincer grasp, self-feeding, scribbling, printing, and
Adolescents. Much of the data that comprise the
tying shoes.
social history of the adolescent client focus on assess-
• Language milestones can be assessed by asking
ing the teen’s school performance; relationships with
about when the child spoke his or her first word with
adults, peers, family members, and teachers; involve-
meaning, combined two to three words, and spoke
ment in risk-taking behaviors such as alcohol or drug
in sentences. It is important to ask about the intel-
use, reckless driving, and sexual activity; depression
ligibility of the child’s speech and about any history
and body image issues; and involvement in violent
of otitis media, which can affect hearing and thus
activities, such as gang membership. The adolescent
language acquisition.
social history should be obtained without the parent
• Psychosocial development can be assessed by ask-
present so that the teen feels comfortable providing
ing the parent about the child’s temperament, play,
truthful answers. The provider should reassure the
attachment to and ability to separate from the pri-
adolescent client that what he or she discusses with
mary caregiver, self-care abilities, peer relationships,
the provider will be treated with utmost confiden-
and school performance.
tiality unless the teen reveals information that the
provider believes will result in self-harm or harm to In some instances, specific developmental screening
others. tools are necessary to assess a child’s developmental
A sexual history is an essential part of the adoles- status thoroughly (see Chapter 2 for an in-depth dis-
cent’s social history. The provider should approach cussion of the assessment of pediatric growth and de-
this subject sensitively and nonjudgmentally. This velopment, birth through adolescence).
part of the history is done with the parent out of the
room so that the teen feels comfortable giving honest Spiritual History
answers to the questions asked. Using open-ended Both the family and child’s religious and spiritual beliefs
questions, the provider should explore the teen’s dat- can affect the child’s health. For this reason, it is impor-
ing patterns, sexual activity, and use of contraception tant for the health care provider to conduct a spiritual as-
and condoms. The provider should ascertain the num- sessment as part of the initial health history. The provider
ber of sexual partners and the teen’s knowledge of safe should begin by asking about the family’s religious beliefs
sex, and screen for sexually transmitted infections and and how these beliefs impact the child’s health. It should
pregnancy (see Table 6-6, which summarizes the pedi- be noted whether the family is involved in their church
atric social history, according to age and developmen- and to what extent (see Table 6-7 for a summary of the
tal level). components of a complete pediatric health history).
TABLE 6-6
Age-specific Pediatric Social History
AGE-GROUP QUESTIONS TO ASK
Infants (Birth to How is attachment/bonding? How do the parents describe the infant’s temperament? How do the
12 months) parents deal with any persistent crying? What types of toys and developmentally stimulating activities
are provided for the infant? Does the infant have a security blanket or toy? How many caregivers or
babysitters does the child have? Is the infant in day care? Is the home or apartment adequately baby
proofed? Does the parent or caregiver report any behaviors such as head-banging or bed-rocking?
Toddlers (1 to How do the parents describe the child’s temperament? Does the child have temper tantrums or breath-
3 years) holding spells, or does the child hit or bite others? If so, how does the parent handle these behaviors?
Do they use corporal punishment? How do the parents feel about the child’s current toilet training
progress? How do the parents deal with toileting accidents? How well does the toddler play with other
children? Is the child aggressive? What type of toys does the child have? In what type of play does the
child engage? How much and what type of television does the child watch? Do the parents read to the
child each day? How does the toddler separate from his or her parents? Is the toddler showing a desire
for independence? Does the child regress developmentally in times of stress?
Preschool (3 to How do the parents describe the child’s temperament? Do the parents have concerns about the
6 years) child’s behavior such as any instances of lying or stealing? Does the preschooler have any imaginary
friends and does this concern the parent? Does the child separate well from the parents? Can the
child converse with and relate well to those outside the family? Does the preschooler have excessive
fears? Is the child enrolled in preschool? If so, how is the child doing in school? Does the teacher
have any concerns about the child’s behavior? How well does the child play with others? With what
type of toys does the child play? How much and what type of television does the child watch? Does
the parent read to the child each day? Is the child fully toilet trained and, if not, how do the parents
deal with toileting accidents? Does the child know about “good touch/bad touch”?
School-aged (6 to How do the parents describe the child’s temperament? Is the child excessively shy? Does the child
12 years) have any difficulty separating from the parents? Does the child have friends? A best friend? How
does the child interact with family members, classmates, and peers? In what type of play activities
does the child engage? Is the child enrolled in sports, after-school activities; does the child have any
particular hobbies or collections? How many hours of television does the child watch a day? How
many hours a day does the child spend on the computer or playing video games? Does the child
read books for pleasure? How is the child’s school performance? Does the teacher have any concerns
about the child’s behavior or academic progress? Is there excessive absenteeism? Is the child in
special education classes? Does the child have any nervous habits such as nail biting? Does the child
have any problems with bedwetting? Does the parent report excessive sleeping, social withdrawal, or
other indicators of possible depression? Does the child know about “good touch/bad touch”?
Adolescence Does the parent have any concerns? How does the parent describe the teen’s temperament? Does this
(12 to 18 Years) coincide with how the teen sees him- or herself? With the parent absent from the room, ask the teen how
they get along with their parents. Does the teen feel that the rules at home are reasonable? How does
the teen get along with adults in general, including his or her teacher or other authority figures? Does
the teen feel that he or she can confide in the adults in his or her life? Is the teen satisfied with his or
her body? Does the teen diet, binge, purge, or fast? How is school going? Has the teen been chronically
truant or been having academic difficulty? Is the teen in special education classes? How much time does
the teen spend watching television, using the computer, or playing video games a day? Does the teen
read for pleasure? Does the teen have a job? Does the teen have a best friend? Several friends? Is the teen
involved in any groups, clubs, sports, or after-school activities? Does the teen engage in any aggressive
or violent behavior toward him- or herself or others? Does the teen have easy access to firearms? Is
the teen involved with any gang activity? Ask if the teen is involved in a romantic relationship and
whether he or she is sexually active. What are the teen’s feelings about sex? Does he or she think there
is something wrong with their feelings about sex? Have they ever been touched in a manner that made
them uncomfortable? Would the teen like to ask any questions about contraception? What is the teen’s
knowledge of safe sex and sexually transmitted infections? How does the teen cope with stress? Does the
teen use alcohol or drugs? Does the teen smoke cigarettes? The teen should be asked if he or she ever feels
sad or depressed and if he or she ever feels like killing himself or herself. If the teen answers yes, it should
be determined whether he or she has a concrete plan and, if so, the teen should be referred immediately.
An acronym, BIHEADSS, can assist the provider in conducting a comprehensive assessment of the
teen’s social situation:
BI ⫽ Body image
H ⫽ Home situation
E ⫽ Education or school performance
A ⫽ Activities (e.g., friends, what teen does for fun)
D ⫽ Drugs or dating patterns
S ⫽ Sexuality: Does teen know about safe sex?
S ⫽ Safety (risk-taking), suicidal ideation, or depression
TABLE 6-7
Components of a Pediatric Health History
Biographical Data Name, age, sex, birth date, ethnicity, religion, child and family’s primary spoken language,
home address, and telephone number
Source of Information Person providing historical information
Reason for Seeking Care Also referred to as chief complaint; the reason for seeking health care is recorded in child
or parent’s own words.
History of Present Illness Chronologic narrative of the chief complaint; a summary of the details of the problem
Past Medical History Provides information regarding all aspects of the child’s general health
1. Prenatal, birth, and neonatal history
2. Previous acute and chronic illnesses
3. Childhood infectious diseases
4. Hospitalizations
5. Surgeries
6. Injuries, ingestions, or emergency room visits
7. Immunizations
8. Screening tests
9. Family medical history
10. Allergies
11. Medications
12. Pain assessment
Review of Systems Done to establish the past and present health state of each body system
1. General
2. Integument
3. Head
4. Eyes
5. Ears
6. Nose
7. Mouth or throat
8. Neck
9. Chest
10. Lymphatic
11. Respiratory
12. Cardiovascular
13. Gastrointestinal
14. Genitourinary
15. Gynecologic
16. Musculoskeletal
17. Neurologic
18. Endocrine
19. Hematologic
20. Psychosocial
Nutritional Assessment Assesses nutritional adequacy and identifies teaching needs
Physical Activity Notes amount of physical and sedentary activities
Elimination Patterns Assessment of stool and urination patterns according to age
Safety Assesses the safety of the child’s environment and identifies teaching needs
Sleep Patterns Hours of sleep per night, naps, or sleep problems
Social History Varies according to child’s age; includes assessment of family situation, child’s behavior
and temperament, and school performance
Sexual History Body image, dating patterns, sexual activity, use of contraception, knowledge of safe sex,
and screening for sexually transmitted infections
Growth and Development Assessment of physical and psychosocial developmental milestones
Spiritual History Assessment of family’s religious or spiritual beliefs and how they affect health and illness
INTERVAL HISTORY problem not stated in the chief complaint, the provider
Like the initial health history, the interval history is should not ignore the secondary problem, but treat it
comprehensive and includes the child’s past and pres- as necessary, unless the child’s current health status is
ent health status. The interval history contains in- serious or critical, requiring immediate medical inter-
formation that updates the history since the child’s vention. The provider should assess whether or not the
last visit. The format is the same as the initial health caregiver can safely care for a sick child. This is espe-
history, except the questions concern the child’s cur- cially relevant if the parent or primary caregiver is very
rent age and developmental level. The reason for the young, uses drugs or alcohol, is homeless, or is other-
visit is ascertained, usually a health maintenance visit, wise challenged in providing safe, consistent, reliable
and it should be determined if the parent (or child, care to a young child.
if age-appropriate) has any particular concerns. Ques- History of Present Illness
tions should be asked regarding any recent illnesses,
An important component of the focused health his-
hospitalizations, surgeries, acute or chronic pain, in-
tory is the history of the present illness (HPI). The
juries, or emergency room admissions since the last
HPI is essentially a chronologic narrative of the chief
visit. The allergy history should be updated if appli-
complaint. The HPI includes questions to ascertain the
cable, as well as whether the child is currently taking
onset of the symptoms, illness, or problem; the location
any medications, including the name of the drug, the
of symptoms, particularly pain; the timing and dura-
dose, and frequency of administration. The child’s im-
tion of the symptoms, illness, or problem; and charac-
munization status should be reviewed. An updated
teristics of the symptoms, including the severity, quality,
ROS should be obtained. The provider should ask age-
quantity, and aggravating or alleviating factors. A helpful
appropriate questions to update the child’s nutritional
mnemonic to remember the elements of the HPI is OP-
status, daily physical activity, elimination patterns, the
PQRST, which is described in Box 6-1 (Bickley, 2007).
safety of the child’s environment, sleep patterns, social
Although many providers find the above mnemonic
situation, including sexual history if applicable, and
useful to guide them in obtaining the HPI, it is limited
physical and psychosocial growth and development.
because it focuses on physical illness. Parents do not
always seek care for their children for illness, fever, or
FOCUSED HISTORY
A focused (episodic, problem-centered) history is
conducted when the child presents with a particular BOX 6-1
problem such as the onset of an acute illness, injury, The OPPQRST Mnemonic:
psychosocial problem, or the exacerbation of a chronic A Guide to the History of the
illness or condition. The focused history addresses only Present Illness
the illness or problem for which the child presents,
usually involving only one or two body systems. O ⴝ Onset of symptoms such as the date, time,
sudden vs. gradual onset: “When did it start?”
Chief Complaint P ⴝ Palliative: “What makes the problem better
(e.g., medications, positioning)?”
The chief complaint is the reason for seeking health
P ⴝ Provoking factors: “What brings on the problem?”
care. Common illness complaints in the pediatric pop-
“What makes the problem worse (e.g., exercise-
ulation include fever, rhinorrhea, sneezing, cough, sore induced wheezing)?”
throat, respiratory illnesses, vomiting, abdominal pain,
Q ⴝ Quality of symptoms describes the nature of the
diarrhea, refusal of feedings, lethargy, irritability, and symptoms: “What does it feel like?”
inconsolability. It is important to document the chief
R ⴝ Region/radiation (with pain as a complaint): Use a
complaint in the child or parent’s own words while as- developmentally appropriate pain scale to quantify
sessing whether or not the informant is a reliable source pain: “Where is the pain?” “Where does it radiate?”
of information. As with other types of health histories, S ⴝ Severity of symptoms: “How bad is it?” Note
inquiries should be made about the use of current med- aggravating/alleviating/precipitating factors
ications, including both prescription and OTC prepa- (e.g., cold air exacerbating wheezing or cold air
rations, folk remedies, and CAM therapies. Allergies improving croup).
should be noted, along with a current, up-to-date ROS, T ⴝ Timing such as frequency and duration of
PMH, inquiries about any recent illnesses, and a review symptoms: “Are the symptoms continuous or
of the child’s current immunization status. Data col- intermittent?” “How often do they occur?” “How
lection focuses only on the illness or problem at hand. long do they last?” “Why was help sought now?”
If, however, during the course of the visit, the provider (e.g., “What was the catalyst that caused you to
notes that a young child is developmentally delayed, seek help?” “Was the pain getting worse?”)
is not up-to-date on immunizations, or has any other
provider should ask the parent or child what, if any-

BOX 6-2
thing, they have been doing to make the problem bet-
The CLIENT OUTCOMES ter, such as applying heat or cold, taking prescribed or
Mnemonic: A Guide for a OTC medications, ingesting home remedies, or visiting
Comprehensive Assessment a traditional healer. The provider should determine
C ⴝ Character of the symptoms, including intensity or whether or not the child has been adhering to the pre-
severity scribed treatment plan, and if not, why not. Reasons
L ⴝ Location, including radiation (if present) for not continuing with a provider’s recommendations
I ⴝ Impact of the symptoms or illness on the child’s
may include the fact that the child exhibited signs of a
ADLs or the quality of life of the child and family medication allergy or that the prescribed treatment may
E ⴝ Expectation (parent and child, if school-aged or
have made the problem worse. In some cases, the fam-
older) of what the health care visit will do for them ily may simply not be able to follow the recommended
N ⴝ Neglect or abuse, including signs of physical,
plan, because of such things as financial or transporta-
verbal, emotional or sexual abuse in the child, or tion constraints or cultural or language issues. The pro-
evidence of malnutrition, or delayed immunizations vider should also ask the child or parent if they have
T ⴝ Timing, including onset, duration, and frequency any additional problems or concerns. Further follow-up
of symptoms is necessary if the problem has not fully resolved.
O ⴝ Other symptoms that are associated with the
major presenting symptom
EMERGENCY HEALTH HISTORY
U ⴝ Understanding or beliefs of the child or parent
about the possible cause of the problem The emergency pediatric health history is often con-
T ⴝ Treatment such as medication, elevation, hot
ducted in urgent care clinics, emergency rooms, or
or cold remedies, or any other therapies used to pediatric intensive care units. This history involves
alleviate the symptoms/condition the rapid collection of data in emergent, potentially
C ⴝ CAM therapies, including the type of therapies tried, life-threatening situations. These data are similar to
such as herbs, traditional healing practices, visits to a those obtained in a focused history, except that data
traditional healer, message, and acupuncture collection must happen quickly (e.g., “What sub-
O ⴝ Options for care that are important to the parent stance was ingested and how much?”) and is often
or child (e.g., requesting a second opinion) accompanied by a simultaneous physical examina-
M ⴝ Modulating factors (i.e., factors that precipitate, tion or intervention.
aggravate, or alleviate the symptoms or problem) After the health history is completed, the provider
E ⴝ Exposure to infection, toxins, chemicals, or should ask the parent and child if they would like to dis-
secondhand cigarette smoke cuss anything else or if they have any other concerns.
S = Spirituality, including beliefs, values, and needs of If there are no further questions or concerns, objective
the child and family that impact health care data are then obtained. Analysis of both subjective and
objective data allows the provider to create a problem
list, which is a consideration of all the possible diag-
noses based on the information gathered through in-
pain but may do so for temper tantrums, biting, bedwet- terviewing and examining the child. For each problem
ting, or other psychosocial problems. A comprehensive enumerated, a corresponding plan must be formulated.
approach includes both physical illness and psychoso-
cial concerns. The provider should note how the reason
for seeking health care impacts the family and how the
REFERENCES
American Academy of Pediatrics (AAP). (2005). Task force on infant
child’s culture and social situation influence the manage- position and sudden infant death syndrome: The changing con-
ment plan for any problems identified. A mnemonic that cept of sudden infant death syndrome: diagnostic coding shifts,
guides this comprehensive assessment is CLIENT OUT- controversies regarding the sleep environment, and new vari-
ables to consider in reducing risk. Pediatrics, 116(5), 1245–1255.
COMES, which is described in Box 6-2 (Rhoads, 2006). Bickley, L. S. (2007). Bates’ guide to physical examination and history
taking. (9th ed.). Philadelphia: Lippincott Williams & Wilkins.
Burns, C. E. (2009). Sleep and rest. In Burns, C. E., Dunn, A. M.,
FOLLOW-UP HISTORY Brady, M. A., Starr, N. B., & Blosser, C. G. (Eds.). Pediatric primary
care: A handbook for nurse practitioners. (4th ed.). (pp. 304–319).
A follow-up history is necessary when a child returns Philadelphia: W.B. Saunders
to the office or clinic after an illness or injury has been Centers for Disease Control and Prevention (CDC). (2009a). Ad-
visory committee on immunization practices: Recommended
diagnosed, or some other type of problem has been childhood immunization schedule-United States. Retrieved
identified. Historical questions are generally brief and November 4, 2009, from http://www.cdc.gov/vaccines/recs/
focus on ascertaining whether or not the problem is acip/default.htm.
Centers for Disease Control and Prevention (CDC). (2009b). Web-
better, worse, or remains the same. Specific questions based injury statistics query and reporting system. National
are tailored to the child’s particular diagnosis. The Center for Injury Prevention and Control, Centers for Disease
Control and Prevention (producer). Retrieved November 4, Hockenberry, M. J., & Wilson, D. (2007). Wong’s nursing care of
2009, from http://www.cdc.gov/injury/wisqars/index.html. infants and children. (8th ed.). (p. 120). St. Louis: Mosby.
Dennison, B. A., & Boyer, P. S. (2004). Risk evaluation in pediatric Howard, B. J., & Wong, J. (2001). Sleep disorders. Pediatrics in
practice aids in prevention of childhood overweight. Pediatric Review, 22(10), 327–342.
Annals, 33(1), 25–30. Instone, S. L. (2002). Developmental strategies for interviewing
Dunn, A. M. (2009). Elimination patterns. In Burns, C. E., Dunn, young children. Journal of Pediatric Health Care, 16(6), 304–305.
A. M., Brady, M. A., Starr, N. B., & Blosser, C. G. (Eds.). Pedi- Joint Commission on Accreditation of Healthcare Organizations.
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(pp. 253–268). Philadelphia: W. B. Saunders. Retrieved January 1, 2006, from http://www.jointcommission.
Gordon, M. (2002). Manual of nursing diagnosis. (10th ed.). St. org/standards/.
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Hagan, J. F., Shaw, J. S., & Duncan, P. M. (Eds). (2008). Bright Crocetti, M. & Barone, M. A. Oski’s essential pediatrics. (2nd ed.).
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Hockenberry, M. J., & Barrera, P. (2007). Communication and Rhoads, J. (2006). Advanced health assessment and diagnostic rea-
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CHAPTER
Assessing the Health
7 and Safety of the

Child’s Environment
ELLEN M. CHIOCCA
INFANT AND CHILD MORTALITY

HEALTH AND SAFETY IN
Because of a variety of factors (see Chapter 1), infants
CHILDREN and children have different health problems than
adults, depending on their age and developmental level.
Unintentional injury is currently the most significant
Throughout history, infants have had high death rates,
health threat to children living in industrialized na-
particularly in the immediate neonatal period, mainly
tions. It is the number one cause of death and disability
because of infection. In 2005, the leading causes of death
in children and adolescents living in the United States,
in neonates (birth to 28 days) were congenital anoma-
surpassing all diseases combined (Heron, 2007). In
lies, prematurity, sudden infant death syndrome, and
2004, childhood injuries resulted in over 11,000 deaths;
maternal complications of pregnancy (National Center
almost half of these injury-related fatalities in children
for Injury and Prevention Control [NCIPC], 2008). Non-
involved motor vehicle collisions, the leading cause of
Hispanic black infants have the highest infant mortal-
death in children in the United States (Heron, 2007).
ity rates (MacDorman & Mathews, 2008). The provider
In addition to motor vehicle collisions, drowning, fires
should know which populations have the highest infant
and burns, suffocation, firearms, falls, and poisonings
mortality rates to assess for specific risk factors and plan
are also considered unintentional childhood injuries
appropriate public health programs that target the groups
(National Center for Health Statistics [NCHS], 2007).
with highest risk. In 2004, the United States ranked 29th
After unintentional injuries, suicide and homicide
for infant mortality, behind many other industrialized
ranked second and third, respectively, as leading causes
nations (MacDorman & Mathews, 2008). In 2005:
of death in children aged 15 to 19 years (Heron, 2007).
The number of childhood deaths each year in the • The leading causes of death among children between
United States resulting from unintentional injuries is un- 1 and 4 years of age were unintentional injuries, con-
acceptably high, but it does not compare to the number genital anomalies, malignant neoplasms, homicide,
of children who require emergency treatment or hospi- and diseases of the heart (NCIPC, 2008).
talization or who suffer permanent disability because of • The five leading causes of death in children between
injuries. Injuries are the second leading cause of hospital- 5 and 9 years of age were unintentional injury, can-
ization and the leading cause of emergency room visits cer, congenital anomalies, homicide, and diseases of
among children younger than 18 years of age (Centers the heart (NCIPC, 2008).
for Disease Control and Prevention [CDC], 2008). • The leading causes of death in children between the
The U.S. government formulated objectives to images of 10 and 14 years were unintentional injuries,
prove the health of American people in the 21st century cancer, suicide, homicide, and congenital anomalies
in a report entitled Healthy People 2010 (U.S. Department (NCIPC, 2008).
of Health and Human Services [USDHHS], 2000). The • The leading causes of death in adolescents aged 15
specific goals and objectives in this report that relate to to 19 years of age were unintentional injuries, fol-
children focus on reducing the morbidity and mortality lowed by homicide, suicide, cancer, and diseases of
from the major unintentional injuries. Reaching these the heart (NCIPC, 2008).
goals will require regular childhood health supervision • Of all fatal unintentional injuries in children and
that focuses on injury risk assessment according to age adolescents, motor vehicle collisions were the lead-
and developmental stage. ing cause of mortality (NCIPC, 2008).
109
INFANT AND CHILD MORBIDITY abuse drugs or to have suicidal thoughts (Hagan & the
Morbidity describes illness, specifically the ratio of sick American Academy of Pediatrics Committee on Psycho-
to well persons in a population, presented as the number logical Aspects of Child and Family Health and the Task
of ill people per 1000 population. Morbidity refers not Force on Terrorism, 2005). All of these factors can inter-
only to acute and chronic illness, but disability as well. In fere with a child or adolescent’s social and academic per-
2006, there were 3.5 million hospital discharges of chil- formance (Hagan & the American Academy of Pediatrics
dren 1 to 21 years of age in the United States (USDHHS, Committee on Psychological Aspects of Child and Family
2009). For children 1 to 4 and 5 to 9 years of age, respira- Health and the Task Force on Terrorism, 2005) and should
tory diseases were the major cause of hospitalization and be assessed during the history and physical, particularly
accounted for 39% and 24% of their discharges, respec- if no obvious physical problems are identified. Even if
tively (USDHHS, 2009). Despite the fact that injuries are a child is not directly affected by any of these disasters,
the leading cause of death in children older than 1 year, media coverage of these events can be very frightening,
injuries could only be ascribed to 25% of the hospital dis- possibly causing nightmares, bedwetting, poor academic
charges of children 1 to 14 years of age in the year 2006 performance, and depression (Hagan & the American
(USDHHS, 2009). Pregnancy and childbirth were the Academy of Pediatrics Committee on Psychological As-
leading cause of hospitalization (42% and 64%, respec- pects of Child and Family Health and the Task Force on
tively) for adolescents 15 to 21 years of age, followed by Terrorism, 2005). In some cases, the provider should as-
hospitalizations for mental disorders (USDHHS, 2009). sess for post-traumatic stress disorder and make appropri-
ate referrals when necessary (see Chapter 24).
Psychosocial Illnesses: The New Morbidity Many immigrant children from war-torn or devel-
With the advances of immunizations and antibiot- oping countries have been psychologically traumatized
ics in the 20th century, communicable diseases have as a result of experiencing either natural or man-made
become less threatening as major causes of morbidity disasters or crimes against humanity. When caring for
and mortality in American children, and pediatric so- children from these areas, the provider must remem-
cial illnesses (also known as the new morbidity) have ber to assess for signs of psychologic trauma, taking
emerged as concerns to pediatric health care providers. into account the child’s age and developmental stage,
These illnesses are primarily psychosocial in nature and as these experiences can cause long-term psychologic
include depression, eating disorders, abuse and neglect, consequences (see Chapter 4 for a discussion of the as-
and drug and alcohol abuse. Also included are psycho- sessment of immigrant and refugee children and Chap-
somatic and stress-related illnesses related to exposure ter 24 for overall pediatric mental health assessment).
to bullying and peer violence, conflict with friends, ac- When assessing for pediatric social illnesses, the pro-
ademic and extracurricular pressures, parental divorce vider should conduct a cursory assessment of the men-
or domestic violence, media violence, living with pov- tal health of the child’s primary caregiver because the
erty or homelessness, and bereavement (Ryan-Wenger, parent needs to be emotionally available to the child.
Sharrer, & Campbell, 2005; Skybo, 2005). While it is outside the scope of the pediatric provider’s
practice to assess, diagnose, and treat a child’s parent,
Natural and Man-made Disasters if a parent is unable to care for a child because of men-
Natural and man-made disasters, including war, acts of tal health issues, appropriate referrals must be made.
terrorism, being a victim of violence with a weapon,
school shootings, as well as earthquakes, floods, hurri-
PEDIATRIC MORBIDITY AND
canes, or airplane crashes, can have a major psychologic
impact on children. Depending on the child’s age, devel-
MORTALITY STATISTICS
opmental level, cognitive abilities, educational level, and Before the provider assesses for injury risk to an infant,
social situation, all of these events can adversely affect a child, or adolescent, it is important to be familiar with
child or adolescent. Young children often show increased the facts about injuries in children. This includes the
dependence on their primary caregiver, developmental type of injuries that are most prevalent in certain age
regression, and sleep disturbances (Hagan & the Ameri- groups and the related risk factors that are likely to be
can Academy of Pediatrics Committee on Psychological present. This knowledge helps direct the health assess-
Aspects of Child and Family Health and the Task Force ment in an age-appropriate way so that the provider
on Terrorism, 2005). School-aged children may also may design relevant prevention strategies.
show developmental regression, irritability with peers
and family, somatization, and poor school performance Motor Vehicle Collisions
(Hagan & the American Academy of Pediatrics Commit- Motor vehicle collisions are the leading cause of injury
tee on Psychological Aspects of Child and Family Health death in children of all ages from birth through ado-
and the Task Force on Terrorism, 2005). Adolescents may lescence. In 2005, more than 1400 children 14 years
experience somatization, anxiety, depression, guilt, sleep and younger died in motor vehicle collisions, and ap-
disturbances, and nightmares and may even begin to proximately 203,000 were injured as occupants in motor
C HAP T E R 7 A s s e s s in g th e He alth an d Saf e ty o f th e Ch ild’s E nvir onment • 111
vehicles (National Highway Traffic Safety Administration injuries from coffee or teapots left on the table, pots on
[NHTSA], 2005). In 2006, 3490 15- to 20-year-old driv- the stove, and when being held on the lap of an adult
ers were involved in fatal motor vehicle collisions, and who is holding hot food or liquid. A working smoke
272,000 were injured (NHTSA, 2008). Of these children detector and sprinkler system in the home can greatly
who died or were injured, nearly 50% were unrestrained reduce fire-related deaths in children and families.
(NHTSA, 2005), and 25% involved a drinking driver. In
2006, an impaired driver was responsible for half of the Suffocation, Choking, and Strangulation
fatally injured children 14 years and younger (NHTSA, Injuries related to airway obstruction are the leading
2006). Most motor vehicle injuries occur when the child causes of unintentional injury deaths in children young-
is an occupant of the motor vehicle, except for the 5- er than 1 year of age (Borse, Gilchrist, Dellinger, Rudd,
to 9-year age group, when death related to injuries sus- Ballestros, & Sleet, 2008). In 2004, 963 children aged
tained as a pedestrian are more common (Harborview 14 years and under died from unintentional airway ob-
Injury Prevention and Research Center, 2009). Use of struction; most of these children were under the age of
car seats, booster seats, and seatbelts is the most effec- 4 (NCHS, 2007c). Most of these deaths are due to chok-
tive way to prevent motor vehicle injuries to children; ing on small pieces of food such as hot dogs, gum, hard
in spite of this, in 2006, 45% of children killed in motor candy, popcorn, grapes, and raw vegetables. Nonfood
vehicle collisions were unrestrained (NHTSA, 2008). items that can cause choking include toys with small,
detachable pieces and latex balloons. Airway obstruction
Pedestrian Injuries and Deaths injuries can occur as a result of entanglement in window-
In 2005, 339 children and adolescents 14 years and blind cords, clothing drawstrings, or from strings tied
younger died from pedestrian injuries (NHTSA, 2005). around a child’s neck to secure a pacifier, for example.
Most child pedestrian injuries and deaths involve chil- Infant mortality rates due to accidental suffocation and
dren crossing the street. Children younger than 10 years strangulation in bed have quadrupled since 1984 (Sha-
of age do not have the developmental abilities to inter- piro-Mendoza, Kimball, Tomashek, Anderson, & Blan-
pret traffic signs or judge distance, which puts them at ding, 2009). Children can become entangled between
greater risk for pedestrian-related injury or death. crib slats and between spaces in bunk beds, baby stroll-
ers, and high chairs. Young infants can suffocate when
Drowning placed in the prone or side-lying sleeping position or in
Drowning is the second leading cause of unintentional soft bedding; these are considered risk factors for sudden
injury death in children aged 1 to 4 years; most were infant death syndrome in infants (Moon & Fu, 2007).
boys younger than age 4 (NCHS, 2007, 2007a). Young-
er children are more likely to drown in the bathtub, Firearm Injuries
backyard swimming pool, or other standing water left The easy availability of firearms to American children
unattended at home, whereas adolescents are more contributes to the high number of firearm-related inju-
likely to drown in natural bodies of water while swim- ries and deaths in children. In 2005, 4714 children and
ming or boating (SAFE KIDS Worldwide, 2007). Parents adolescents 21 years of age and younger were killed in
should be aware of the fact that children are not de- gun-related violence (CDC, 2008b). In 2007, there were
velopmentally ready for swimming lessons until after 26,290 nonfatal firearm-related injuries in children 21
their fourth birthday (American Academy of Pediatrics years of age and younger (CDC, 2007). Approximately
[AAP], 2004). Adult supervision is the most important one third of American families with children keep at
way to prevent drowning in children. least one gun in the home (Smith, 2007). Rural house-
holds are more likely to contain a firearm than urban
Fires and Burns households; neither group consistently follows safe gun
Injuries caused by fires and burns are the third lead- storage practices with children in the home, which in-
ing cause of unintentional injury deaths in children, cludes storing guns locked, unloaded, and with the am-
mainly in children younger than age 5 years. Approxi- munition stored and locked separately (Connor, 2005).
mately 528 children aged 14 years and younger die due The presence of a firearm in the home, especially if kept
to unintentional fire and burn-related injuries annually loaded and unlocked, greatly increases the risk of unin-
(NCHS, 2007a). An estimated 116,000 children 14 years tentional firearm fatalities among children (Brady Center
and younger are treated in hospital emergency rooms to Prevent Gun Violence, 2009). Male children are much
for burn-related injuries each year (NCHS, 2007b). Most more likely to be injured fatally from unintentional fire-
of the fires and burns occur in the home, with death re- arm injuries than female children, as are urban black
sulting from smoke inhalation and asphyxiation rather children of lower socioeconomic status (NCHS, 2007a).
than from actual burns (CDC, 2008a). Younger children Not all firearm injuries involve gang activity; most occur
are more at risk for dying of fire-related injuries because between family members and are acts of rage. Also, par-
of their inability to escape from a burning building inde- ents often misjudge a young child’s capabilities regard-
pendently. Young children are also at risk for scald burn ing guns, with many believing that firearms in the home
are safe from their children. Before 8 years of age, few paint chips in old homes or from toys painted with lead
children can distinguish between real and toy guns or paint can cause lead poisoning, resulting in anemia and
fully understand the consequences of pulling the trigger damage to the kidneys and central nervous system.
( Jackman, Farah, Kellermann, & Simon, 2001). To reduce
firearm injuries in children, it is essential for the provider Toy Safety
to assess for safe storage of firearms in the home. Unsafe toys pose a variety of hazards, depending on the
child’s age and developmental level and the type of toy.
Homicide Most toy-related deaths in children are caused by chok-
Homicide is the leading cause of injury-related death in ing and subsequent suffocation on a small toy ball or
infants younger than 1 year of age (NCHS, 2007), peak- balloon (McDonald, 2006). Riding toys (e.g., bicycles,
ing during the first week, and then peaking again in the scooters, skateboards, skates) are associated with more
second month of life, most likely due to the caregiver’s injuries than any other category of toys (U.S. Consumer
reaction to the infant’s persistent crying. Shaken baby Product Safety Commission [USCPSC], 2006). Darts
syndrome (SBS) is an often fatal form of child abuse in and trampolines are dangerous at any age, and their use
infants and toddlers that involves violent shaking and should be strongly discouraged. Darts and other pro-
is often committed impulsively as a result of frustration jectile or propelled toys can cause cuts or serious eye
when a young child cries persistently. Approximately injuries (Stephenson, 2005). Trampolines are especially
1300 infants and toddlers are affected by SBS annually hazardous because of the increased risk of neck hyper-
(National Center on Shaken Baby Syndrome, 2009). flexion, hyperextension, and rotation if the child falls
Homicide is the fourth leading cause of death in chil- from the trampoline. Spinal cord injuries can occur,
dren 1 to 14 years of age, and the second leading cause specifically cervical disc herniation; younger children
of death in teenagers 15 to 19 years of age (NCHS, 2007). are at greatest risk for this injury (Windsor, Nieves, Sul-
The leading mechanism of injury in these homicides is livan, Thampi, King, & Hiester, 2006). Fatal trampoline
firearms (NCHS, 2007). While most homicides of in- injuries are most often due to spinal cord injuries and
fants and young children are perpetrated by caregivers head trauma (Stratbucker & Green, 2006). The American
(U.S. Department of Justice [USDOJ], 2007; Friedman, Academy of Pediatrics (AAP) advises that trampolines
Horowitz, & Resnick, 2005), homicides of adolescents should not be provided for children under any circum-
most often are perpetrated by peers or acquaintances stances. Ball-bearing (BB) guns, pellet guns, air rifles,
(USDOJ, 2007). Children between these ages are vic- and paint ball guns can cause serious injury to children
tims of homicides by caregivers, family members, or and adolescents, including penetration injuries to the
sex offenders (USDOJ, 2007). Firearms and handguns eye, skin, internal organs, and bone (AAP, 2008) and
in the home greatly increase the chance that a child or should be thought of as weapons and not toys.
adolescent will become a homicide victim.
Falls
Suicide Falls are common in children and, depending on the
Suicide is rare in children under age 10 years, but in 2005, child’s age and developmental stage, may occur several
it was the second leading cause of injury death among times a day, especially in toddlers just learning to walk.
children aged 10 to 14, and the third leading cause of In 2005, 82 children under 14 years of age died as a
injury deaths among children aged 15 to 19 years (CDC, result of falls (NCIPC, 2008). In that same year, more
2008b). In 2005, a total of 1883 young people aged 10 than 2.2 million children aged 14 years and under were
to 19 years killed themselves; 822 of them used a gun to treated in hospital emergency rooms for falls; 40% of
take their life (CDC, 2008b). Native American and Alas- these children were younger than 3 years of age (NCHS,
kan Native teenagers are at the highest risk for suicide, 2007b). In fact, falls are the leading cause of emergency
followed by Hispanic female teenagers (CDC, 2008c). room visits and overnight hospitalizations in children
Although more male than female teenagers complete and the most common cause of nonfatal childhood in-
suicide, attempts at suicide are much more common in jury, accounting for more than half of nonfatal child-
female than male teenagers (CDC, 2008c). hood injuries (CDC, 2007). African American and His-
panic children are more likely to be injured from falls
Poisonings from heights because of the increased likelihood that
The incidence of unintentional poisonings in children they live in urban, high-rise, often deteriorating, low-
has decreased dramatically in the last 50 years because income apartment houses (AAP, 2007a). These kinds of
of a combination of factors: child-resistant containers, falls tend to be from windows and occur more in spring
anticipatory guidance, and the establishment of poison and summer when windows are more likely to be open.
control centers, among others (AAP, 2007). Despite this, Infants and toddlers often fall in the home by falling
young children, especially those under 6 years of age, off changing tables or beds when crib rails are left down
are vulnerable to unintentional ingestions of poisons. and the child is unattended. In 2004, more than 3900
Adolescents are also at risk for poisonings, both inten- children aged 4 years and under were treated in hospi-
tional and unintentional. Exposure to lead paint from tal emergency rooms for baby walker–related injuries
(USCPSC, 2006). Of children who fall while in baby

walkers, 75% fall down the stairs at home; these inju-
ries most often cause head injury and hospitalization
(AAP, 2008c). Most children who suffer severe injury or
die from falls do so because of head injuries (Harbor-
view Injury Prevention and Research Center, 2009).
Bicycle and Tricycle Injuries

Each year, approximately 200 children die in bicycle
crashes and an additional 350,000 are seen in emergen-
cy departments for bicycle-related injuries. Two thirds of
bicycle-related deaths are due to traumatic brain injury
(Stratbucker & Green, 2006). Most bicycle-related fatali-
ties involve collisions with motor vehicles (Harborview
Injury Prevention and Research Center, 2009). The most
effective way to reduce bicycle-related head injuries and FIGURE 7-1. Young children need a safe play area with adult
fatalities is through the use of bicycle helmets; however, supervision.
it is estimated that only 20% of children wear helmets
when riding a bicycle or other wheeled equipment such
as in-line skates, skateboards, and scooters (Stratbucker Playground Injuries
& Green, 2006), and most children who use helmets In 2004, approximately 207,000 children under 14
wear them improperly. Some states and the District years were treated in hospital emergency rooms for
of Columbia, as well as some local governments, have playground equipment-related injuries; 75% of these
passed laws requiring children to wear helmets while children were aged 5 to 14 years (Fig. 7-1) (USCPSC,
bicycling or participating in other wheeled activities 2005). Strangulation from entanglement or entrapment
(Bicycle Helmet Safety Institute, 2009). The provider is the leading cause of playground equipment–related
should always inquire about helmet use at every health fatalities, and falls are the most common playground-
maintenance visit and as needed during episodic visits. associated injury (Tinsworth & McDonald, 2001). Falls
from slides, swings, playhouses, and monkey bars
All-terrain Vehicles can cause head injuries, which account for 75% of
fall-related deaths involving playground equipment
Children are injured and die both as drivers and as pas-
(Tinsworth & McDonald, 2001). Lack of adult super-
sengers on all-terrain vehicles (ATVs). In 2007, 107 chil-
vision is associated with 40% of playground injuries,
dren younger than 16 year of age died and roughly 40,000
including playgrounds in schools, parks, and childcare
were injured in ATV-related collisions (USCPSC, 2008).
centers (Fig. 7-2) (Petrass, Blitvich, & Finch, 2009).
Most fatal ATV-related injuries involve severe head inju-
ries, and death is often instantaneous (Keenan & Brat-
ton, 2004). Other injuries to children who ride ATVs in-
clude nonfatal head injuries, orthopedic injuries, spinal
cord injuries, abdominal injuries, and multiple trauma,
including lacerations and fractures (Bhutta, Greenberg,
Fitch, & Parnell, 2004; Keenan & Bratton, 2004). ATVs
are extremely difficult to maneuver, and children young-
er than 16 years of age do not have the requisite cogni-
tive or physical skills to operate these vehicles safely;
also, children younger than 16 years of age should not
ride as passengers on ATVs (AAP, 2007b; American Acad-
emy of Orthopedic Surgeons, 2005; American College
of Surgeons, 2005). Children must be at least 16 years
of age to drive a car; the same standard should apply to
the operation of an ATV. The AAP strongly discourages
the use of ATVs in the pediatric population; in fact, the
AAP has published a policy statement recommending
passage of legislation in all 50 states to prohibit the use
of two- and four-wheeled off-road vehicles by children
under 16 years and has asked for a ban on the sale of all
three-wheeled ATVs, including a recall of all used three- FIGURE 7-2. Very young children need close supervision
wheeled ATVs (AAP, 2007b). with outside play.
Sports-related Injuries
IDENTIFYING RISK FACTORS
The risk of injury when playing sports depends on the
age of the child and the type of sports-related activity FOR CHILDHOOD INJURY
in which the child engages. Sports-related injuries in DURING A HEALTH ASSESSMENT
children result in a large number of emergency room
visits and hospitalizations. More than 3.5 million The study of epidemiology furnishes the health care
children 14 years old and younger are treated each provider with an understanding of the nonrandom
year for sports injuries, mainly resulting from falls, distribution of risk to certain populations by examin-
collisions, and overexertion injuries, and as many as ing the specific factors that increase the risk (risk fac-
3.8 million sports and recreation–related concussions tors) or lower the risk (protective factors) for injury.
occur every year (CDC, 2007a). The sports associ- This study shows that injuries are predictable, prevent-
ated with the most injuries are contact and collision able, and understandable. It is important for the pro-
sports: baseball, football, basketball, soccer, and gym- vider to note that the term accident, which implies lack
nastics, and those that predispose children to falls of control over the occurrence, random chance, and
such as skateboarding and in-line skating (Stratbucker lack of responsibility, has been replaced with the term
& Green, 2006). Numerous injuries can also occur unintentional injury, which implies personal responsi-
when playing hockey; these injuries primarily involve bility and control over the cause of the injuries. It is
the upper extremities, particularly fractures, abra- widely thought that if injuries are viewed as avoidable
sions, lacerations, and contusions (Hostetler, Xiang, and not random, parents and children can be taught
& Smith, 2004). Adolescent males have the greatest prevention strategies, and injuries will consequently
number of hockey-related injuries (Hostetler, Xiang, decrease in frequency.
& Smith, 2004). Baseball has the highest fatality rate The assessment of injury risk in the pediatric popu-
among all sports played by children aged 5 to 14 years lation depends on specific factors. Haddon (1972), in
(Stratbucker & Green, 2006). Most of these deaths are his classic work, developed a conceptual framework
a result of impact injuries to the head (e.g., intracra- to guide the assessment of injuries, which, in turn,
nial bleeding) or to the chest wall (e.g., commotio cor- has helped the health care provider to devise strate-
dis and subsequent ventricular fibrillation and asys- gies for injury prevention. Haddon’s approach consid-
tole) from contact with the ball or bat (Harborview ers the interplay of one or more factors that converge
Injury Prevention and Research Center, 2006). Many to create circumstances that are favorable for injuries
sports-related injuries in children can be prevented to occur (Table 7-1). Haddon’s matrix has two axes:
if the child wears appropriate protective gear such as one that examines the host (e.g., infant), agent (e.g.,
knee and elbow pads and, especially, helmets (Dixon toy with small parts), and environment (e.g., crawling
& Gittelman, 2008). on floor unattended near the toy), and another that
TABLE 7-1
Haddon’s Matrix, Choking Injury Example
HUMAN PHYSICAL SOCIOCULTURAL
FACTORS HOST AGENT ENVIRONMENT ENVIRONMENT
Pre-event Non–childproofed Infant; Toy with small No safe play area Unsupervised child
environment developmentally parts for infant
unaware of
choking hazards
Event Choking episode Infant putting Size of toy Infant crawling on Product standards
small toy parts parts floor
in mouth and
obstructing
airway
Postevent Parents’ knowledge Degree of Ease of removal Distance to Specialized pediatric

of foreign body choking/ of foreign body hospital facilities
removal in infant; aspiration of
time of arrival foreign body
of emergency in the infant’s
personnel airway
Source: Haddon, W. (1972). A logical framework for categorizing highway safety phenomena and activity. Journal of Trauma, 12, 193–207.
depicts the environmental circumstances before (pre- children and adolescents may deliberately engage in
event factor), during (event factor), and after (post- risky behaviors in an attempt to rebel or express au-
event factor) the injury. This approach illustrates, for tonomy. Adolescents are prone to injury because they
example, how a child’s age and developmental stage, are risk takers, desire to be accepted by their peers, and
combined with an unsafe toy in an unsupervised en- as such, often do not consider safety before action (see
vironment, can lead to an unintentional injury in the a discussion of this topic in Assessment of the Ado-
child. The time–interval axis stresses how many child- lescent). Temperament plays a role as well. Children
hood injuries are predictable and preventable. With who are very active, curious, persistent, and defiant are
this example, the pre-event factor is whether the in- more likely to become injured.
fant’s environment was childproofed, the event factor
is the potential choking episode, and the postevent
factor is the availability of emergency services after RISK FACTORS RELATED TO
the injury. PARENTING
Assessment of injury risk to a child is a critical Parental knowledge deficits, particularly among very
component of injury prevention in children. When young parents and parents who are unaware of nor-
assessing for the risk of injury to a child, it is im- mal growth and developmental patterns in children,
portant to assess for the types of preventive measures can contribute to the incidence of childhood inju-
that the parent or caregiver already have in place to ry. Parents who may not be aware of their infant or
prevent injury to the child. Active strategies to pre- child’s capabilities may unwittingly leave them in
vent injury are those that require action on the part circumstances in which they can become injured.
of the child or parent. An example of an active strat- For example, an older infant or toddler who is given
egy is the use of a car seat. Passive strategies to pre- a toy with small detachable parts is at risk for chok-
vent injury in children are automatic and require no ing. Parenting style also influences a child’s risk for
action on the part of the parent or child. An example injury. Corbett, Morrongiello, Lasenby, Johnston,
of a passive strategy is childproof caps on medication and McCourt (2006) found that highly permissive
bottles. In general, the more effort required on the parenting styles were more likely to be associated
part of the child or parent, the less effective the safety with injuries severe enough to require medical at-
intervention. tention. Parents may also ask older children in the
Certain children are more at risk for injury than home to care for younger siblings, who may not be
others, depending on their age, developmental stage, aware of safety hazards to small children. Lack of
socioeconomic status, and other factors. It is impor- age-appropriate adult supervision of young children
tant for the provider to be aware of these risk factors, and parental drug or alcohol use are risk factors for
which allow him or her to direct questions properly unintentional injury.
during the health care encounter. This knowledge can
also help the provider design and implement relevant
teaching strategies. ENVIRONMENTAL RISK FACTORS
Certain environmental risk factors predispose a child
to injury. The most important risk factor is poverty,
DEVELOPMENTAL RISK FACTORS the primary predictor of injury risk in children (She-
The causes and types of childhood injuries vary widely nassa, Stubbendick, & Brown, 2004). Children living in
according to the child’s age and developmental stage. poverty are more likely to live in substandard or over-
Certain anatomic characteristics predispose young crowded living conditions, near busy streets, and near
children to injury. For example, young infants are unsafe playground facilities, all factors that increase in-
more prone to head injuries in the first few months jury risk (Shenassa, Stubbendick, & Brown, 2004). The
because of poor head control and large head size. The safety of the home environment is paramount, and
small, light body of a young child makes the child how this is evaluated is age-dependent. For example,
more prone to injury, especially with motor vehicle with young children in the house, electrical outlets
or pedestrian injuries, because the child’s small body need to be covered and cleaning solutions stored high
may be thrown more easily. Certain cognitive charac- and locked. For adolescents, this may mean close mon-
teristics make children at higher risk for injury as well. itoring of Internet use. Children living in rural areas
As children become mobile, their natural curiosity and are at increased risk for injury-related death because
desire to learn, coupled with their lack of ability to as- of certain environmental conditions (see the section
sess danger and poor impulse control, can predispose on Rural Homes) (The National Children’s Center for
the child to numerous safety hazards. Young children Rural and Agricultural Health and Safety, 2006). The
are unable to assess their surroundings for danger, and safety of the school and neighborhood also play a role
they lack abstract thinking and decision-making skills in determining a child’s safety risk. This includes as-
to protect themselves from injury. Older school-aged sessing whether the child is being bullied, whether the
child is left home alone, or if stranger safety is a risk.

BOX 7-2
Having a firearm in the home is another environmen-
Risk Factors That Predispose
tal risk factor for injury to children and adolescents.
Children to Unintentional
Injuries
NONMODIFIABLE RISK FACTORS Age
Risk factors for injury in children that cannot be changed Younger children are more prone to injuries due to
include age (see the section Developmental Risk Fac- anatomic and cognitive characteristics.
tors); male gender, which is associated with increased Race
risk-taking behaviors and rough play; left-handedness, Developmental Characteristics
which presents environmental biases that can increase Depending on age, child may be unaware of risks or
risk for injury; and having a history of a previous injury. willing to take risks.
Cognitive and developmental disabilities in children Physical abilities of the child impact injury risk.
may predispose them to injury as well. Race is another
Children With Developmental or Physical Disabilities
nonmodifiable risk factor for injury, although this may
Temperament
have more to do with living in poverty than with race
(NCHS, 2007). American Indian and Alaskan Native Some children are more aggressive and fearless than
others.
children suffer the highest mortality rates after uninten-
tional injury, followed by African Americans and His- Male Child
panics (NCHS, 2007). The rate of motor vehicle injuries Male children are associated with increased risk-taking
among American Indian and Alaskan Native children is and rough play.
three times higher than among Caucasian and African Environmental Risk Factors
American children in the same age group, and the rate Poverty
of pedestrian injury is four times higher (Stratbucker & Crowded, unsafe living conditions
Green, 2005). Deaths by drowning in American Indian Live near busy streets
and Alaskan Native children occur at a rate twice that of Live in a rural area
Caucasian and African American children; fire and burn Non-childproofed environment
injuries are almost three times higher (Stratbucker & Stress
Green, 2005). Certain risk factors predispose American Family/social situation
Indian and Alaskan Native children to unintentional Parenting
injuries; these risk factors are summarized in Box 7-1.
Permissive parenting style
Box 7-2 summarizes specific risk factors that predispose
Parental knowledge deficits
children and adolescents to unintentional injuries.
Lack of supervision
Addicted parents
History of Previous Injuries
BOX 7-1
Alcohol/Drug Use in Child or Teen
Risk Factors for Unintentional
Having Firearms in the Home
Injuries in American Indian and
Alaskan Native Children
• Poverty
• Male gender
• Alcohol abuse INJURY PREVENTION THROUGH
• Alcohol-impaired driving
• Substandard housing
HEALTH ASSESSMENT
• Rural residences
Assessment for risk of injury and injury prevention in
• Low seatbelt use rates children is an important form of health promotion. Pri-
• Limited access to medical care and emergency services mary care providers can significantly reduce the num-
• Lack of medical insurance ber of unintentional injuries in children by assessing
• High rates of depression the safety of the child’s environment at each well-child
visit and as warranted with episodic care, especially
Source: New Mexico Department of Health. (2005). New Mexico during health care visits to treat injuries or ingestions.
American Indian health status report. Retrieved February 27, 2006, These assessments provide concrete, specific data that
from http://www.health.state.nm.us/pdf/health_status_report_final.pdf; identify risks to the child and assist greatly in formu-
SAFE KIDS Worldwide. (2005m). Facts about children at higher risk for
accidental injuries. Retrieved January 13, 2006, from http://www.usa lating individualized teaching plans to prevent future
.safekids.org/content_documents/Atriskfacts.pdf. injuries; their importance cannot be overemphasized.
Some children live in unsafe environments because The Home Environment

injuries that they sustain are intentional. These inju- In 2004, approximately 2300 children 14 years of age
ries may be a result of abuse or self-inflicted harm (see and younger died in their homes due to unintentional
Chapters 23 and 24). injuries (Home Safety Council, 2004). Almost 80% of
these deaths were among children aged 4 and under
(National Safety Council, 2006). Children are at in-
HISTORY creased risk for death resulting from unintentional
An assessment of the health and safety of the child’s injuries occurring in the home largely because this is
environment is part of every infant, child, and ado- where they spend most of their time. Most home in-
lescent’s wellness examination. It begins by obtain- jury deaths are a result of choking, fire, burns, drown-
ing the history using a developmentally focused ing, firearms, falls, and poisoning; with the exception
approach. An example would be to start by asking of firearm injuries, most deaths are in children aged
open-ended questions such as, “Do you use a car seat 4 years or younger (National Safety Council, 2006).
for Kylie?” “Does Jamal take a bottle to bed?” “Julie, The home safety assessment begins with general
do you use your seatbelt each time you ride in the questions about the child’s home environment. For
car with Mom?” “Does Juanita wear a bicycle helmet children younger than preschool age, the parent
each time she rides her bike?” and “Michael, can you should be asked if the home is childproofed. This in-
tell me what you would do if a stranger asked you to cludes covering outlets, padding table corners, placing
come with him?” A checklist is useful when making gates at the top of stairs, and removing dangling cords,
these assessments as it ensures that all the relevant especially those belonging to window blinds, which
safety and illness prevention questions are asked for pose strangulation hazards. The provider should ask
the child’s particular age and developmental level. A parents who live in upper level dwellings or with bal-
checklist also helps to expedite the pace of the health conies about window guards and railings on balco-
care visit. Using Bright Futures: Guidelines for Health nies. Families with toddlers should be asked whether
Supervision of Infants, Children, and Adolescents and doors are kept locked to prevent curious toddlers from
the AAP health supervision guidelines as resources leaving the home unattended. The provider should
to guide these assessments is ideal (Hagan, Shaw, & determine if parents know first aid as well as how to
Duncan, 2008). The AAP has also developed The In- perform the Heimlich maneuver and cardiopulmo-
jury Prevention Program with the goal of decreasing nary resuscitation (CPR). The provider should ask pre-
injuries in children by providing education to parents school-age and older children if they know how to dial
(AAP, 2007c). 911. The provider should ask if the Poison Control
Answers to the questions asked during the history Center number is clearly posted and readily available.
determine not only what general and specific injury The provider should also ask parents about firearms in
prevention measures are used for the child, but the the home (i.e., if they are locked and unloaded). It is
parent’s knowledge of basic child growth and develop- also important to determine if lawn and garden equip-
ment as well. For example, what are the parents’ ex- ment is kept stored in a locked garage or shed.
pectations of the child? Do they expect a young child The provider should ask about the parent’s role mod-
to have knowledge of street safety? Is the parent or eling of safety, including safety belt use, drinking and
caregiver aware of choking hazards posed to infants driving, and obeying posted speed limits. Parents should
and toddlers? Are the parents aware of the dangers of also wear bicycle helmets when riding their bicycles.
leaving young children unattended, especially near The provider should ask about the use of tobacco, illegal
stairs and water? If there are children under 3 years of or prescription drugs, or alcohol in the home environ-
age in the home, is it childproofed? Is there an adoles- ment, and the provider should ask if the child is exposed
cent in the home who is suffering from depression? to interpersonal violence among family members.
The information gleaned from these assessments can
be used to develop concrete teaching plans and safety Urban Homes. The effects of poverty often greatly im-
interventions as needed. pact the health status and safety of children living in
Some specific health and safety assessment ques- urban settings. Other factors affecting the safety of a
tions should be asked at every visit, regardless of the child living in an urban area include crowded or unsafe
child’s age, most involving motor vehicle safety, fire living conditions, traffic-related safety hazards, lead
safety, sun and water safety, secondhand smoke expo- paint exposure in old buildings, exposure to pesticides
sure, environmental sanitation, living conditions, the used in urban schools and homes, noise, crime, air
family’s social situation, whether the family owns any pollution, and gang activity, among others. Homeless
firearms, and the child’s exposure to violence in differ- children have a higher incidence of trauma-related in-
ent forms. Box 7-3 summarizes these universal health juries, and runaway youth and young people living on
and safety assessments that should be made regardless the streets are at risk for violent injury and victimiza-
of the child’s age. tion (DuPlessis, Cora-Bramble, & American Academy of
BOX 7-3
Universal Pediatric Health and Safety Assessments
Safety of Home Environment
Is home childproofed? Are outlets covered? Are gates and window guards used?
Are window-blind cords out of reach?
Is the child exposed to secondhand smoke?
Are there toys with small parts in the house with children under 3?
Is there age-appropriate adult supervision?
Is there any lead paint in the older home or apartment?
Is the child exposed to interpersonal violence among family members or is there evidence of child abuse?
Are there any drug or alcohol users in the home?
Motor Vehicle Safety
Are all motor vehicle restraints properly used (see Box 7-1)?
Are children allowed to ride in the cargo area of a pickup truck?
Pedestrian/Traffic/Cyclist Safety
Do children use helmets when bike riding?
Is there age-appropriate supervision when crossing streets?
Fire and Burn Safety
Are there smoke and carbon monoxide detectors in the home?
Are space heaters used in the winter?
Are infant bottles warmed in a microwave?
Are there fire extinguishers in the home? Is there a family plan for escape in case of fire?
Sun Safety
Are children allowed to play in the sun without protective clothing?
Are infants younger than 6 months of age kept out of direct sun?
Do all children older than 6 months of age use sunscreen?
Do teens use tanning beds?
Water Safety
Are all young children closely supervised around water?
Have children 4 years of age and older had swimming lessons (AAP, 2004)?
Animal Safety
Have children been taught safe handling of animals; for example, no teasing and no handling of animals when they
are eating?
What kinds of pets are in the house? Are these pets healthy?
Sports/Recreational Safety
Do children use helmets and other protective gear when playing sports?
School Safety
Are children bullied by others?
Is it safe for children to travel to school unsupervised?
Stranger Safety
Media Safety
Do children see violent media of all types?
Is Internet use monitored in school-aged children and adolescents?
Firearm Safety
Are there firearms or other weapons in the home?
Are guns and ammunition locked and stored separately?
General Health
What are the household hand-washing practices, especially with a newborn in the house, during cold/flu season, and
with other illnesses?
Are toys ever washed?
What is the immunization status of everyone in the family, especially members who travel back and forth to
developing countries?
BOX 7-4
Safety Assessments for the Child Living in an Urban Setting
• Is the child living in an old, unsafe building? Was it built before 1960?
• Is the child exposed to lead paint or lead paint dust from chipping paint or remodeling of an old home?
• Does the child live in crowded housing conditions? Are there continual loud noise levels?
• Does the child live in a high-rise building? If so, are window guards in place on all windows to prevent falls?
• Is the child exposed to pesticides (e.g., chlorpyrifos) that may have been applied in their home, school, or daycare
center to control cockroaches, rats, termites, or other vermin?
• Does the child stay off the grass after lawn chemicals and pesticides have been applied?
• Does the child live in an urban area with high levels of air pollution and poor air quality? (If yes, has the child had
episodes of wheezing? Has the child been diagnosed with asthma?)
• Does the child take public transportation alone?
• Does the family live near a busy street or highway? Does the child walk to school alone? If so, is the child
developmentally capable of doing so? Is the child competent with traffic safety and street crossing? Is the
neighborhood safe enough for the child to walk to school?
• Does the child take a school bus to school? If yes, how does the child get physical activity?
• Has the child ever been the victim of bullying? If so, to what extent? Was physical violence involved?
• Does the child live in a high crime area? Is the child (preschool-age and older) familiar with the concept of “stranger
danger”?
• Is the child involved in or been the victim of any gang-related activity?
• Does the family own any firearms? Are the firearms stored locked with the ammunition kept separately? Has the child
been taught about gun safety?
Pediatrics Committee on Community Health Services, poverty, mobile lifestyle, overcrowded living conditions,
2005). Box 7-4 provides a detailed guide that is tailored poor environmental sanitation, and unreliable trans-
to the assessment of children living in urban settings. portation (DuPlessis, Cora-Bramble, & American Acad-
emy of Pediatrics Committee on Community Health
Rural Homes. Children who live on farms or in rural Services, 2005). Adolescent migrant farm workers are at
frontier areas require a different approach to the assess- risk for these injuries, and they also encounter risks re-
ment of a safe environment. This group of children in- lated to traveling without their parents as part of their
cludes not just farm families but children of hired farm mobile lifestyle. American Indian and Alaskan Native
workers, the children of migrant farm workers, and children are other populations who often live in rural
children who may just be visiting a farm. These chil- areas. As previously discussed, these children are already
dren are exposed to hazards associated with agricultural at an increased risk for injury. This underscores the im-
work and rural environments such as farm machinery, portance of being especially thorough when assessing
vehicles (ATVs, tractors, and automobiles), livestock, for injury risk in these children (Box 7-5 summarizes
and agricultural chemicals and pesticides (National In- safety assessments for children living in rural areas).
stitute for Occupational Safety and Health, 2007). Falls
from unstable structures, drowning, animal trauma,
horseback riding injuries (Pickett, Brison, Berg, Zentner, Motor Vehicle Safety
Linneman, & Marlenga, 2005), electrical hazards, and Because motor vehicle collisions are the leading cause of
firearm-related injuries are also safety risks to children death in American children over 1 year of age, it is par-
living in rural areas. Children who live in rural areas ticularly important that the provider ask parents during
with a low population density who live a long distance routine health care visits if their children are properly
from health care facilities may also be at increased risk restrained when riding in a motor vehicle. All children
for morbidity and mortality related to injuries sustained should be secured in a weight- and age-appropriate ve-
while on a farm, as it may take longer to travel to a ter- hicle restraint that is installed properly. The provider
tiary facility to receive urgently needed care. may need to determine whether the car or booster seat
Migrant farm workers’ children of all ages are at in- has been placed in the vehicle properly and if the child
creased risk for intentional and unintentional injuries is positioned in the seat correctly. The provider should
and farm-related injuries (DuPlessis, Cora-Bramble, & determine whether an infant weighing 20 pounds or
American Academy of Pediatrics Committee on Com- less rides in a rear-facing car seat in the back seat of the
munity Health Services, 2005). Factors that may be at- vehicle (Fig. 7-3). Infants and children younger than
tributed to this increased risk include language barriers, 13 years old should never ride in the front seat of a
BOX 7-5
Specific Safety Assessments for the Child Living in a Rural Environment
• Does the child regularly visit or live on a farm?
• Is there an enclosed play space for young children away from work areas, animals, and farm machinery?
• Before operating any farm equipment or machinery, is the work area always checked for the presence and location of
small children?
• Does the child or adolescent operate farm equipment and, if so, does the child or teen have the requisite knowledge,
maturity, and physical abilities to do so? Is the child who operates farm machinery younger than 16 years of age?
• Does the child always use seatbelts when operating a tractor or any other type of farm machinery?
• Are there rollover protection structures on the tractors?
• Is there more than one rider on tractors, mowers, all-terrain vehicles or other farm machinery?
• Does the child ever ride in the cargo area of a pickup truck?
• Is the child ever involved in applying toxic pesticides to crops?
• Are farm chemicals and cleaning agents properly stored?
• Is the young child always supervised around standing water or any body of water? Has the child had swimming
lessons? Does the child ever swim alone?
• Is the small child kept away from livestock?
• Has the family taught the child safe handling of pets, farm animals, and livestock?
• Does the child wear appropriate safety gear (e.g., helmets) when riding horses?
• Does the child or teen wear hearing-protective equipment when actively involved in farm work?
• Are there any electrical hazards on the farm, especially in barns?
• Does the family have firearms? Are they stored locked and is the ammunition kept separately? Has the child been
taught not to handle guns?
• Do the child and family use appropriate hand washing after handling animals or animal manure?
vehicle because air bag deployment can result in fatal in- the provider should ask about seatbelt use for every car
jury. Once a child is older than 1 year and weighs more ride, no matter what the distance. Children with special
than 20 pounds, the provider should ask if the child needs such as premature infants or children with physi-
continues to use a car seat; this car seat can now be for- cal disabilities may need some modifications to their ve-
ward-facing (Fig. 7-4). The health care provider should hicle restraints; the provider should determine if these
also inquire about vehicle restraints in older children. adaptations are in place. When obtaining a health histo-
Once children weigh 40 pounds or more, they should ry on adolescents, the provider should ask teens if they
be placed in an approved booster seat in the back seat of wears seatbelts consistently, obey speed limits, drink or
the car. The provider should ask parents about the use use drugs when driving a car, or ride with anyone who
of booster seats until the child weighs 80 pounds; then does. The provider should determine if the parents also
FIGURE 7-3. Infants who weigh less than 20 pounds and

younger than 1 year of age need to be placed in a rear-facing FIGURE 7-4. Once children weigh 42 pounds, they may ride
car seat. in a forward-facing car seat.
consistently wear a seatbelt. Children are more likely to

use their seatbelt if they see this behavior consistently in
their parents. The provider should ask parents who drive
pickup trucks if their children ever ride in the cargo area
of the truck. This practice is exceptionally dangerous;
each year, approximately 50 children and adolescents
21 years of age and younger die while riding in the cargo
area of a pickup truck (AAP, 2008a) (see Box 7-6 for a
summary of proper vehicle restraints for children).
Pedestrian and Traffic Safety

Assessment of motor vehicle safety also includes specifi-
cally inquiring about whether the child is always super-
vised near the street and in driveways, and if the child
younger than 8 years of age always holds an adult’s
hand when crossing the street (Fig. 7-5). The provider
should determine if the child rides his or her bicycle,
skateboard, or scooter in the street. Children, if school-
aged or older, can be asked directly if they know how
and where (i.e., crosswalks) to cross the street. Also, the
provider should determine if the child walks to school
FIGURE 7-5. Young children need close supervision in drive-
alone. It is important to determine both safe pedestrian ways and near streets.
practices and safety around strangers.
Bicycle Safety
BOX 7-6 The provider should ask parents if their child rides a
Summary of Proper Vehicle tricycle or bicycle and, if so, if the child wears a hel-
Restraint in Children met that meets bicycle helmet safety standards of the
American National Standards Institute or the Snell Me-
Infants 20 pounds or less: morial Foundation (Fig. 7-6). The provider should ask
• Must ride in rear-facing car seat. parents to replace helmets that have been damaged or
• Must ride in back seat of vehicle.
• Must ride in back seat with side air bags disabled.
Infants who weigh 20 pounds before they reach
1 year of age:
• Should remain in rear-facing car seat until 1 year.
Toddlers age 1 year or older and at least 20 pounds:
• Must still ride in rear seat of vehicle.
• Can ride in forward-facing car seat in vehicle.
• Should remain in car seat until they weigh 40 pounds.
Children weighing 40 pounds or more:
• Should ride in forward-facing booster seat.
• Should still ride in rear seat of vehicle.
• Should remain in booster seat until 4 feet, 9 inches in
height and 8–12 years of age.
• After this age, should wear a seatbelt for all rides, no
matter the distance.
• If younger than 13, should not sit in the front seat of
the vehicle.
Premature infants:
• Should use a car seat without a shield harness.
• Should have an adult ride in the back seat if possible.
Source: American Academy of Pediatrics. (2006). Car safety seats: A FIGURE 7-6. Even preschoolers should wear helmets when
guide for families. Elk Grove, IL: American Academy of Pediatrics. riding bicycles.
are outgrown. The provider should inquire about chil- the provider should determine if school-aged children
dren riding as passengers in a rear-mounted seat on an or adolescents ever swim alone.
adult bicycle. Infants younger than 1 year should not
ride on the back of an adult’s bicycle in an infant seat Animal Safety
because infants this age cannot support the weight of Having an animal in the home can pose a safety risk to
the helmet and hold their head up during the ride (AAP, children, particularly children ages 5 to 14 years who
2008b). It should be determined if children older than are most likely to be bitten (Garth & Harris, 2008). Chil-
1 year who ride in a rear-mounted seat on the back of an dren living on farms are also at risk for animal-related
adult’s bicycle wear an approved helmet for the ride. injuries. During the health history, the provider should
determine the kind of pets kept in the home. The pro-
Fire Safety and Burn Prevention vider should determine if infants and young children
The provider should always ask parents if there are work- are supervised around animals and taught safe handling
ing smoke and carbon monoxide detectors on every level of pets and farm animals: to avoid touching animals
of the home and if the batteries are changed at least twice they do not know, not to tease or play roughly with an
a year. The provider should determine if the family has animal, and never to touch an animal when it is eating.
a fire extinguisher in the home and whether there is an If the parents have recently acquired a pet such as a dog
escape plan in the event of a fire. When age-appropriate, or cat, the provider should ask if the animal has been
children should be taught to feel a door for heat and re- properly immunized and examined by a veterinarian to
frain from opening the door if it is hot; to stay close to minimize the chance of spreading disease to the child.
the floor if there is smoke; and to stop, drop, and roll if
their clothes catch fire. Preschool-aged children and older Sports and Recreational Safety
should be asked if they know how to dial 911 to report a Children of all ages need toys or age-appropriate ac-
fire. The provider should ask the parent if the home’s hot tivities to enhance their psychosocial development and
water heater temperature is set at 120° Fahrenheit or lower. learning. As part of the well-child visit, the health care
The provider should ask parents about using a microwave provider should determine what toys the child plays
to heat bottled infant formula; this causes uneven heat- with, not just to gauge the child’s developmental level,
ing of the formula, which can burn an infant’s mouth. but also to determine whether there are any safety haz-
The provider should determine if there are fireworks in ards present. Although many toys are packaged with la-
the home to which the child or adolescent has access. bels that state “not intended for children younger than
3 years,” this is usually not because the toy is develop-
Sun Safety mentally advanced for a child that age but because it
Because young children have a thin, undeveloped contains small, detachable pieces on which a child un-
epidermis, they develop sunburn more quickly than der 3 can easily choke. When beginning a sports safety
adults. Assessment of sun safety includes asking the assessment, the provider must first consider the child’s
parent about keeping their infant or child out of direct age and developmental stage, and formulate questions
sunlight and the use of sunscreen, protective clothing, from that standpoint (see the next section: Assessment
hats, visors, and sunglasses for protection. Sunscreen of Risk for Injury by Age and Developmental Stage).
should not be used on infants younger than 6 months For older children who ride skateboards, scooters,
of age, and children of this age should be kept out of or in-line skates or who participate in sports, the pro-
direct sunlight at all times. The provider should ask vider should inquire about appropriate protective gear,
parents whether they apply sunscreen to their children including helmets and mouth guards (AAP, 2009). The
6 months of age and older when their children are in provider should ask about trampoline use in children
the sun for prolonged periods. of all ages and take time to educate parents on the
dangers associated with trampoline use. Adolescents
Water Safety should be asked if they ride ATVs and, if so, whether
Because of the prevalence of drowning deaths in chil- they wear a helmet. The provider should discourage
dren of all ages, the health history should always in- parents from allowing children and teens to ride ATVs,
clude information about whether the child is continu- snowmobiles, or jet skis before they are 16 years of
ously supervised around pools, bathtubs, and natural age because of the upper body strength and coordina-
bodies of water and whether the child wears a life jacket tion needed to operate these machines (Stratbucker &
near water. The provider should ask parents of infants Green, 2006). The provider should ask children who
and toddlers if they ever leave their child alone in the ride horses if they always wear a helmet when riding.
bathtub or around pools or buckets of standing water.
The provider should determine whether a child 4 years Stranger Safety
of age or older has had swimming lessons. If the fam- Beginning in the preschool aged-group, children should
ily has a backyard pool, the provider should ask if it be asked what they know about “Stranger Danger.” Chil-
is properly fenced with self-closing, self-latching gates; dren should be able to articulate that they would never
go with a stranger, even if bribed or told by the stranger of the movies should be noted. The provider should also
that they knew the child’s parents. During the history, the ask if the child has a television or computer in the bed-
provider could start the assessment by asking the child, room, as this makes parental screening of content more
“Alyssa, what would you do if a man you did not know difficult; it also makes it next to impossible for the parent
came up to you and nicely asked you to come with him to know exactly how much time their child is spending
to help him find his lost puppy?” Responses resembling, watching television or online. The provider should also
“I would never go with someone I did not know,” or “I ask if the television is on at mealtimes or during home-
would scream and run and tell an adult” indicate that the work time and if parents watch television or movies
child is aware that going with a stranger is dangerous. with their child and discuss what they see. This gives the
Adolescents are also at risk for being hurt by strang- provider an opportunity to educate the child and parent
ers that they may meet through Internet chat rooms about the negative effects of excessive media time, espe-
or e-mail, Internet dating services, or at parties where cially exposure to media violence. Children and adoles-
drugs or alcohol may be used. Because of this, stranger cents who view violent media can become desensitized
safety must be assessed at health maintenance visits to violence, show increased aggressive behaviors, use
in this age group as well. Special attention should be violence as a method of conflict resolution, and see the
given to the multiple stranger safety risks that the In- world as an overly violent and scary place (AAP, 2001).
ternet poses to children and adolescents. These risks
include exposure to harassing or threatening e-mails, Firearms
being lured into activities that have legal consequenc- Regardless of the child’s age, at every visit the provider
es such as revealing personal or financial information, should ask if firearms are kept in the home and how and
and other safety issues, including sexual assault or where the firearms are stored. Any firearm in the home
other injury as a result of sharing personal informa- is dangerous, including BB, pellet, and paint ball guns,
tion online and then meeting the stranger in person which can cause serious injuries to the eye, sometimes
(McColgan & Giardino, 2005). Parents, children, and leading to blindness. During the safety portion of the
adolescents should be asked about how much time the health assessment, when the provider asks the parent if
child or teen spends online each day, if the time is lim- any guns are kept in the home, the provider should ask
ited by the parent, whether the computer is kept in a if the firearm is stored unloaded and if it is in a locked
common area of the house, and if parental controls are container. The provider should determine whether the
used. With the parent out of the room, the child or ad- child or adolescent knows where the gun is kept; only
olescent should be asked about what type of Internet the parent should know where the gun is stored. The
sites they visit, if they have their own e-mail account, provider should determine whether the ammunition
or are involved in Internet chat rooms. is stored separately and in a locked container. The pro-
vider should know that this portion of the history may
Exposure to Media not always be entirely accurate if the child’s mother
It is estimated that the average American child spends brings the child for health care visits. Coyne-Beasley,
an average of 3–6 hours per day in front of a television, Baccaglini, and Johnson (2005) found that the child’s
computer, or video screen (Christakis, Zimmerman, mother may not be the best source for determining fire-
& Garrison, 2006; Roberts, Foehr, & Rideout, 2006; arm ownership and storage practices in the home. These
Christakis, Ebel, & Rivara, & Zimmerman, 2004). When researchers showed that more men (80%) reported the
watching television, children are exposed to repeated presence of firearms in the home than women (72%)
references to and advertisements for junk food, alco- and most men (82% versus 17% of women) owned the
hol, and tobacco (AAP, 2001). Children and adolescents guns. Obtaining an accurate safety assessment of fire-
are also exposed to violent and sexual content through arm ownership and safe storage practices is a challenge
television, movies, video and computer games, the In- because fathers do not usually bring the child for a well-
ternet, and through the lyrics of songs. The AAP recom- child visit. Firearm safety assessment and counseling
mends that children 2 years of age and younger watch should include the male head of the household to im-
no television or videos at all, and children older than prove knowledge about the presence and storage prac-
age 2 engage in no more than 1 to 2 hours a day of total tices of firearms in homes with children and adolescents
“screen time,” which includes television, movies, hand- (Coyne-Beasley, Baccaglini, & Johnson, 2005). Parents
held video games, and computer time (AAP, 2001). of children and adolescents should also be strongly en-
During the health maintenance visit, the health care couraged to eliminate firearms from the home.
provider has an excellent opportunity to assess a child’s
exposure to various types of media as part of the health General Health Practices
history. This assessment includes asking the parent how It is important to keep a child safe not just from physi-
many hours a day their child watches television and cal injury but from illness as well. The provider should
movies, uses the computer and Internet, or plays video ask parents if they routinely wash their child’s hands,
games. If the child watches movies each day, the content especially before meals, after using the toilet, and when
the child returns home from school, daycare, or playing

outside. The immunization status of all children should
also be assessed at every health care visit. Secondhand
smoke exposure should be assessed as well. The pro-
vider should also ask parents if they know first aid, the
Heimlich maneuver, and CPR, especially if the child
has a chronic or life-threatening health condition.
ASSESSMENT OF RISK FOR INJURY BY

AGE AND DEVELOPMENTAL STAGE
In addition to universal safety assessments, pediatric
clients must be assessed for risks to safety according to
age and developmental stage. All children and adoles-
cents are at risk for injury because of their natural curi-
osity, impulsiveness, and, depending on developmental FIGURE 7-7. When infants begin creeping and crawling, the
home environment must be childproofed.
level, inability to assess (younger children) and desire to
take risks (adolescents). With each new developmental
achievement, children enjoy exploring their surround-
ings and are driven to test newly acquired skills. Chil- termine if the parent uses plastic sheets to cover the
dren and adolescents often attempt activities before crib mattress or has plastic bags near the crib, both of
they have developed the requisite cognitive and physi- which present a suffocation risk. The provider should
cal skills needed to accomplish the task safely. As chil- ask parents of infants 2 months of age and younger if
dren grow, their gross and fine motor abilities develop, they know the signs of illness in a baby this age, such
but at a faster rate than their cognitive abilities, making as fever, refusing feedings, persistent vomiting or diar-
them more vulnerable to injuries. In addition, children, rhea, inconsolability, lethargy, jaundice, or skin rash.
especially toddlers and adolescents, in a desire for au- The provider should ask parents of newborns and in-
tonomy and independence, often challenge rules, defy fants if they attend the child at all times when the child
their parents, and become oppositional, making rule en- is on a bed, a changing table, or in a bath. The provider
forcement sometimes difficult for parents. School-aged should also determine if parents ever consume hot liq-
children and adolescents in particular develop a strong uids while holding their infant. The provider should
desire for peer approval as they grow older, which may ask about what kind of toys are provided for the infant,
lead to risk-taking behavior to impress friends. Personal- noting if any of these toys present safety hazards such
ity and temperament of the child also play a large role in as marbles, latex balloons, or toys with small, remov-
influencing injury risk; some children are more aggres- able parts, which can cause choking. Batteries should
sive than others and thus are more prone to injury. always be kept away from small children. Toys with
sharp edges or points may cause unintentional cuts or
Assessment of Infants lacerations. The provider should ask if the infant plays
Infants younger than 6 months of age have poor head with toys that have long strings or has a pacifier on a
control and until 2 years have a large head in propor- string, both of which are strangulation hazards.
tion to their body; both factors make them more vul- When assessing infants aged 6 to 12 months, the
nerable to head and shaking injuries. Older infants provider should ask if the parents have childproofed
become more mobile as they learn to roll over, creep, the home. Are there gates at the tops of stairs and
crawl, and pull to stand. Infants also explore their en- window guards in upper level rooms? Are outlets cov-
vironment by putting things into their mouths. The ered? Are sharp corners of walls and furniture padded?
developing pincer grasp makes it easier for older in- Are electrical cords concealed to prevent accidental
fants to place small objects in their mouth, presenting chewing, which can result in electrical burns? Parents
choking hazards and making older infants at risk for should be encouraged to keep a gate at the entrance of
poisoning and ingestions (Fig. 7-7; Table 7-2). the kitchen to keep the infant away from knives and
Parents of infants should be asked if their child is the stove. As gross and fine motor skills progress (e.g.,
placed in an approved car safety seat for all car rides crawling on the floor, finding a small piece of a toy),
and whether it is rear-facing and installed correctly (see older infants are at high risk for choking (Fig. 7-8) and
Box 7-1). The provider should ask parents of newborns their environment should be assessed for this. The pro-
about sleep position, cosleeping practices, the space vider should ask about keeping cleaning solutions, poi-
between crib slats, if the crib mattress fits snugly, and sons, and medications high, locked, and out of reach.
if there are stuffed toys and pillows in the crib, which The Poison Control Center telephone number should
present suffocation hazards. The provider should de- be readily available. The provider should ask parents
TABLE 7-2
Safety Assessment Guidelines for Infants
AGE AND PHYSICAL/DEVELOPMENTAL POTENTIAL
CHARACTERISTIC OF INFANT INJURIES RELEVANT ASSESSMENTS
Birth to 6 months Injury to neck or Assess how the infant is picked up, held, and moved. Is the neck supported? Are older children
Poor head control head supervised around the infant? Is the infant left alone with pets? Is the infant ever shaken? What do
Large head (birth to 2 years) parents do when the baby gets fussy? Is the infant placed in a rear-facing car seat for every car ride?
Primitive reflexes: suck, grasp, rooting, startle Aspiration of foreign Is there plastic in or around the infant’s bed or changing table? Is the infant placed supine for
objects, suffocation, sleeping? Does the family cosleep? Is the infant placed on a waterbed or beanbag to sleep? Does
strangulation, the infant sleep in a crib or adult bed? Does the crib have pillows or stuffed bedding/bumper pads
choking inside? Are there toys, stuffed animals, or crib mobiles with small, detachable parts, strings, or
cords? Is the crib positioned close to window blinds? Are the crib slats ⱕ 2 3/8 inches apart? Does
the infant have anything tied around his neck such as a bib or pacifier secured with a string or
shoelace? Does anyone feed the infant small finger foods? Is the infant’s bottle propped? Are latex
balloons kept away from the infant?
Thin epidermis Burns Do the parents hold the infant while cooking or consuming hot food or beverages?
Is the infant held while the parent is smoking? Is the home’s hot water heater thermostat set to
ⱕ120° F? Are there working smoke and carbon monoxide detectors in the home? Are the batteries
checked routinely?
Sunburn Is the infant exposed to direct sun? Do the parents refrain from using sunscreen on infant and keep
the infant out of direct sunlight instead? Does the infant wear a hat in the sun and are all other skin
exposed areas covered?
Increasing gross motor abilities correlating with Falls Is the infant ever left unattended on a bed or changing table, sofa, or chair? Is the infant placed in
spinal cord myelination: a bouncy seat while on a table, kitchen counter, or other high surface? Is the baby placed in a safe
• Rolls, turns, scoots, moves, pushes against place such as a crib or playpen when not being held? Are there gates at the top of stairs when the
objects with feet infant begins to crawl? Are window guards in place on all windows above the first floor? Is the baby
• May begin to creep or crawl as early as 6 months ever in a walker?
May slide between crib Does the infant sleep in a crib with a mattress that fits snugly against the crib rails?
mattress and crib slats
Slip or slide in sink Is the infant ever left unattended during a bath?
or tub during bath
Motor vehicle safety Is the infant placed in an approved rear-facing car seat in the back seat for every car ride? Does the
infant ever ride in the front seat of the car? Does the car have a passenger air bag? Does the infant
ever ride held on an adult’s lap?
Immature body temperature regulation Hypothermia Is infant dressed appropriately with head covered in cold weather?
Hyperthermia Is infant dressed in light, loose clothing in hot weather? Do parents ever leave infant alone in a parked car?
Immature nonspecific and specific immunity Infection/sepsis Are parents aware of cord care and circumcision care in the newborn? What are the hand-washing
(birth to 2 months) patterns? Can parents recognize early signs of illness: fever ⬎100.4° F, irritability, inconsolability,
lethargy, poor feeding, red eye or drainage, vomiting, diarrhea, or cyanosis? Do parents know that
125
no antipyretics are given for fever in infants ⬍2 months of age?
(continued)
TABLE 7-2
126
Safety Assessment Guidelines for Infants (Continued)
AGE AND PHYSICAL/DEVELOPMENTAL POTENTIAL
CHARACTERISTIC OF INFANT INJURIES RELEVANT ASSESSMENTS
6 to 12 months Falls Is the infant supervised at all times? Is the infant ever left alone on a bed or changing table, or in a
Increasing gross motor abilities: high chair? Is the crib mattress low enough so older infants cannot climb out of the crib? Are there
• Beginning to sit unassisted bumper pads in the crib on which the infant can climb? Are crib slats ⱕ 2 3/8 inches apart? Are
• Increased mobility with creeping, crawling, gates at the top of all stairs? Are doors closed? Are window guards installed on all windows above
and cruising; likes to explore the first floor? Is sharp-edged furniture padded? Is the infant ever placed in a walker? Is the infant
• Begins to push up on hands and knees ever left alone with pets or young siblings?
• Pulls to stand
• May stand alone or with support
• May walk or climb
Motor vehicle safety Does the infant ride in the back seat in a rear-facing car seat for all car rides? (see Birth to 6 months
Assessments)
Drowning Is the infant ever left unsupervised in a bath? Is the bathroom door kept closed and is the toilet lid
down? Are buckets of water removed? Are there protective enclosures around pools, hot tubs, ponds,
or fountains?
Poisonings, Are medications, chemicals, and cleaning agents stored high and locked? Do cabinets have safety
ingestions latches? Do all medication bottles in the house have childproof caps? Are there any poisonous
houseplants in the home? Is the Poison Control Center number placed near the phone? Are parents
aware that syrup of ipecac is no longer recommended?
Increasing fine motor abilities; pincer grasp Aspiration of foreign Is there a safe place to put the baby such as a crib or playpen when parent is unable to hold infant?
developing: objects; choking Are outlets covered and drawers and cabinet doors latched? Are small, sharp objects kept off the
• Increasing hand-eye coordination floor and out of reach? Are there toys with small, detachable parts? Is the baby ever fed small, hard
• Infant learning to pick up small objects pieces of food such as popcorn, nuts, hard candy, raw carrots, or other vegetables, hot dogs, apples,
• Begins to pull and grab at things raisins, grapes, or peanut butter? Is the infant’s bottle propped? Are topical numbing gels used for
• Transfers objects from one hand to the other teething (may suppress gag reflex and increase chance of aspiration)? Do the parents know CPR and
• Objects are explored by touching and placing the Heimlich maneuver?
in mouth
• Increasing curiosity; does not like to be restrained
Suffocation Are balloons, plastic bags, and plastic wrappers kept out of the infant’s reach? Does the infant have a
Strangulation pacifier tied around his neck? Does the infant ever sleep on a beanbag chair? Are bibs removed after
meals? Are crib toys strung across the crib?
Burns, electrocution Is bath water checked before the infant is placed in the tub? Is the microwave used to heat formula
or baby food? Do the parents drink hot beverages, eat hot food, or smoke while holding the infant?
Are tablecloths removed from tables (can pull down hot liquids)? Are there dangling cords that may
be within the infant’s reach? Are electrical outlets covered with plastic plugs?
Are working smoke and carbon monoxide detectors in the home? Are the batteries checked routinely?
Sunburn See Birth to 6 months Assessment. Is sunscreen used? Is prolonged exposure to the sun avoided?
Source: Dunn, A. M. (2009). Health perception and health management patterns. In Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., & Blossner, C. G. (Eds.). Pediatric primary care: A handbook for
nurse practitioners. (4th ed.). (pp. 183–184). Philadelphia: W. B. Saunders.
to medication as candy to coax the child into taking

the drug. Other common household products that
are poisonous if ingested include cosmetics, alcohol,
insecticides, pesticides, hydrocarbons (e.g., gasoline,
kerosene, lighter fluid, paint thinner), and antifreeze.
Toddlers are still susceptible to choking, so the pro-
vider should determine if the children play with toys
with small parts or eat food that may cause choking
(e.g., grapes, hot dogs, popcorn, nuts, hard candy,
gum, peanut butter). Toys with long strings can pres-
ent a strangulation risk, as can pacifiers that are tied
around the toddler’s neck with a string. The provider
should ask if the child is continuously supervised and
never left alone while in the bath or swimming pool.
Since toddlers like to climb, the provider should ask
FIGURE 7-8. An infant’s play area should be assessed for
choking hazards. if pot handles are turned to the rear of the stove dur-
ing cooking and if gates are placed at the entrance of
the kitchen for especially active toddlers. The provider
if the infant is ever placed in a walker, which presents should determine if matches and lighters are kept out
numerous safety risks (see the section on Falls). of reach and if there are any firearms in the home; if so,
they should be stored high and unloaded in a locked
cabinet with the ammunition stored separately. Elec-
Assessment of Toddlers
trical hazards persist in this age group; the provider
Once children are walking, they begin to explore their
should determine if parents keep appliances unplugged
environment actively, and then walking progresses to
when not in use, especially shredders, lawnmowers,
running, climbing, and jumping. Once toddlers learn
and power tools.
to climb, nothing is out of their reach (Table 7-3). Tod-
dlers have no sense of fear. The fully developed pincer
grasp in a toddler increases the risk for aspirations and Assessment of Preschoolers
choking, and this fine motor dexterity allows toddlers Preschool-aged children are even more physically ac-
to remove bottle caps and to turn doorknobs, making tive than infants and toddlers and like to explore their
this age group at great risk for ingestions, falls, and environment (see Table 7-3). They need supervision
wandering from the safe confines of home or school. around streets, water, and during play. Preschool-aged
Assessment of toddler safety begins by ensuring that children are still concrete thinkers with active imagi-
the family puts the child in an approved car safety seat nations and magical thinking. As a result, they cannot
(see Box 7-1). The provider should ask parents if the assess danger or imagine consequences. Preschoolers
child always rides in the back seat of the vehicle. For also like to imitate parental behavior, and they need
newly active and ambulatory toddlers, it should be de- role models for safety.
termined whether there are gates at the tops of stairs During the safety assessment, the provider should
and window guards on windows. Parents should be ask the parents of preschoolers about the use of a
asked if they ever place their child in a walker. booster seat in the rear seat of a motor vehicle. The
It is particularly important to screen this age group provider should also ask about supervised play, espe-
for a childproofed environment (see the section Assess- cially near the street and at playgrounds, where inju-
ment of Infants). Since this age group is particularly ries frequently happen (see the section Playground In-
prone to ingestions, the provider should ask whether juries). The provider should determine if the children
household cleaning products and medications are are supervised while crossing the street and if the child
stored high and locked, if poisonous plants have been wears a helmet while riding a bicycle, scooter, or skate-
removed, if caustic agents or toxic chemical products board. The provider should ask if the child ever bathes
are stored in their original container, and if the par- or swims unattended. Parents of preschoolers should
ents have ready access to the Poison Control Center know that the home should still be childproofed. The
telephone number. The provider should also inform provider should inquire about whether matches, light-
the parent that it is no longer recommended to keep ers, medications, and poisonous substances are stored
syrup of ipecac on hand at home, and that this drug high and locked. It should also be determined if out-
should no longer be used to treat poisonings in the lets are covered and electrical cords are out of reach.
home (AAP, 2007). Many poisonings in this age group Parents should be asked if guns are kept out of reach
involve ingestion of medications, especially if the child and if the preschooler knows how to use the telephone
sees an adult take medication or if the parent refers to call 911.
TABLE 7-3
Safety Assessment Guidelines for Toddlers and Preschoolers
DEVELOPMENTAL AND POTENTIAL
PHYSICAL CHARACTERISTICS INJURIES RELEVANT ASSESSMENTS
Increasing gross motor abilities: Falls Is the young child supervised at all times during play activities? Do other young children ever
• Can walk, run, jump, throw objects supervise younger children? Is outdoor play confined to a fenced in area? Does the family have
• Active climbers outdoor playground type equipment? Is the equipment safe and undamaged, without holes or sharp
• Can move chairs to kitchen counters edges? Is there a soft surface (e.g., wood chips, sand) under the play equipment? Until the child is
and climb to cabinets at least 3 years of age, are gates placed at the tops of all stairs at home? Are doors kept locked and
• May be tall enough to reach stove are child-resistant doorknob covers used for doors that lead to stairs or any other elevated area? Is
• Can ride tricycle the toddler ever placed in a walker? Is play supervised near driveways, sidewalks, or streets? Does
• May ride bicycle by age 5 years the child wear a helmet when riding a bicycle or if riding in a seat on an adult bicycle? Does the
preschooler wear a helmet and other protective gear when skating or using a scooter or skateboard?
Are window guards used for windows above the first floor? Are bumper pads removed from the crib
so the toddler cannot climb? Is the crib mattress lowered to the lowest level to prevent falls? Are
crib slats no more than 2 3/8 inches apart? If the child sleeps in a toddler bed, is the mattress close
enough to the floor to minimize injury if the child falls out of bed? Does the child sleep on a bunk
bed? Does the child play on a trampoline?
Drowning At home, is the bathroom door kept closed with the toilet lid down? Is the child ever left alone in the
bathtub? Do the parents know not to leave standing buckets of water around small children? Are all
swimming pools fenced? If the child is 4 or older, has the child had swimming lessons? Are parents aware
that swimming lessons do not substitute for close supervision in pools, lakes, streams, or oceans? Are the
child and family near water or on a boat frequently? Does the child wear a life vest when boating?
Contusions, Is the play of small children supervised? Does the parent use distraction or time out vs. spanking to
lacerations, deal with tantrums or biting? Are small children supervised around pets, especially when the animal
abrasions, bites is eating?
Increasing fine motor abilities: Poisonings, Are cleaning solutions, chemicals, paint, alcohol, and medications stored in a high, locked cabinet?
• Turns doorknobs, removes bottle ingestions Are childproof caps used on all medication bottles? Do parents refer to medicine as candy? Are “Mr.
caps, and unscrews lids Yuk” labels placed on bottles of all toxic materials? Is the number to Poison Control Center clearly
• Opens doors, windows, gates, posted near the phone? Are there poisonous plants in the house? Are parents aware that syrup of
drawers, bottles ipecac is no longer recommended? Are pet litter boxes kept away from the child’s environment?
• Pulls on cords, blinds, and tablecloths
• May be able to undo seatbelt; may Aspiration of foreign Is the home childproofed? Are cords hidden? For young toddlers, is there a mobile or other toys
resist car seat objects; suffocation; strung across the crib rails? Is the crib positioned near window blinds? Are door and drawer latches
• Explores by putting objects in mouth strangulation used? Is the automatic garage door opener inaccessible? Do toy chests in the home have heavy,
hinged lids? Are old appliances discarded with doors removed? Are plastic bags kept away from small
children? Does the child have a pacifier tied on a string around his or her neck?
Choking Are mealtimes and snacks supervised? Does the child eat foods that could cause choking such as
popcorn, grapes, carrots, other raw fruits or vegetables, gum, hard candy, nuts, or peanut butter?
Does the toddler play with toys with small parts? Is the child allowed to run with sharp objects or
lollipops in his or her mouth? Are latex balloons kept away from the child?
Developmental characteristics: Firearms Does the family have a weapon in the home? Is gun safety taught? Are guns kept out of reach,
Toddlers: locked, and unloaded?
• Increasing temper tantrums
• May hit, bite, or throw things
Burns Is the hot water heater thermostat turned to ⬍120° F? Is bath water checked before placing the child
• Do not like to share
in the bathtub? When cooking, are pot handles turned toward rear of stove? With especially active
• Oppositional behavior to be expected
toddlers, does the parent place gates at the entry to the kitchen while cooking? Are tablecloths
in toddlers
removed so the toddler does not pull heavy objects, hot food, or liquids off the table onto himself or
• Displays negativism and desire for
herself? Is the child kept away from fireplaces, curling irons, electrical tools, and space heaters? Are
autonomy
matches, candles, and lighters kept out of reach? Are unused electrical outlets plugged with plastic
• Easily distracted and unable to assess
outlet covers? Are there working smoke and carbon monoxide detectors in the home? Once the
danger
child reaches age 4 years, does the family conduct fire drills at home? Can the preschooler call 911?
• Reasoning with toddlers is ineffective
Does the child live in a smoke-free environment?
and impractical
• Very curious; like to explore
• Want to be more independent Sunburn Is sunscreen used? Is prolonged exposure to the sun avoided? Does the child wear a hat in the sun?
• Engage in more active play
• Unable to assess danger
Motor vehicle Does the child ride in a forward-facing car seat if ⬎20 pounds? Does the child sit in a belt-
• Have no sense of fear
trauma (passenger or positioning booster seat when he or she weighs 40 pounds? Does the child ride in the rear seat of the
pedestrian) vehicle? Does the child ever ride in front seat with passenger air bags? Is child ever left unattended
Preschoolers:
in a parked car? Is the child allowed to cross the street unsupervised? Is the child supervised when
• Active and inquisitive
playing near a driveway or street?
• Still concrete thinkers
• Cannot assess danger or problem
solve but can understand and heed Abuse Has the parent taught the preschooler about stranger safety and uncomfortable touches?
precautions better than toddlers
• Has an active imagination; likes to try
new things but has many fears
• Emergence of magical thinking
makes preschooler think he can
attempt dangerous things and escape
unharmed
• Likes to please adults, therefore
susceptible to role modeling of good
behavior; imitate adults in their lives
Source: Dunn, A. M. (2009). Health perception and health management patterns. In Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., & Blossner, C. G. (Eds.). Pediatric primary care:
A handbook for nurse practitioners. (4th ed.). (pp. 183–184). Philadelphia: W. B. Saunders.
Assessment of stranger safety depends on the age of the on playgrounds, should be assessed. The child should
preschooler. For younger children in this age group, the be asked what he or she knows about crossing the street
provider should determine if parents have taught their safely. The provider should ask the child if he or she has
child to avoid contact with strangers. Older preschoolers had swimming lessons and knows to swim only when an
can be asked directly by the provider if they know to stay adult is present. Assessment of stranger safety and how
away from strangers. The provider should also ask parents to handle unwanted touching is also important in this
if they have introduced the concept of “good touch/bad age group. The provider should ask school-aged children
touch” to their preschooler. The provider can ask older if they know that they should never touch a gun, and
preschool-aged children questions such as: “Are you ever if they know how to call for emergency help by dialing
afraid of anyone?” “Does anyone ever hurt you?” and 911. The provider should assess school-aged children for
“Does anyone make you keep secrets?” cigarette smoking, preferably without the parent present
so that an honest response is more likely.
Assessment of School-aged Children
Motor skills continue to progress in this age group Assessment of Adolescents
(Table 7-4). Many school-aged children ride a bicycle, Adolescents are at special risk for injury because they
which is dangerous without a helmet and safety gear. are risk takers (Table 7-5). The adolescent’s desire for
Independence increases in this age group as well (e.g., peer approval is a strong motivating factor for experi-
riding a bicycle takes a child away from home). School- mentation and risk-taking behaviors. In early adoles-
aged children are still concrete thinkers and not adept cence, teens are concrete thinkers and because of this,
at fully assessing danger. Older school-aged children often do not fully understand the consequences of
begin to look to peers for approval and may begin risk- their actions. Adolescents are especially prone to mo-
taking behaviors to win approval or to gain acceptance tor vehicle collisions resulting from poor judgment,
from a peer group. Some children in this age group have inexperience, reckless driving, speeding, driving under
unsupervised time after school (“latchkey kids”) while the influence, failure to use seatbelts, and peer pres-
their parents work, which may present safety risks. sure. Peer pressure can also lead to a variety of other
School-aged children can be asked directly about injuries related to guns, the use of drugs, and alcohol
their safety habits, with confirmation from the parent consumption. Unsafe sex is another manifestation
as needed. The child should be asked if he or she always of risk-taking behaviors. Because of marked physical
wears a seatbelt for every ride in any kind of vehicle. and emotional changes during this time and under-
The provider should also ask if the child ever rides in developed coping skills, adolescents are also prone to
the cargo area of a pickup truck. The provider should depression (see Chapter 24 for screening for suicidal
determine whether the child wears a helmet for bicycle, ideation in children and adolescents).
skateboard, and scooter use, and protective gear such as Injury risk assessment in the adolescent client is
helmets and knee and elbow pads for in-line skating. The best done with the parent out of the room. The pro-
type of play and whether younger school-aged children vider is more likely to get honest answers to ques-
are supervised during play, especially near streets and tions involving risk-taking behaviors than if the teen
TABLE 7-4
Safety Assessment Guidelines for School-aged Children
Increasing motor abilities: Motor vehicle Does the child wear a seatbelt for every ride? Does the
• Is more physically coordinated, trauma (passenger, child sit in the rear seat of the vehicle? Does the child
but increased motor abilities pedestrian, or ever ride in the front seat with passenger air bags? If the
increases risk for injuries cyclist) child is ⬍80 pounds, is a booster seat used? Does the child
• Growth in height exceeds ever ride in the cargo area of a pickup truck? Is the child
muscular growth and coordination ever left unattended in a parked car? Does the parent
• Increased fine motor abilities hold a child’s hand while crossing the street if the child is
• Engages in more active play; younger than 8 years of age? Is the child allowed to cross
enjoys physical activity the street unsupervised if younger than 9 years of age?
• Rides bicycle by age 5 years, which Does the child know pedestrian safety rules? Is the child
takes child away from home supervised when playing near a driveway or street? Does
• Often involved in organized sports, the child ride a mini bike or ATV?
thus prone to sports-related injuries

Developmental characteristics: Drowning Are all swimming pools fenced? Has the child had
• Wants to produce and achieve; swimming lessons? Are parents aware that swimming
eager to learn new things; a good lessons do not substitute for close supervision in pools,
time to do health and safety lakes, streams, or oceans? Does the child ever swim
teaching alone? Are the parent and child aware of safe diving
• Adventurous; likes to explore practices? Are the child and family near water or on a boat
• May frequently play in hazardous frequently? Does the child wear a life vest when boating?
places or accept dares to do Do the child and family know CPR?
dangerous things
• Still a concrete thinker; abstract Fires and burns Is hot water heater thermostat turned to ⬍120° F? Is there
thinking does not begin until late a working smoke and carbon monoxide detector in the
adolescence home? Does the family conduct fire drills at home? Does
• Cognitive skills in school-aged the child know how to call 911? Has the child been taught
children aids in preventing some to avoid playing with matches and flammable liquids?
types of injuries to which younger Does anyone in the home smoke? Has the child tried
children are more susceptible (e.g., smoking?
can take swimming lessons, learn
fire safety, use of seat belts and Sunburn Is sunscreen used? Is prolonged exposure to the sun
bicycle safety gear); older school- avoided? Does the child wear a hat in the sun?
aged children can cross street
safely Firearm safety Does the family have a weapon in the home? Is gun
• Becomes more independent safety taught? Are guns kept out of reach, locked and
from parents; still needs parents unloaded?
to provide guidance and close
supervision Falls, contusions, Is the younger school-aged child supervised at all times
• Older school-aged child may lacerations, during play activities? Do other young children ever
begin risk-taking behaviors such abrasions, fractures, supervise younger children? Is outdoor play confined
as experimentation with alcohol, bites to a fenced in area? Does the family have outdoor
tobacco, drugs, failure to use playground type equipment? Is the equipment safe
seatbelts in cars or helmets or knee and undamaged, without holes or sharp edges? Is there
and elbow pads when riding a a soft surface (e.g., wood chips, sand) under the play
bicycle, roller blades, skateboard, equipment? Is play supervised near driveways, sidewalks,
or scooter or streets? Does the child engage in sports and strenuous
• Begins to be influenced more by physical activity? Does the child wear a helmet when
peers than family riding a bicycle? Does the child wear a helmet and
other protective gear when skating or using a scooter or
skateboard?
Does the child play on a trampoline? Does the child
sleep on bunk beds? Is the child aware of safe handling
of animals? Is the child allowed to operate a power lawn
mower or electric tools?
Suffocation, Does the child know basic first aid? Is automatic garage
strangulation, door opener inaccessible? Are old appliances discarded
choking with doors removed?
Poisonings, Are cleaning solutions, chemicals, paint, alcohol,

ingestions or medications stored in a high, locked cabinet in
original containers? Do parents refer to medicine as
candy? Are safety caps used on medication containers?
Is the number to Poison Control clearly posted near
the phone? Does the child know how to call 911?
Are parents aware that syrup of ipecac is no longer
recommended?
Abuse Has the parent taught the child about stranger safety and
uncomfortable touches?
Has the child been a victim of bullying or excessive peer
pressure? Does the child spend excessive amounts of time
watching television or surfing the Internet?
Source: Dunn, A. M. (2009). Health perception and health management patterns. In Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., &
Blossner, C. G. (Eds.). Pediatric primary care: A handbook for nurse practitioners. (4th ed.). (pp. 184–185). Philadelphia: W. B. Saunders.
TABLE 7-5
Safety Assessment Guidelines for Adolescents
Increased body size and physical Motor vehicle trauma Does the teen wear a seatbelt for every car ride? Has
abilities: (passenger, pedestrian, the teen taken driver’s education classes? Does the
• Rapid growth in height and weight or cyclist) teen ever drive alone? Does the teen drive at night,
• Maximum increase in height in alone, or with friends? Do the teen’s friends encourage
early adolescence; growth in height risk-taking behavior while in the car, such as speeding,
ends in females in mid-adolescence drag racing, and taking dares? Does the teen ever drive
(16–17 years of age) and males while talking on a cell phone? Is the teen aware of
in late adolescence (18–20 years pedestrian safety? Does the teen ever ride in the cargo
of age) area of a pickup truck? Does the teen ever drive under
• Increased physical strength the influence of alcohol or drugs? Does the teen have
• More physically coordinated but a reasonable curfew?
increased motor abilities increase
risk for injuries
• Often involved in organized sports,
thus prone to sports-related injuries
Developmental characteristics: Firearm safety Does the family have a weapon in the home? Is gun
• Egocentric safety taught? Are guns kept locked and unloaded?
• Impulsive Does the teen carry a weapon? If so, why? Does the
• Retains concrete thinking in early teen have a non-gunpowder firearm (e.g., BB gun)? Do
adolescence; abstract thinking does the teen’s friends carry weapons or have weapons in
not begin until later in adolescence. the home? Does the teen belong to a gang?
Under stress, may return to concrete
thinking Drowning Are all swimming pools fenced? Has the teen had
• In late adolescence, teen can think swimming lessons? Does the teen ever combine
abstractly, can plan, make better drugs or alcohol when swimming? Does the teen
choices, is more understanding of ever swim alone? Is the teen aware of safe diving
consequences of actions practices? Are the teen and family near water or on a
• Peer-centered; desires to be part of a boat frequently? Does the teen wear a life vest when
group; need for independence from boating? Does the teen and family know CPR?
parents; begins to be influenced
more by peers than family; may Fires and burns Does the teen smoke? Does anyone in the home
rebel against authority smoke? Are there working smoke and carbon
• Risk-takers; may accept dares, monoxide detectors in the home? Does the family
particularly to impress peers; often conduct fire drills at home? Does the teen handle
feels invulnerable firecrackers?
• Often experiments with alcohol,
tobacco, drugs; fails to use seatbelts Sunburn Is sunscreen used? Is prolonged exposure to the sun
in cars or helmets and knee and avoided? Does the teen wear a hat in the sun?
elbow pads when riding a bicycle,
Falls, contusions, Does the teen wear a helmet when riding a bicycle?
roller blades, skateboard, or scooter
lacerations, abrasions, Does the teen wear a helmet and other protective
fractures gear when skating or using a scooter, skateboard,
or roller blades? Does the teen ride a minibike,
motorcycle, all-terrain vehicle, or snowmobile? Does
the teen engage in sports and strenuous physical
activity on a regular basis? Does the teen jump on
a trampoline? Does the teen operate a lawn mower,
tractor, or any power tools? Does the teen know basic
first aid and CPR?
Abuse Does the teen practice stranger safety? Does the

teen ever hitchhike? Does the teen feel comfortable
saying “no” to unwelcome touches? Does the teen
feel safe at school? Does the teen get into fights on
a regular basis? Does the teen have any self-defense
skills? How does the teen deal with anger? What does
the teen know about nonviolent conflict resolution?
Has the teen been a victim of bullying or excessive
peer pressure? Is the teen in an abusive intimate
relationship?

Self-injury Does the teen or family have concerns about the teen
being depressed? How is the relationship between
the teen and his or her parents? Has the teen lost
pleasure in usual interests? Has the teen recently lost
or gained a notable amount of weight? Is the teen
sleeping too much or too little? Does the teen seem to
be extremely active or overly fatigued? Does the teen
spend excessive amounts of time watching television
or on the Internet? Does the teen express feelings of
worthlessness or excessive guilt? Has the teen’s inability
to concentrate affected his or her school performance
or relationships? Does the teen have a distorted body
image? Does the teen have vague, nonspecific physical
complaints for which no cause can be found? Does the
teen have recurrent thoughts of death or suicide? How
does the teen handle feelings of anger?
Poisonings, ingestions Does the teen use alcohol or drugs? How much? How
Alcohol; drug use often? What type of drugs? Street drugs? Steroids?
Sexual activity Is the teen sexually active? Monogamous? Does the

teen use condoms for each sexual encounter? What
type of contraception does the teen use? Does the
teen combine substance abuse with sexual activity?
Source: Dunn, A. M. (2009). Health perception and health management patterns. In Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., &
Blossner, C. G. (Eds.). Pediatric primary care: A handbook for nurse practitioners. (4th ed.). (p. 185). Philadelphia: W. B. Saunders.
is worried about the consequences of revealing his or day that a teen may drive and how many teens 18 and
her behavior to the parent. Questions that are asked under may be in the car at one time. The adolescent
using a matter-of-fact, respectful, and nonjudgmental should also be asked about speeding, drag racing, and
tone tend to be answered honestly, as are those that driving under the influence of drugs or alcohol. The
are culturally sensitive. Adolescents should be reas- teen should also be asked if he or she is ever a passen-
sured that whatever they discuss with the provider ger when someone is intoxicated and driving.
will not be shared with the parents or caregivers un- Adolescents should be assessed for alcohol use, in-
less the adolescent agrees or the teen discloses infor- cluding how much, what kind of alcohol, and how
mation that clearly demonstrates a danger to himself often they drink. Drug use should be assessed as well,
or others (e.g., evidence of an eating disorder, threats including the use of marijuana, cocaine, inhalants,
of violence or suicide). Asking open-ended questions is amphetamines, and steroids. The provider should as-
especially useful in this context, as is asking the ques- sess the quantity and frequency of drug use. The pro-
tion in third-person to put the teen at ease; for exam- vider should also determine if the teen smokes ciga-
ple, “some teenagers think it’s silly to wear a seatbelt. rettes, and if so, how many packs a day.
What about you?” This indirect manner may make an Involvement in sports, bicycle, skateboard, ATV, and
adolescent feel more comfortable. For adolescents who scooter riding should be assessed along wtih wheth-
are especially reticent about answering sensitive ques- er the teen wears relevant protective gear, including
tions, a checklist questionnaire may be a more useful helmets. The provider should also assess whether the
way to gather data. adolescent knows how to swim and is knowledgeable
Assessment of motor vehicle safety is especially about water and boating safety, including the dangers
important in the adolescent population because of of swimming alone and drinking alcohol while swim-
the teen’s tendency toward risk taking and desire for ming or boating. The provider should ask if the teen
peer approval. In every health care encounter with an knows CPR.
adolescent, the provider should ask whether the teen Another important area to assess is peer and family
wears a seatbelt for every ride, whether driver or pas- relationships, particularly whether these relationships
senger, and if he or she ever rides in the cargo area of pose any safety threat to the teen. Assessment should
a pickup truck. The health care provider should check include specific questions about gang involvement,
with their state’s laws on graduated licensure; some peer violence, intimate partner violence, and conflict
states also have requirements regarding hours of the in the home, including domestic violence between
parents. The provider should also ask the teen how he the child’s injury required hospitalization, and if so,
or she is disciplined; physical discipline is never appro- the length of the hospital stay and where the child was
priate in this age group. School performance should hospitalized. It is important for the provider to clarify
also be assessed; poor grades often fuel conflict at home with the historian the difference between an emergen-
and can be a sign of depression in the teen. cy room visit and an overnight inpatient hospital stay,
Adolescents should be asked if they are sexually as this sometimes causes confusion. Knowledge of pre-
active; the provider should ask about the number of vious injuries can help the provider identify possible
partners and whether the teen uses contraception and developmental delays in the child, parental/caregiver
a condom for each sexual encounter. The teen should teaching needs, inadequate parental supervision, and
also be asked how he or she deals with unwanted sex- child abuse or neglect.
ual advances. At this time, the provider could inquire
about the teen’s body image, and if he or she ever skips Current Injury
meals or takes laxatives to lose weight to maintain an Any child who has sustained more than a minor injury
“ideal” body weight. is at risk for death. When obtaining the history of the
Adolescents are not too old to be asked about injury, the provider must consider whether the child is
“stranger danger.” The provider should reiterate to the severely injured and be prepared to begin resuscitation
teen that the Internet is especially dangerous, as teens if indicated. Often, the history of a current injury is ac-
can be stalked or harassed through e-mail, chat rooms, companied by simultaneous physical examinations or
or other messages that threaten or demean. The teen interventions if necessary.
should also be reminded that the Internet can also be With minor injuries, the provider should first deter-
used to lure him or her into meeting a stranger in per- mine the cause and type of injury, then ask when and
son. The provider should ask adolescents if they ever how the injury occurred. Intentional injury should
hitchhike. be considered if there is a delay in seeking medical
Screening for depression in the adolescent is also an care or if there is a discrepancy in the history (see
important safety assessment. The provider can help pre- Chapter 23). Parents should be asked if they applied
vent suicide in adolescents by becoming familiar with any first aid treatments of their own to the injury,
the symptoms of depression and suicidal behavior in and if so, what type and for how long. A description
this age group and assessing for this during health care of symptoms should be sought, including the onset,
encounters (see Chapter 24). This also underscores the location, duration, characteristics, and any aggravat-
importance of asking about the presence of firearms in ing and relieving factors. Older children can be asked
the home and discouraging people from owning fire- historical questions directly (see Chapter 6 for a more
arms. If the family does own a gun, it is very important detailed discussion of obtaining a focused pediatric
to assess the home for safe firearm storage practices, health history).
especially if there is a depressed teen in the home.
Grossman, Mueller, Riedy, Dowd, Villaveces, Prodz-
inski, et al. (2005) found that keeping guns unloaded SAFETY ASSESSMENT OF THE
and locked up, with ammunition stored separately and HOSPITALIZED CHILD
also kept locked, was associated with a reduction in The assessment of a safe, healthy environment does
child and teen gun suicides and unintentional firearm not just apply to well, ambulatory children. Hospital-
injuries. Tables 7-2 through 7-5 provide detailed guides ized children are also at risk for injury, and young chil-
to age-appropriate safety assessments in the pediatric dren still need close supervision while hospitalized.
client, infancy through adolescence. Staffing shortages can put a child at risk for injury.
When caring for a hospitalized child, the safety of the
ASSESSMENT OF PREVIOUS AND room environment should be assessed. This includes
making sure that window-blind cords are away from
CURRENT INJURIES
all beds and cribs. The potential for falls should be as-
Previous Injuries sessed. Bed and crib rails must be raised while the child
It is important for the provider to include questions is in bed, and caregivers should not step away from a
in the history about previous injuries, ingestions, or bed with the side rail down, even for a moment. Fall
falls. The provider should inquire about all minor and potential assessment also includes ensuring that floors
major injuries, including the nature of the injury, the are not wet. The provider should assess whether the
date the injury occurred, the child’s age at the time of bed controls need to be moved away from the child,
the injury, and the injury’s cause and severity. The pro- especially if he or she has a tendency to play with the
vider should ask if the child needed emergency medi- controls and move the bed in different positions, as
cal treatment for the injury; for example: Were sutures this presents a significant injury risk. When dealing
required for lacerations? Was surgery necessary to cor- with children younger than school age, no unattended
rect a fracture? The provider should also determine if basins of water should be left at the bedside. Children
in restraints need to be assessed at least every hour if American Academy of Pediatrics Committee on Sports Medicine
and Fitness and Committee on Injury and Poison Prevention.
they are younger than 9 years ( Joint Commission on
(2004). Policy statement: swimming programs for infants
Accreditation of Healthcare Organizations [ JCAHO], and toddlers. Pediatrics, 114(4), 1126; reaffirmation of policy:
2009). Children 9 to 17 years of age must be evaluated (2000) Pediatrics, 105(4), 868–870.
American Academy of Pediatrics Committee on Injury, Violence
every 2 hours, including assessment of the circula-
and Poison Prevention. (2007). Policy statement: poison
tion, motion, and sensation of the restrained extrem- treatment in the home. Pediatrics, 119(5), 1031; reaffirmation
ity ( JCAHO, 2009). The feeding and toileting needs of of policy: (2003) Pediatrics, 112(5), 1182–1185.
American Academy of Pediatrics. (2007a). Policy statement: falls from
restrained children must also be assessed, as do their
heights: windows, roof and balconies. Pediatrics, 120(3), 1438;
range of motion needs, level of consciousness, and reaffirmation of policy: (2001) Pediatrics, 107(5), 1188–1191.
emotional needs ( JCAHO, 2009). American Academy of Pediatrics. (2007b). Policy statement:
all-terrain vehicle injury prevention: two-, three-, and four-
Potential choking hazards also need to be assessed,
wheeled unlicensed motor vehicles. Pediatrics, 119(5), 1031;
such as the presence of syringe caps in or around the reaffirmation of policy: (2004) Pediatrics, 114(4), 1126.
child’s bed. Infants still need to be placed in a supine American Academy of Pediatrics Committee on Injury and Poison
Prevention. (2007c). Office-based counseling for injury pre-
position for sleep. When prescribing and administer-
vention. Pediatrics, 119 (1), 202–206; reaffirmation of policy:
ing medications, care must be taken to ensure that the (1994). Pediatrics, 94(4), 566–567.
exact dose is calculated and administered according to American Academy of Pediatrics Committee on Injury, Violence
and Poison Prevention. (2008). Injury risk of non-powder
the child’s current weight, and medication should nev-
guns. Pediatrics, 122(2), 450; reaffirmation of policy: (2004)
er be left unattended around a child. Other miscella- Pediatrics, 114(5), 1357–1361.
neous injuries can occur in the hospitalized child such American Academy of Pediatrics Committee on Injury and Poi-
son Prevention. (2008a). Children in pick up trucks. Pediatrics,
as needle sticks, injuries related to intravenous or other
119(5), 1031; reaffirmation of policy: (2004) Pediatrics, 106,
tube placement, injection administration, and oxygen (4), 857–859.
delivery in a neonate. A child should never be unat- American Academy of Pediatrics Committee on Injury and Poison
Prevention. (2008b). Policy statement: bicycle helmets. Pedi-
tended in the unit playroom. Children with a history
atrics, 122(2), 450; reaffirmation of policy: (2001) Pediatrics,
of a seizure disorder should have seizure precautions in 108(4), 1030–1032.
place. To maintain overall health, hand washing and American Academy of Pediatrics Committee on Injury and Poi-
son Prevention. (2008c). Policy statement: Injuries associated
universal precautions should always be in use.
with infant walkers. Pediatrics, 122(8), 450; reaffirmation of
policy: (2001) Pediatrics, 108(3), 790–792.
American Academy of Pediatrics. (2009). Policy statement: skate-
board and scooter injuries. Pediatrics, 123(1), 188; reaffirma-
SUMMARY tion of policy: (1995) Pediatrics, 95(4), 611–612.
American College of Surgeons. (2005). March 15 Letter to U.S.
Consumer Product Safety Commission Regarding ATVs. Re-
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All-terrain vehicle and bicycle crashes in children: epidemi-
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from http://www.ojp.usdoj.gov/bjs/homicide/children.htm.
Windsor, R. E., Nieves, R. A., Sullivan, K. P., Thampi, S. P., King, American Red Cross
F. J., & Hiester, E., D. (2006). Cervical disc injuries. Retrieved http://www.redcross.org/services/hs/tips/healthtips/safewater.html
SECTION 3
P H Y S I CA L A S S E S S M E NT
CHAPTER
The Pediatric Physical
8 Examination
ELLEN M. CHIOCCA
The physical examination is an important part of the to the practice or who are being seen for their annual
pediatric health assessment. The health care provider health maintenance visits, school physicals, or sports
must possess strong assessment skills and a knowledge physicals require a full head-to-toe physical examina-
base specific to the developing bodies and minds of tion. A focused physical examination complements the
children. These assessment skills include inspection, focused history (see Chapter 6) and simply concentrates
palpation, percussion, and auscultation. Specialized on the area of the chief complaint. This type of physi-
knowledge includes an awareness of the physical cal examination is done when a child presents to the
and psychosocial developmental stages from infancy emergency room or clinic with an illness, injury, or
through adolescence (see Chapters 1 and 2), which other specific complaint.
allows the provider to adapt his or her approach to The physical examination is typically done im-
the child’s age and developmental level and obtain mediately after the history is completed. For young
the most accurate findings while maintaining optimal children, it may be wise to conduct the developmen-
comfort for the child. tal assessment before the physical examination to
take advantage of the child’s relatively cooperative
state; young children are often agitated after intru-
PEDIATRIC PHYSICAL sive procedures, such as the otoscopic examination,
and may not cooperate for the developmental assess-
EXAMINATION ment if it is performed last. Obtaining the history
and physical examination on a newborn is discussed
The physical examination is the part of the assessment in in Chapter 11.
which objective data are collected through various exami-
nation techniques to validate the subjective data gathered
during the history-taking phase of the examination. The
history is important because the information obtained PREPARATION OF THE ENVIRONMENT
from the parents or the pediatric patient guides the phys- The examination room should have a comfortable
ical examination. The pediatric physical examination temperature and be well-lit (see Chapter 6). The room
differs from the adult examination in that the approach should be in a nonthreatening area and decorated in
to the patient and the sequence of the examination dif- an age-appropriate manner. All instruments should be
fer, according to the child’s age and developmental level. kept out of the child’s view until use, and the exami-
Together, the history and physical provide information nation room should be childproofed (see Chapter 6).
that leads to the child’s diagnosis and forms the basis for Age-appropriate toys and reading material should also
the provider’s management plan. be nearby as a distraction and as a means of assess-
There are two types of physical examinations: coming development. Privacy should be maintained at all
plete (head-to-toe) and focused. Children who are new times for children of all ages.
138
C H A P T E R 8 Th e Pe diatric Ph y s ical E xamination • 139
PROVIDER PREPARATION anxiety. If a portion of the examination is going to be

The health care provider should first determine painful, the provider should always be honest with the
whether a full head-to-toe examination is required or child, informing him or her in a calm, reassuring man-
whether a focused examination will suffice. Knowledge ner. Lying to the child fosters mistrust and causes the
of normal child growth and development is essential provider to lose credibility.
so the provider can choose an age-appropriate se-
quence in which to conduct the physical examination
and determine the best place to conduct it (i.e., the
EXAMINATION TECHNIQUES
exam table, parent’s lap, examiner’s lap). The provider Physical assessment involves four major assessment
should always wash his or her hands before the exami- skills: inspection, palpation, percussion, and auscultation.
nation, preferably within the parents’ or older child’s These skills are normally performed in this order.
view. The provider should also wear gloves during the However, when assessing the abdomen, the sequence
physical examination if the child has bloody or exuda- is altered: inspection, auscultation, palpation, then
tive lesions. A mask, gown, or eye protection may be percussion (see Chapter 19).
necessary if blood spattering is anticipated. When examining a child, providers must use their
senses to gather objective data. For example, sight is used
to assess color, respiratory effort, posture, and gait. Smell
EQUIPMENT FOR PHYSICAL assesses hygiene and can help diagnose infections. Touch
ASSESSMENT can help providers find masses or detect skin changes.
Hearing allows the provider to assess body sounds.
When providing health care to children, it is necessary
to have appropriately sized equipment for the physical
Inspection
examination, including blood pressure cuffs, otoscope
specula, and pediatric resuscitation equipment. All Inspection is always the first step in the physical ex-
equipment needed for the physical examination should amination, an assessment skill that involves thought-
be readily available. Equipment should be clean or sterile ful observation of the child from the beginning of the
as the examination or procedure dictates. It may be nec- encounter until the end. It begins with inspection of
essary to warm some equipment before use to make the the child’s overall appearance (see the next section,
examination more comfortable for the infant or child. General Survey), then continues with a thorough in-
Any equipment that may be frightening to a young child spection of each individual body system. Inspection is
should be kept out of view. A sharps container should not simply looking at the patient. It involves skilled,
be within easy reach for quick disposal of needles and purposeful, and systematic observation. The provider
syringes. To prevent needlestick injuries, needles should uses the technique of inspection to assess behavior and
not be recapped. Box 8-1 is a list of the equipment neces- color; it is also used to assess patterns, size, shape, lo-
sary for a pediatric physical examination. cation, and symmetry of lesions and masses, as well
as body movement. Inspection allows providers to as-
sess for health concerns or problems so they can then
PREPARATION OF THE CHILD prioritize these problems and develop corresponding
management and teaching goals.
Before examining the pediatric client, the provider
should first consider the child’s age and developmen-
tal level. Before beginning the examination, he or she
should take time to get acquainted with the child in
an age-appropriate manner so that the child is as com-
fortable as possible (see Chapter 3). This may involve
using play techniques with infants and young children
or talking with a school-aged child or adolescent about
his or her interests. When appropriate, toddlers, pre-
schoolers, and school-aged children should be allowed
to handle the equipment before the examination be-
gins to demonstrate to the child that the equipment
will not be painful; for example, allowing the child to
listen to heart sounds of the parents or provider (Fig.
8-1) or their own heart sounds is something that most
children greatly enjoy, and it often reduces the child’s
anxiety. During the physical examination, the provid-
FIGURE 8-1. Allowing the children to handle examination
er should also explain to the older child what he or she instruments may make them less frightened of the
plans to do next; this helps alleviate apprehension and examination when they are used.
1 4 0 • S e c t i o n 3 P HYS I C AL AS S E SSM ENT
BOX 8-1
Equipment and Supplies Necessary for the Physical Examination of Infants,
Children, and Adolescents
FOR VITAL SIGN MEASUREMENT: FOR NOSE AND ORAL CAVITY:
• Thermometers (oral, axillary, rectal, tympanic) • Penlight
• Pediatric stethoscope with bell and diaphragm • Tongue depressors
• Various infant and pediatric-sized blood pressure cuffs • Otoscope (to view inside nares)
• Sphygmomanometer
FOR LUNGS, HEART, AND ABDOMEN:
• Doppler
• Stethoscope with appropriately sized bell and diaphragm
FOR ANTHROPOMETRIC MEASUREMENTS: • Doppler to assess peripheral pulses
• Beam balance scale to measure weight (both infant and FOR MUSCULOSKELETAL EXAM:
adult platform scales)
• Measuring tape
• Paper to line infant scale
• Measuring board to measure recumbent length in FOR NEUROLOGIC EXAM:
infants (may also measure recumbent length on paper- • Reflex hammer
covered surface) • Tuning fork
• Wall-mounted stadiometer (for most accurate • Tongue depressor
measurement of standing height)
• Sharp and dull testing instruments
• Paper or metal tape measure (to measure head or arm
• Penlight (to test pupillary reflex)
circumference)
• Cotton-tipped swabs (to test corneal and blink reflexes)
• Skin fold calipers (e.g., Lange calipers) to measure
skinfold thickness • Salt and sugar (to test discrimination of sweet and sour taste)
• Age- and gender-specific Centers for Disease Control • Coffee, alcohol, or soap (to test smell)
Growth Charts FOR FEMALE GENITAL EXAM:
• Weight-for-age (birth to 36 months) • Gloves
• Length-for-age (birth to 36 months) • Vaginal specula (including pediatric sized)
• Weight-for-length (birth to 36 months) • Lubricant
• Head circumference-for-age (birth to 36 months) • Sterile cotton-tipped swabs or applicators
• Weight-for-age (2 to 20 years) • Bifid spatula
• Stature-for-age (2 to 20 years) • Saline
• Weight-for-stature (2 to 20 years) • Slides, fixative, and container
• Body mass index-for-age (2 to 20 years) • Specimen containers
FOR INTEGUMENTARY ASSESSMENT: FOR DEVELOPMENTAL ASSESSMENT:
• Ruler with centimeter markings • Selected developmental assessment tools (e.g., Denver
• Wood’s lamp II screening test; Ages and Stages)
• Magnifying glass • Puppets, raisins (for assessing pincer grasp), blocks,
stuffed toys, and squeak toys (also for gaining infant’s
FOR HEAD AND NECK: or toddler’s attention and for assessing hearing)
• Small glass of water (for child to swallow during thyroid
gland assessment) MISCELLANEOUS SUPPLIES:
• Nasal specula • Pediatric history and physical forms
• Wristwatch or clock with a second hand
FOR EARS:
• Calculator (to calculate body mass index; drug doses)
• Otoscope with pneumatic bulb • Various sized paper gowns
• Cerumen scoops • Examination drapes
• Tuning fork • Paper to line examination table
FOR EYES: • Various sized syringes and needles
• Penlight • Puncture-resistant sharps disposal container
• Ophthalmoscope • Paper towels and tissue
• Snellen Eye Chart, tumbling E chart, and Allen cards for • Cotton balls
vision screening • Culture media
• Cover card • Potassium hydroxide
• Gauze
The provider should completely expose the body It is used to assess organ location and size and to as-
part that he or she is inspecting while covering the sess for swelling, masses, or lumps. Areas of tenderness
rest of the child’s body with a disposable paper drape or pain are also palpated, but tender or painful areas
to preserve privacy. Adequate lighting and a comfort- should be palpated last. If the child experiences ten-
able room temperature are essential to obtain accurate derness or pain during palpation, the provider should
inspection findings. Sunlight is the best light in which discontinue palpating that area immediately. Watch-
to obtain inspection findings. Fluorescent lighting can ing the child’s face during palpation helps the provider
alter the child’s actual skin color, and inadequate, dim ascertain whether or not the child is experiencing any
lighting can cause some abnormalities to be missed. pain, as this will be reflected in the child’s facial expres-
The room should be warm but not hot, which may sions. Maintaining eye contact with the child is also
cause flushing or sweating. A room that is too cool reassuring to him or her in the event that the child is
may cause mottling or shivering in the child, con- fearful during this portion of the examination.
fusing assessment findings. Most inspection involves Different parts of the provider’s hands are used dur-
strict observation; some body systems require the use ing palpation. To assess temperature, it is best to use
of special equipment to assess them completely (e.g., the dorsum of the hand. The fingerpads should be used
an otoscope to inspect the tympanic membrane, an to palpate skin texture and consistency, pulses, and
ophthalmoscope to inspect the eye). organ or mass size. Vibrations are best assessed using
Although the sequence of the total physical ex- the ulnar or palmar surface of the hand. The provider’s
amination in the pediatric client is altered according hands should be warm and fingernails kept short to
to the child’s age and developmental level, the tech- optimize the child’s comfort. Children require a calm
nique of inspection should be conducted in the fol- and gentle approach when palpation is performed.
lowing systematic sequence (King, 1983), regardless of Palpation can be light or deep, depending on the
the child’s age: amount of pressure applied. Light palpation is used to
• General to specific: The provider should first look at assess skin temperature, moisture, turgor, and texture;
the child as a whole person, then narrow the focus it is also used to assess muscle tone, large masses, ede-
to systems, organs, and then to the sites of any com- ma, and superficial tenderness. Deep palpation is used
plaints (e.g., first do a general survey, then inspect to palpate the position of organs, large blood vessels,
the mouth, and then focus on the teeth and their or masses and to note their size, shape, consistency,
overall condition). and mobility. It may also be used to assess for tender-
• Head to toe: The provider should begin inspection ness that was not appreciated with light palpation.
at the top of the child’s head and end at the feet to Light palpation is done with the dominant hand
be sure that no area of the body is missed. and with the fingers together. The fingers are placed
• Outside to inside: When inspecting a body struc- on the skin and the area is gently pressed 1 cm (0.4
ture with an orifice, the provider should inspect the inches) deep in a circular motion (Fig. 8-2). Young
outside first and then the inside (e.g., when inspect- children are often ticklish during light palpation
ing the ear, first inspect the auricle, then the external of the abdomen; this effect can be lessened if the
auditory canal, and then the tympanic membrane).
• Medial to lateral: When performing inspection
on a body system or specific structure, the provider
should inspect the area from the middle outward
(e.g., to examine the breast, first inspect the areolae
and nipples, then the breasts, axillae, and then the
supraclavicular region).
• Anterior to posterior: The provider should always in-
spect the front of the body first and then the back.
• Distal to proximal: This inspection technique ap-
plies to the extremities (e.g., the provider should first
inspect the toes, and then proceed up the leg to the
shin, knee, thigh, and hip).
Palpation
Palpation is an examination technique in which the
provider uses touch to gather assessment findings. This
technique follows inspection and often confirms what
the provider has visualized. Palpation is used to assess
skin temperature, moisture, hydration, and texture;
peripheral circulation; pulsations; mobility; and shape. FIGURE 8-2. Light palpation.
FIGURE 8-3. Deep palpation.
provider places the child’s hand over the provider’s

palpating hand or by the use of age-appropriate dis- FIGURE 8-4. Direct percussion of the sinuses.
traction techniques. Light palpation is performed be-
fore deep palpation.
Deep palpation involves the use of both hands ity (Table 8-1). Dense structures produce less sound
(Fig. 8-3). The provider should place his or her with percussion. Structures that are filled with air
dominant hand on the child’s skin and then place the produce loud sounds when percussed. Percussion is
nondominant hand on top of the dominant hand and also used to assess tenderness or pain, as with blunt
depress to a depth of approximately 4 to 5 cm (1.5 to percussion, and to elicit reflexes, which requires the
2 inches). This extra pressure permits the provider to use of a reflex hammer (see Chapter 22). Percussion
feel structures that are covered by muscle or fat. Deep can be direct, indirect, or blunt.
palpation is most often used during abdominal and gy- • Direct percussion involves tapping an area of the
necologic assessments. body with one or two fingers directly on the skin
(e.g., percussion of the sinuses to assess for pain)
Percussion (Fig. 8-4).
Percussion involves the use of tapping to assess un- • Indirect percussion requires the use of both hands.
derlying organs and structures, either directly or This type of percussion is most often used when as-
indirectly. This tapping produces sounds that indi- sessing the chest and abdomen. To perform indirect
cate the density of these structures and the borders percussion, the provider should gently place the
of internal organs. These sounds are characterized middle finger (pleximeter) of the nondominant hand
according to pitch, intensity, duration, and qual- on the child’s body. Only the pleximeter should be
TABLE 8-1
Percussion Sounds
PERCUSSION WHERE SOUND IS
SOUND INTENSITY PITCH DURATION QUALITY HEARD BEST
Flatness Soft High Short Flat Muscle and bone
Dullness Soft to medium High Medium Thud-like Liver, stomach, and

diaphragm
Resonance Medium to loud Low Long Hollow Normal lung
Tympany Loud High Medium Drum-like Gastric air bubble
Hyperresonance Very loud Very low Long Booming Lungs of a very young
child or lungs with air
trapping
stomach, and intestines. Most of these sounds require

the use of a stethoscope to be heard adequately. Some
of these sounds can be heard directly by the ear, es-
pecially those produced by the upper airway, lungs,
gastrointestinal tract, and even speech. For example, a
child’s inability to speak a complete sentence without
respiratory distress tells the provider much about the
child’s respiratory status.
Sounds heard during auscultation are classified ac-
cording to intensity (loud or soft), pitch (high or low),
duration (length), and quality (musical, crackling).
The bell of the stethoscope is used to auscultate low-
pitched sounds (e.g., abnormal heart sounds, cardiac
murmurs), and the diaphragm is used to auscultate
FIGURE 8-5. Indirect percussion. high-pitched sounds (e.g., normal heart sounds, lung
and bowel sounds).
To auscultate body sounds accurately, the provider
touching the body part that is being percussed. The
should ensure that the examination room is as quiet
next step is to use the middle finger (plexor) of the
as possible, with little or no environmental noise. It is
dominant hand (taking care that this fingernail
important for the provider to use a stethoscope with
is short) to strike the distal joint of the pleximeter
an appropriately sized bell and diaphragm, according
(Fig. 8-5). This blow should be quick and sharp,
to the infant or child’s size. For example, auscultating
the wrist movement crisp, and the plexor must be
the chest of a newborn with an adult-sized diaphragm
perpendicular to the pleximeter. Two taps should be
yields both heart, lung, and possibly bowel sounds,
delivered as the provider listens to the tone elicited,
and the provider is then not able to differentiate the
percussing from resonance to dullness.
sounds, making it impossible to perform an accurate
• Blunt percussion involves placing one hand flat
assessment.
across the surface of the child’s body part to be
Proper earpiece alignment of the stethoscope is also
assessed and using the fist of the other hand to strike
essential to hear optimally. The slope of the earpieces
the back of the hand while it remains on the body
should point forward toward the examiner’s nose,
surface. This technique is often used to assess for cos-
matching the natural slope of the ear canal. Not all
tovertebral angle tenderness (Fig. 8-6).
ear canals are the same; thus, it is sometimes necessary
to adjust the fit. This is important to block out any
Auscultation extraneous noise; this also enhances the acoustic per-
Auscultation is usually the final step in the four-part formance of the stethoscope.
physical examination. However, when assessing the The provider should make sure that the stethoscope
abdomen, auscultation should be done before palpa- tubing is not too long, as this increases the distance
tion and percussion, both of which may alter bowel that the sounds must travel, which can distort the
sounds. Auscultation involves listening to body sounds sounds. In addition, it is essential for the provider to
produced by the airway, lungs, heart, blood vessels, avoid placing the diaphragm of the stethoscope too
firmly on the surface of the child’s skin, as this too
can alter the auscultatory findings. Similarly, placing
the bell of the stethoscope too firmly against the skin
causes the skin to stretch, thus causing the bell to act
like a diaphragm. The stethoscope should always be
warmed first and then placed directly on the child’s
skin. Auscultation should not be done through cloth-
ing, as this may muffle or alter the sounds. Because of
the prevalence of viral respiratory infections in young
children, it is wise for the pediatric provider to clean
the stethoscope after each patient to avoid the spread
of infection among patients.
GENERAL SURVEY
The “general survey” is the first assessment the pro-
FIGURE 8-6. Blunt percussion to assess kidneys. vider makes at the beginning of the client encounter;
it begins as soon as the provider enters the examina- straight spine and balanced posture. The general sur-
tion room. The general survey is a cursory head-to-toe vey may allow the provider to assess a lateral curvature
assessment, done before the full, detailed physical as- of the spine in an older child, which necessitates fur-
sessment. This first impression can tell the provider ther assessments and measurements to confirm a diag-
much about the child’s overall state of health by just nosis of scoliosis. In older children, a slumping posture
observing the child’s general appearance. The general may indicate extreme fatigue or depression.
survey helps the provider to determine assessment Upon entering the examination room, the provider
and intervention priorities; for example, an immedi- should find the infant or young child sitting on the
ate intervention is required before a full history is ob- parent’s lap, in a chair, or on the examination table
tained if a child is dusky in color or is in noticeable in no apparent distress; older children or adolescents
respiratory distress. Any abnormalities or distress ob- should be comfortably seated in no apparent distress.
served during the general survey requires an in-depth An ill child may assume another body position to al-
assessment of the affected body system. The general leviate pain or respiratory distress; for example, a child
survey consists of several elements, all of which are in severe respiratory distress may assume the tripod
discussed below. position (sitting upright, leaning forward with mouth
open) to alleviate difficulty breathing, or the provider
General Appearance may find a child with the knees curled up to chest be-
The child’s general appearance is the health care provid- cause of severe abdominal pain.
er’s assessment of the child’s overall physical appearance If the child is old enough to walk independently,
and includes the child’s level of consciousness, facies, the child should walk smoothly and with normal bal-
posture, position, mobility, hygiene, nutritional state, ance. A toddler normally appears bow-legged with a
behavior, demeanor, and interpersonal interactions wide-based gait when walking. Any limp should be
with parent and provider. A cursory evaluation of the noted during the general survey; this pertains to all
child’s developmental level should be made by noting age groups. Alterations in range of motion or absence
the child’s age and comparing that to his or her speech of limb movement can be assessed during the general
and motor abilities. Assessment of general appearance survey.
also includes a brief assessment of the child’s color and
respiratory status and whether any intervention is re- Hygiene
quired before the visit continues. The child should be As part of the general survey, the child’s skin, hair,
pink and in no respiratory distress. Any obvious inju- teeth, and nails should be briefly assessed. Skin and
ries should be noted, as well as whether the child is in hair should be clean and well groomed. Teeth should
any pain. be clean without evidence of decay, and nails should
be trim and clean. Poor hygiene in a child or infant
Level of Consciousness can be manifested by severe diaper rash or other skin
The provider should note whether the child looks com- rashes; body odor; lack of overall body cleanliness; dry,
fortable or restless, and whether the child is alert and dull, unkempt, dirty hair; or dirty clothing. Poor hy-
oriented. Chapter 22 discusses in detail the assessment giene can be the result of homelessness, poverty, pa-
of level of consciousness and neurologic status. rental knowledge deficits, mental illness, or neglect.
Facies Nutritional Status

The child’s facial expression can tell the provider The general survey includes an overall impression of
a great deal about the child’s current physical and the child’s nutritional status. The child should ap-
mental health. Facial expressions can indicate pain, pear well nourished with normal body weight, stature,
respiratory distress, fear, anxiety, lethargy, sadness, or muscle mass, and muscle tone. The child’s hair and skin
depression. The provider should keep in mind that it should be lustrous and shiny. Obesity, malnutrition,
is normal for many children to be fearful during the or evidence of certain eating disorders can be assessed
health care visit, and these children often cry. Facial during the general survey. More specific subjective and
features should be symmetric and move symmetrically objective data to gather regarding these disorders are
with changes in facial expression. discussed in Chapters 10 and 24.
Position, Posture, Gait, and Mobility Behavior

The provider should observe the child’s position, pos- A behavioral assessment is important because an alter-
ture, gait, and mobility. A newborn’s arms and legs are ation in a child’s behavior is often the first clue that a
normally in a flexed position. A toddler normally has a health problem exists. Assessment of behavior includes
pot-bellied appearance due to lordosis, a normal find- the child’s mood, affect, personality (e.g., shy, slow to
ing in this age group. An older child should have a warm up, outgoing), level of activity, responsiveness to
parents, and the parent’s comfort measures. The child adolescents. Regardless of the child’s age, the provider
should be alert, active, and show age-appropriate reac- should always remember to perform the least distress-
tions to fear, pain, or stress. Older infants and toddlers ing aspect of the physical examination first and the
normally are wary of the provider and cling to the par- most embarrassing, intrusive, or painful portion last.
ent. Toddlers are often especially challenging to exam- For example, older infants and toddlers often become
ine because of the difficulty they have separating from uncooperative during the otoscopic examination; thus,
their parents and a desire to express autonomy; this this should be done last. Adolescents are cooperative
is within normal limits. Children preschool age and with this portion of the examination, as it is not per-
older should be able to cooperate with the physical ceived as a body boundary intrusion the way it feels to
examination, maintain eye contact, and interact with an older infant or toddler. However, adolescents may
the provider. Lack of eye contact or separation anxiety become embarrassed or uncomfortable during the gen-
(when age-appropriate) may indicate child abuse or ne- itourinary portion of the physical examination; older
glect. In certain cultural groups, however, lack of eye infants and toddlers have not yet reached the stage
contact is normal and a sign of respect (see Chapter 4). when they experience embarrassment when their gen-
Attention span should be noted in children preschool itals are examined.
age and older. Children in this age group should be
able to focus for short periods of time, cooperate with Developmental Approaches to Examining
the provider, and follow simple directions. The ado- Infants, Children, and Adolescents
lescent’s behavior should also be assessed in the areas Before beginning the physical examination, the pro-
of eye contact, parent and provider interaction, mood, vider should be familiar with normal physical and psy-
interest in surroundings and what is going on during chosocial developmental milestones in children. For
the health care visit, reactions to provider or parent example, infants younger than 4 to 6 months do not have
requests, distractibility, and cooperation with the his- firm head control, so their heads need to be supported
tory and physical. during the physical examination. Also, stranger anxi-
ety peaks at 7 to 8 months, so it is important to keep
Development the infant’s primary caregiver nearby. If necessary, the
Developmental assessment must be part of every physical examination of the infant can even be con-
pediatric health care visit. The provider should begin ducted on the parent’s lap (Fig. 8-7). Young children
with a general overview of developmental milestones are often slow to warm up and may not be cooperative
for age; any initial impressions of developmental with the examination. The use of play (e.g., puppets,
delays need to be verified with appropriate screen- peek-a-boo, role playing) can assist the provider in
ing tests such as the Ages and Stages questionnaire enlisting the young child’s cooperation. Children pre-
(see Chapter 2). Areas to assess include gross and school-aged and older can be allowed to handle the
fine motor abilities, speech, interaction with the equipment to see that they will be safe and unharmed.
provider, and types of play. The provider should The provider should remember to be kind but firm;
assess whether sexual development is appropriate canceling the physical examination is not an option.
for the child’s gender and age. During an attempt to Whenever possible, however, school-aged children and
engage the child, the provider can conduct a gross
assessment of speech, hearing, and vision. The pro-
vider should also assess whether the child appears to
be the stated age. Children who appear older than
stated age may be living with difficult circumstanc-
es such as homelessness, family violence, or addic-
tion. Children who appear younger than stated age
may be malnourished or developmentally delayed.
Developmental delays can indicate neglect or vari-
ous medical problems.
GENERAL APPROACH TO THE

PEDIATRIC PHYSICAL EXAMINATION
When performing a physical examination on infants,
children, and adolescents, the provider should modify
his or her approach to the examination according to
the client’s age. Providers obviously take a different ap- FIGURE 8-7. Allowing the parent to hold the young child
proach with infants or toddlers than they take with during the physical examination makes the child feel safe.
adolescents should be allowed to make choices about the physical examination, and providing reassurance
their care, when appropriate. Adolescents have a strong about specific fears. Health care providers should teach
need for privacy, and this needs to be taken into consid- parents never to lie to the child about a health care
eration when conducting the physical examination. visit (e.g., telling the child that he or she is going to
school instead of the clinic, that an injection or blood
Sequencing of the Physical Examination draw will not be painful, or that they will receive an in-
Regardless of the child’s age, the provider should always jection if they misbehave) as this can exacerbate fears
gather as much data as possible by inspection first. related to visiting the health care provider.
When determining the sequence of the remaining phys- Children who have been physically or sexually
ical examination, the provider should use a systematic abused may be very frightened during the physical
approach; however, flexibility is required to accommo- examination, and the provider must take care to dis-
date the child’s age, developmental level, and behavior. tinguish an abused child from a fearful one, making
In children that are late preschool-aged and older, the every effort to gain the child’s trust and keeping in
physical examination should proceed in a head-to-toe mind that suspected or confirmed abuse must be re-
fashion. The rationale for this is to have a consistent, ported to Child Protective Services (see Chapter 23).
systematic approach to be sure that no area of the exam- The techniques for examining fearful children apply to
ination is omitted. When examining infants, toddlers, abused children as well, as both require patience and
and young preschoolers, the provider should modify sensitivity during the examination. The provider and
the sequence according to the child’s developmental parent should remain calm and matter-of-fact during
stage while ensuring that all body systems have been the physical examination, and the parent should stay
assessed. This alteration in the examination sequence nearby. Distraction techniques, using toys or games,
is to take advantage of the child’s quiet state to be able may be helpful. In addition, the provider may allow
to hear heart, lung, and bowel sounds adequately. For the child to see and touch the equipment before the
example, infants and toddlers dislike having their eyes, examination begins. It may also be a good idea for the
ears, and mouth examined. While the infant or toddler provider to establish brief, nonthreatening physical
is quiet, the provider should conduct a general inspec- contact with the child prior to the examination, such
tion and heart, lung, and abdominal auscultation. The as handing the child a toy or even playing with the
more intrusive portions of the examination, such as ex- child briefly. If none of these techniques are effective,
amining the ears and mouth, can be done at the end of the provider should just begin the examination, using
the examination, while the infant or toddler is crying. a calm, gentle, but firm approach, keeping the parent
Table 8-2 summarizes approaches to the physical exami- nearby. If necessary, the child may need to be gently but
nation, according to age and developmental level. firmly restrained and protected from injury with the
examination performed as quickly but as thoroughly
Challenging Pediatric Patients as possible. The provider or parent should not reward
tantrums or similar behavior; however, children who
Some children may be uncooperative or physically
are extremely agitated and upset may need to have the
resistant during the physical examination. This is de-
examination deferred until they have quieted.
velopmentally appropriate in older infants, toddlers,
and young children who may resist body boundary in-
trusions and separation from parents. Some children
may even have temper tantrums. Reasons for this may PHYSIOLOGIC AND
include fear or separation anxiety; some children may ANTHROPOMETRIC
have been sexually or physically abused, and some
children may just be manipulative (Schmitt, 1984). If MEASUREMENTS
a child is uncooperative with the physical examina-
tion, the provider should explore the possible reasons Obtaining accurate physiologic and anthropometric
for this. One potential reason is that many parents measurements in young children is important because
teach their young children not to let strangers touch or these quantify the child’s overall health status. The young
undress them; parents should talk to their child before child’s cooperativeness, the provider’s technique in ob-
the health care visit so that the child feels safe. A more taining these measurements, and the consistency and ac-
common reason that children may resist the physical curacy of all measurements are variables to be considered
exam is fear (Mahat, Scoloveno, & Cannella, 2004). In as critical components of child health assessment.
young children, this is age appropriate and can be min-
imized by allowing the child to express his or her fears
about the examination or health care providers, having PHYSIOLOGIC MEASUREMENTS
the parent or provider explain to the child truthfully Physiologic measurements, or vital signs, are very im-
and in age-appropriate terms what will happen during portant in evaluating a child’s physical status. These
TABLE 8-2
Sequence of Pediatric Physical Examination According to Age
and Developmental Level
POSITION FOR DEVELOPMENTAL
AGE GROUP EXAMINATION PREPARATION CONSIDERATIONS SEQUENCE
Newborns and Place supine on Offer breast/bottle/ Lack of head control until Perform least
young infants exam table. pacifier to quiet 4–6 months. Infants respond distressing aspects
(0–6 months) newborn for exam. well to smiling faces and of exam first (i.e., if
Examine while soft voices. May respond quiet, auscultate heart
dressed in a diaper well to noisemakers or toys and lungs; proceed
only; remove to see or touch. Abrupt, head-to-toe, then
while examining rough movements should be examine ears, nose,
genitourinary area. avoided. and throat last while
When examining the child is crying).
neonates, use radiant Elicit Moro reflex last.
heat warmer to
conserve body heat.
Older infants May need to Keep primary Infants prefer smiling faces Perform least
(6–12 months) examine in caregiver and security and soft voices. May respond distressing aspects
parent’s lap object within well to noisemakers or toys to of exam first (i.e.,
because of eyesight of infant. see or hold. Often cry when if quiet, auscultate
stranger anxiety; Ensure that the exam cold; this may interfere with heart and lungs;
if no distress, room is a comfortable the exam. proceed head-to-toe,
place on exam temperature. Abrupt, rough movements then examine ears,
table with parent Offer breast/bottle/ should be avoided. nose, and throat last
in view. pacifier to quiet Stranger anxiety begins at while child is crying).
crying infant. approximately 7–8 months of
Examine while age. Gather as much objective
child is dressed in a data as possible by just
diaper only; remove observing and not touching
while examining (infant will often begin crying
genitourinary area. vigorously when touched by
a stranger). Increased motor
abilities cause need for safety
measures in exam room; this
continues with older pediatric
clients as well.
Toddlers Examine child Gain the toddler’s Stranger anxiety decreases Perform least
on parent’s lap confidence before by approximately age distressing and least
or exam table, beginning the 18 months; separation intrusive aspects
depending on exam; let the anxiety decreases by age of exam first (i.e.,
where the child is toddler see and approximately 2 years. auscultate heart and
most cooperative. touch examination Negativistic; often responds lungs; examine ears,
instruments; keep “no” when toddler means nose, and throat last).
parent and security “yes.” Dislikes body boundary Auscultate, palpate,
object nearby. intrusion; often dislikes and percuss whenever
having clothes removed; have quiet.
parent remove clothes. Offer
simple choices but provider Praise toddler for
should not give toddler a cooperating with
choice where none exists exam.
(e.g., “May I look in your
ears?”). Toddlers are often
uncooperative with exam;
complete exam as quickly
but as thoroughly as possible.
May need to enlist parents’
help in gently restraining
child during exam. Use
distraction techniques (play,
puppets, toys). Praise the
toddler for cooperation.
(continued)
TABLE 8-2
Sequence of Pediatric Physical Examination According to Age
and Developmental Level (Continued)
POSITION FOR DEVELOPMENTAL
AGE GROUP EXAMINATION PREPARATION CONSIDERATIONS SEQUENCE
Preschoolers Exam table with To allay fears, may Likes to “help.” Concrete, Head-to-toe if
parent nearby use dolls, stuffed literal thinkers. Protect cooperative.
animals, or parent modesty. Magical thinking Otherwise use
to “examine” first causes many fears. Provider approach as with
before child. Allow should take care regarding toddler. Should be
preschooler to see and choice of words (e.g., “take” able to examine older
touch equipment. your blood pressure). preschoolers head-
Give preschooler Preschooler may think she to-toe.
gown; ask child to or he is ill because of bad
remove all clothing behavior (magical thinking).
but underwear. Preschoolers need feedback
during the exam (“Your
lungs sound just like they are
supposed to.”)
Games, dolls, or toys
sometimes helpful when
conducting physical exam
to gain child’s cooperation.
Preschoolers should be given
choices when possible.
School-aged Exam table Give child gown Can now address questions Head-to-toe with
child and ask child to more directly to child. genitalia last.
undress except for Answer child’s questions
underpants. Explain honestly and concretely;
purpose of all diagram and teaching
equipment. Young dolls are helpful during
school-aged child explanations. Child often
often prefers parent sees physical exam as “fun”;
to be present; older likes to learn about body.
school-aged child Protect privacy and modesty.
may prefer parent to
leave room during
exam.
Adolescent Exam table Provider should Elicit active participation Head-to-toe with
explain from teen when genitalia last.
confidentiality obtaining health history.
parameters. Offer Confidentiality and privacy
option for parent to important. Protect modesty.
be present or to leave Address teen directly
the room during during exam. Discuss issue
physical exam. of sexuality and body
Give teen a gown; development matter-of-
allow to undress in factly; emphasize normalcy
private; may leave whenever possible. Include
undergarments on. health teaching.
Adapted from: Hockenberry, M. J., & Barrera, P. (2007). Communication and physical assessment and developmental assessment of the
child. In Hockenberry, M. J., & Wilson, D. Nursing care of infants and children. (8th ed.). (p. 165). St. Louis: Mosby Elsevier.
measurements include body temperature, heart rate, ments (see Appendix A). Techniques for measuring
respiratory rate, and blood pressure. At each health su- body temperature, pulse, respiratory rate, and blood
pervision and focused visit, a child’s vital signs should pressure in infants and children are discussed below.
be measured and compared to normal values for that
age group, as well as previous readings for that child. Temperature
The provider must be familiar with age and gender- Accurate measurement of body temperature is very
specific norms for each of these physiologic measure- important in the pediatric population. For example,
subnormal body temperature can be a sign of sepsis The most accurate reflection of a child’s true body
in the neonate. Fever, or elevated body temperature, temperature is the core temperature, which remains
one of the most common presenting complaints in relatively constant despite the environmental tem-
children, is a sign of illness in children and helps perature. In healthy children, the core temperature is
the provider to make diagnoses. The height of a measured rectally. Body temperature in healthy chil-
fever does not necessarily correspond to the sever- dren can also be measured orally, axillary, tympani-
ity of illness in a child, and health care providers cally, and via the temporal artery. It is important to
should remind parents of this. Minor viral illness is measure a child’s body temperature at the appropriate
the most common cause of fever in children (Algren site with the appropriate instrument for age. Choos-
& Arnow, 2007). Normal variations in body temper- ing the route by which to measure a child’s body tem-
ature also occur, and these variations can occur as perature depends on several factors, which are listed in
a result of several factors, which are summarized in Table 8-4. Appendix A lists normal body temperature
Table 8-3. ranges based on the method of measurement.
TABLE 8-3
Factors Affecting Body Temperature in Infants and Children
FACTOR EFFECT
Age Infants have poor body temperature regulation; they cannot
conserve body heat because of neurologic immaturity,
greater body surface area, and less adipose tissue than older
children and adults; infants younger than 6 months cannot
shiver to raise body temperature; marked fluctuations in
body temperature often seen in young infants.
Activity, exercise, and vigorous play Raises body temperature
Autoimmune disorders Raises body temperature
Circadian variation (varies less than 1° in infants younger Body temperature is lowest in early morning.
than 6 months; approximately 1° in children under 2; as Body temperature is highest in early evening.
much a 2° diurnal variation may be seen in children 2–6
years of age
Dehydration Raises body temperature
Drug reactions Raises body temperature
Eating Raises body temperature
Emotion, stress, and crying Raise body temperature
Environmental temperature and humidity Raise body temperature
Immunizations May raise body temperature
Infection (viral and bacterial) Raises body temperature
Inflammation Raises body temperature
Malignancy Raises body temperature
Medications:
Antipyretics, vasodilators, and anesthetic agents Decrease body temperature
Prostaglandins Raise body temperature
Neurologic injury and hypothalamic disorders Raise body temperature
Ovulation Raises body temperature
Rheumatic fever Raises body temperature
Swaddling and overdressing Raise body temperature
Source: Nativio, D.G. (2005). Understanding fever in children. American Journal for Nurse Practitioners, 9(11/12), 47–48; 51–52.
TABLE 8-4
Temperature Measurement: Routes and Procedures in Infants and Children
TYPE OF
MEASURING
ROUTE DEVICE AGE PROCEDURE VARIABLES TO CONSIDER
Oral Electronic or digital Beginning age 4 to 5 Thermometer should Child must be developmentally
thermometer years if cooperative have probe cover. capable of holding thermometer
Place thermometer under tongue and keeping
under tongue in mouth closed and lips together
sublingual pouch. while temperature is being read.
Oral route should not be used
if child has moderate-to-severe
nasal congestion, presence
of nasal cannula or oxygen
mask, recent oral surgery,
recent generalized seizures,
oral intubation, or is comatose
or sedated. Recent ingestion
of cold or hot food or liquids
requires a delay in measuring
the temperature via the oral
route.
Rectal Electronic or digital Birth to 5 years if Thermometer Measures core body

thermometer precise temperature should have probe temperature and thus most
reading necessary cover, be lubricated, accurate measurement of
or no other route is and inserted body temperature; no rectal
feasible (e.g., child too approximately 0.5 temperature measurements
young or agitated to (infants) to 1 inch if child has diarrhea,
cooperate with oral or (children) into rectal irritation, or is on
axillary route; child rectum; thermometer chemotherapy. Preschoolers
obtunded; infant or should not be forced find rectal temperatures a body
child with oral or if difficult to insert. boundary intrusion.
axillary surgery).
Axillary Electronic or digital All age groups Thermometer should Used most often with newborns.
thermometer have probe cover; Also used when oral, tympanic,
probe should be or rectal routes not possible.
placed fully within Reading not accurate in
axilla, held firmly infants who have been tightly
against body, with the swaddled, children with altered
infant or child’s arm peripheral circulation, or those
held close to side of in early stages of fever.
body.
Tympanic Infrared beam Age 6 months and Place thermometer Using pediatric-sized probes
sensor tympanic older tip in external is essential to obtain accurate
thermometer auditory canal. Pinna tympanic temperature reading.
should be pulled as Should not be used in infants
with otoscopy and younger than 6 months because
measurements should ear probe is too large to fit
be taken in the in external auditory canal.
same ear to get most Readings are fast and painless
accurate results. for the child. Readings are
not affected by otitis media or
presence of cerumen.
Temporal Infrared beam sensor Any age Roll temperature Sensitivity in measuring
artery transducer across temperature in children is
child’s forehead to variable, especially in febrile
collect temperature children (Hebbar, Fortenberry,
from arterial blood Rogers, Merritt, & Easley, 2005).
flow.
Whenever possible, the site for temperature measure- TABLE 8-5

ment in children should be the least traumatic for that
Factors Affecting Pulse Rates
particular child. The provider should teach parents that
diagnosing a fever by touching a child’s skin is highly
in Children
unreliable and that the child’s temperature should be FACTOR EFFECT
measured with a thermometer. Fever strips should not
be used to measure body temperature in children, as Activity Increased physical activity
increases heart rate; after time,
they are not accurate (First, 2004). Conflicting data ex-
regular exercise causes pulse rate
ist regarding digital pacifier thermometers (supralingual to decrease.
measurement); some investigators believe sublingual
temperatures are not accurate (First, 2004), while oth- Age Pulse rate decreases with age.
ers assert that the sublingual temperature is accurate in
Crying Crying increases pulse rate.
young children (Braun, 2006). Glass mercury thermom-
eters should not be used to measure body temperature, Disease Diseases can affect pulse rate;
as they are easily broken, and the mercury spillage for example, hyperthyroidism
presents an environmental hazard. Health care provid- increases pulse rate, and
hypothyroidism and anorexia
ers should advise parents to discard old glass mercury nervosa decrease pulse rate.
thermometers. The Additional References section at the
end of the chapter provides information about the En- Fear Fear increases pulse rate.
vironmental Protection Agency web site that explains
Feeding Infants’ pulse rate rises during
how to dispose of old mercury glass thermometers. feeding.
Pulse Fever Fever increases pulse rate.

The measurement of a child’s pulse is a very important Hypovolemia Initially, hypovolemia increases
part of the physical examination and can yield very pulse rate; heart rate falls if it is
important assessment data regarding the child’s car- untreated.
diovascular status, effectiveness of drug therapy, or he- Hypoxia Initially, pulse rate increases
modynamic stability after traumatic injury. The pulse, with hypoxia, then decreases
or heart rate, reflects the pressure that is exerted as the if the cause of hypoxia is
heart pumps blood to the peripheral blood vessels. untreated.
Pulses should be assessed for rate, rhythm, quality, and
Increased intracranial ICP decreases pulse rate.
strength. It is best for the provider to assess an infant pressure (ICP)
or young child’s pulse while he or she is quiet or asleep
to obtain the most accurate result. All children young- Medications Certain medications affect pulse
er than 2 years of age should have their pulse mea- rate, for example, beta2-agonists
(albuterol) increase pulse rate,
sured apically because the radial pulse may not be fully but digoxin decreases pulse rate.
palpable in this age-group. The pulse should also be
measured apically in children with cardiovascular dis- Pain Pain increases pulse rate.
ease or when the radial pulse is irregular or difficult to
palpate. Apical pulse assessment is done by placing the Source: Engel, J. K. (2006). Body temperature, pulse and respirations.
diaphragm of the stethoscope over the point of maxi- In Engel, J. K. Pediatric assessment. (5th ed.). (pp. 75–87). St. Louis:
C. V. Mosby.
mal impulse (PMI) of the heart. In children younger
than 7, this is found at the fourth intercostal space
to the left of the midclavicular line; in children older
than 7, the PMI is at the fifth intercostal space at the Peripheral pulses should be assessed to detect any
midclavicular line (see Chapter 18). In children older circulatory impairment. These pulses include the radial,
than 2 without cardiovascular disease, the radial site femoral, popliteal, and pedal pulses. Pulse strength and
can be used to measure the pulse. The provider should quality can also be graded; Table 8-6 summarizes the
measure the pulse rate for 1 full minute in infants and grading of pulses in children. The radial and femoral
children to detect any abnormal rhythms. A normal pulses should be compared at least once in the new-
variation in the pulse rate is a sinus arrhythmia; this born period to assess for coarctation of the aorta (see
is when the pulse rate increases during respiration and Chapter 18).
falls to normal during expiration. Several factors that
can influence the pulse rate in children are summa- Respirations
rized in Table 8-5. Appendix A lists normal heart rates A child’s respiratory status can be affected by many
in infants and children. things, making careful assessment of respirations
TABLE 8-6 that affect respirations in children (see Chapter 17 for

an in-depth discussion of respiratory assessment).
Grading of Pulses
GRADE Blood Pressure
Blood pressure is part of routine vital sign assessment
0 Not palpable; absent
beginning at age 3. Infants and children younger than
⫹1 Thready, weak, difficult to palpate; 3 who have acute or chronic conditions that may affect
obliterates with pressure blood pressure should also have their blood pressure
measured. Blood pressure measurements should also
⫹2 Difficult to find; may obliterate with
pressure be taken at birth to screen for coarctation of the aorta,
more frequently than annually in children with cardiac
⫹3 Easy to palpate; normal; difficult to or renal disease, and in children who are overweight or
obliterate obese. With the markedly increased incidence of child-
⫹4 Strong, bounding; does not obliterate with hood overweight and obesity, primary hypertension in
pressure the pediatric and adolescent population is becoming
more common (Luma & Spiotta, 2006). Because of this
trend, it is extremely important for the provider to ob-
tain accurate blood pressure readings in children and
important in the pediatric client. Assessment of res- adolescents to identify and treat hypertensive children,
piration in a child involves observing the respiratory thus minimizing long-term health risks.
rate, rhythm, depth, and effort. The respiratory rate is In healthy children, blood pressure is measured non-
best measured while the infant or child is quiet to ob- invasively. The preferred method for blood pressure mea-
tain the most accurate reading. Respirations are count- surement is auscultation (National High Blood Pressure
ed by observing a complete respiratory cycle (the rise Education Program Working Group on High Blood Pres-
and fall of the child’s chest with each inspiration and sure in Children and Adolescents, 2004). In newborns
expiration). The respirations of infants and young chil- and young infants, a Doppler device should be used to
dren are mainly diaphragmatic, so the provider should measure blood pressure. In older children, the aneroid
observe abdominal movements while assessing respi- device is most often used to measure blood pressure,
rations. Respirations should be counted for 1 full min- since mercury manometers are less available because
ute in newborns and very young infants because of the of the environmental toxicity of mercury. The provider
normal, irregular respiratory movements in this age must ensure that the aneroid manometer is calibrated
group. This can be done simultaneously while auscul- according to the manufacturer’s recommendations so
tating the child’s breath sounds. Until approximately that accurate blood pressure readings are obtained. No
age 4 months, infants are obligate nose breathers, so matter what the child’s age or the type of noninvasive
it is important for the provider to ensure that the na- blood pressure measuring device used, it is essential that
res are clear of any secretions that could interfere with the appropriate sized blood pressure cuff (i.e., the inner
breathing and affect the respiratory rate or effort. In inflatable bladder) be chosen for the reading to obtain
older children and adolescents, respirations are thorac- an accurate blood pressure measurement. The correct
ic and can be counted for 30 seconds and multiplied by cuff width should be at least 40% to 50% of the arm cir-
two, unless the child is in respiratory distress; then the cumference when measuring at a point midway between
rate should be counted for 1 full minute. Young chil- the olecranon and the acromion, and the cuff bladder
dren may alter their chest or abdominal movements length should cover 80% to 100% of the arm circumfer-
if they become aware that their respirations are being ence (National High Blood Pressure Education Program
observed; a child may do this in an effort to “help” the Working Group on High Blood Pressure in Children and
provider. Because this may affect the rate and depth Adolescents, 2004). A cuff that is too large will cause a
of the respirations, the provider should avoid telling low blood pressure reading; a cuff that is too small will
the child when the respirations are being counted. An result in a blood pressure reading that is falsely high. For
effective way to accomplish this would be for the pro- obese children and adolescents, an adult-sized or extra
vider to keep his or her fingers on the child’s radial large cuff may need to be used to obtain the most ac-
pulse after the pulse has been counted, then glance at curate measurement. The blood pressure should be mea-
the child’s chest to count the respirations. sured on the right arm versus the left arm in the event of
Respiratory rhythm, depth, and effort are also as- undiagnosed coarctation of the aorta (Luma & Spiotta,
sessed. Respiratory rhythm should be regular; depth is 2006), which may cause low blood pressure readings in
described as normal, shallow, or deep, and expansion the left arm if accompanied by an interrupted aortic arch
should be symmetrical. Respirations should be effort- (Koutlas, Marziarz, Reade, & Love, 2009).
less and unlabored. Appendix A lists normal respira- Blood pressure should be measured after the child
tory rates in infants and children. Table 8-7 lists factors has been quiet for at least 5 minutes. The child should
TABLE 8-7
Factors That Affect Respirations in Children
FACTOR EFFECT
Age The respiratory rate decreases with age; infants are obligate nose breathers until approximately
4 months; infants and young children are abdominal breathers; older children and adolescents
are thoracic breathers. Apnea of 15–20 seconds or less is normal in the neonate. Respiratory rates
decrease with age (see Table 1-1).
Fever Respirations increase in rate and depth.
Hypothermia Respirations increase in rate with mild hypothermia; moderate hypothermia causes slow and
shallow respirations; severe hypothermia causes apnea.
Activity Exercise increases respiratory rate and depth during and shortly after physical activity; sleep
decreases respiratory rate.
Fear or anxiety Respirations increase in rate and depth; crying causes respirations to increase and become irregular.
Medications Opiates, narcotics, anesthetic agents, barbiturates, benzodiazepines, sedatives, large amounts of
alcohol, inhalants, anticholinergics, some anticonvulsants, and bicarbonate decrease respirations;
amphetamines, salicylates, methamphetamines, caffeine, cocaine, nicotine, and xanthines increase
respiratory rate.
Medical conditions Respirations can increase in rate, rhythm, and depth with respiratory conditions that decrease
oxygenation and increase carbon dioxide levels (e.g., pneumonia, bronchiolitis, asthma, heart
failure). Respirations can also be altered with head injuries, increased intracranial pressure, anemia,
cardiac conditions, hypovolemia, hyperthyroidism, pain, and cough.
Position Sitting up or increasing the head of the bed can improve ventilation and decrease respiratory
rate in clients with respiratory illnesses; slumping forward can interfere with normal respiratory
movements.
Pain Respiratory rate can increase or decrease.
Source: Engel, J. K. (2006). Body temperature, pulse and respirations. In Engel, J. K. Pediatric assessment. (5th ed.). (pp. 75–87). St. Louis: C.
V. Mosby.
be seated, feet on the floor with his or her right separate occasions (National High Blood Pressure
arm supported, with the cubital fossa at heart level Education Program Working Group on High Blood
(National High Blood Pressure Education Program Pressure in Children and Adolescents, 2004). Box 8-2
Working Group on High Blood Pressure in Children lists possible causes of hypertension in children.
and Adolescents, 2004). Young children may feel most • Hypotension in children can be caused by hypovo-
comfortable while sitting in the parent’s lap; crying lemia, anorexia nervosa, or certain medications.
or fear can increase blood pressure readings. Once
the blood pressure cuff is secured on the child’s arm, Pain
the bell of the stethoscope should be placed over the Pain is considered the fifth vital sign. The provider
brachial pulse, below the bottom edge of the blood should assess for the presence of pain during each health
pressure cuff, and the blood pressure should be mea- care encounter. This assessment should be tailored to
sured. The child’s pulse pressure should be noted as the child’s age and developmental level. See Chapter 6
well. Decreased pulse pressure is caused by decreased for a discussion of pain assessment in children.
stroke volume or increased peripheral resistance. Nor-
mal blood pressure in children is defined as systolic
blood pressure (SBP) and diastolic (DBP) that are less ANTHROPOMETRIC MEASUREMENTS
than the 90th percentile for age, gender, and height Anthropometric measurements in children include
(National High Blood Pressure Education Program weight, height (or length), and head circumference.
Working Group on High Blood Pressure in Children In certain circumstances, other measurements may
and Adolescents, 2004). Appendix A lists the normal be done, including chest circumference, arm circum-
range of blood pressures in healthy children, accord- ference, skinfold thickness, and arm span. In children
ing to age, gender, and height. 2 and older, body mass index (BMI) is used to assess
• Hypertension in children is defined as the SBP and weight in comparison to height and the child’s risk
DBP being greater than the 95th percentile on three for overweight or obesity. Growth during infancy and
BOX 8-2 ferences among children in the United States (CDC,

2009). The older growth charts also did not reflect the
Causes of Hypertension in
effect that breast or formula feeding has on a young
Children child’s growth (CDC, 2009). The revised growth charts
• Crying also include percentile curves up to age 20 years, and
they added the 3rd and 97th percentiles (CDC, 2009).
• Poison ingestion
Another important addition to the 2000 CDC growth-
• Substance abuse
chart revision was the creation of body mass index for
• Tobacco use
age (BMI-for-age) charts, which is an essential tool in
• Certain medications (e.g., Neosynephrine screening for overweight and obesity in children (see
[phenylephrine hydrochloride], prednisone, albuterol,
Appendix B for the CDC growth charts for children age
ipratropium bromide)
birth to 20 years).
• Anxiety
• Obesity
Ethnic and Racial Variations
• Cardiac
in Height and Weight
• Renal disease
When measuring height and weight in children, it is
• Increased intracranial pressure
important for the provider to be aware of the inherent
• Thyroid disease differences in size that exist among children from
• Pheochromocytoma various racial and ethnic groups. Native American and
Hispanic newborns are shorter at birth than African
American or Caucasian neonates (Andrews & Boyle,
2008). Asian children are smaller in weight and length
childhood is a key indicator of the child’s overall health than all other ethnic groups at all ages (Andrews &
and well-being. Boyle, 2008). The CDC growth charts that were revised
The guidelines set forth by the American Academy in 2000 reflect these normal differences.
of Pediatrics state that children’s growth should be
measured every 2 months until age 6 months, every Breast- and Formula-fed Infants. The 2000 CDC
3 months from age 6 to 18 months, and then once a growth charts can be used for both breast-fed and
year until age 18 years (Hagan, Shaw, & Duncan, 2007). formula-fed infants because these growth charts repre-
Assessment of growth is especially important for chil- sent data collected by measuring the growth patterns
dren who are at risk for growth failure or obesity. Growth of both breast-fed and formula-fed infants in the U.S.
failure may be a sign of illness or neglect and must be population. In exclusively breast-fed infants, growth
evaluated promptly. Obesity can lead to serious physical patterns must be assessed judiciously because these in-
and psychosocial health problems (see Chapter 10). fants have different growth patterns than do infants
To avoid unnecessary medical and endocrine re- who are formula-fed only (CDC, 2009).
ferrals, it is vitally important that all growth mea-
surements be done accurately and precisely. This Premature Infants. The growth of premature infants
includes using proper equipment, accurate technique, should be monitored closely, using the corrected gesta-
and proper positioning. At each health supervision tional age until age 24 to 30 months (U.S. Department
visit, the provider should measure all growth param- of Health and Human Services, 2009; MacDonald,
eters (i.e., weight, length/height, head circumference Mullet, & Seshia, 2005; Tufts, 2004). The premature in-
if applicable, BMI if applicable) and plot the growth fant’s weight, length, and head circumference must be
measurements on age and gender-specific Centers for plotted on appropriate growth charts. The 2000 CDC
Disease Control (CDC) growth charts (0–36 months, growth charts can be used but do not include data from
2–20 years). An important assessment for the provider very-low-birth-weight (VLBW) infant measurements
to make is whether the child’s growth is consistent over (CDC, 2009a). The 1999 Infant Health and Develop-
time, plotting at the same percentile. These growth mental Program (IHDP) Growth Percentiles for low-
charts should be kept as part of the child’s medical birth-weight (LBW) and VLBW infants (⬍1500 grams
record for comparison at the next health care visit. or 3.3 pounds) publishes growth charts for preterm
infants, but these charts may not accurately represent
Growth Charts growth in the current population of preterm infants
In 2000, the CDC revised the National Center for because the data were collected before premature in-
Health Statistics growth charts that had been in use fants were routinely placed on high-calorie formulas
since 1977. The rationale for this change was that the (Carlson, 2005). Carlson (2005) recommends chart-
previous growth charts were not an accurate represen- ing a premature infant’s growth on both the CDC and
tation of the various racial, ethnic, and genetic dif- IHDP charts.
Children with Chronic Conditions. Certain genet-

ic or chromosomal disorders can cause alterations in
growth in children. Some of these conditions include
Turner syndrome, Down syndrome, Prader-Willi syn-
drome, Marfan syndrome, and achondroplasia (CDC,
2009; U.S. Department of Health and Human Services,
2009). When caring for children with these condi-
tions, the provider may elect to use condition-specific
growth charts to plot the child’s growth (see Additional
Resources at the end of the chapter).
Weight
Weight is an important indicator of a child’s overall
health. Because of the expected rapid weight gain dur-
ing the first year of life, the provider should monitor
weight closely to assess normal growth. An infant
should double the birth weight by 6 months, triple the
birth weight by 12 months, and quadruple the birth
weight by 2 years. After 2 years, the BMI should be
used as a guideline to monitor weight. Excessive weight
gain should be noted to identify an overweight infant FIGURE 8-8. Measuring infant weight. Care should be taken
or toddler (Dennison & Boyer, 2004). Early and exces- to ensure the infant’s safety while on the scale. Note the
protective hand to prevent the infant from falling.
sive weight gain is most often because of overfeeding
but can also be caused by lack of physical activity, con-
genital syndromes (e.g., Prader-Willi syndrome), or provider should record it in the infant’s chart and plot
medical conditions such as hypothyroidism. Excessive it on the age- and gender-specific CDC growth chart
weight gain in the first 6 months of life is associated (birth to 36 months).
with overweight and obesity later in life (Agras, Ham- Until a child can stand well, he or she should con-
mer, McNicholas, & Kraemer, 2004). tinue to be weighed lying down on a beam balance
Similarly, the provider should also note the child’s scale. By age 2 to 3, an upright scale can be used to
failure to gain weight. Poor weight gain is most likely a measure the child’s weight (Fig. 8-9). These children
result of malnutrition, malabsorption, neglect, condi- should be weighed wearing only a dry diaper or un-
tions that cause chronic hypoxia (e.g., congenital heart derpants and a light paper or cotton gown. The child’s
disease, chronic lung disease), renal disease, chronic
infections, or psychologic illnesses such as depression
or anorexia nervosa (Duderstadt, 2006; Neumann,
Gewa, & Bwibo, 2004).
All infants, children, and adolescents should be
weighed at each health maintenance visit. Ill chil-
dren should also be weighed; this is done so that the
provider has a current, accurate weight in the event
that medications need to be prescribed. It also quan-
tifies acute weight loss or gain in an ill child, which
may be because of dehydration or fluid retention,
respectively. Infants until age 12 months should be
weighed completely nude on a beam balance scale,
which should measure to the nearest 10 grams (g)
(Fig. 8-8). Since the infant is weighed nude, a paper
liner is placed on the scale and the scale is zeroed be-
fore weighing the infant. Infants in this age group can
be weighed lying or sitting, depending on their devel-
opmental abilities. The provider should take care to
ensure that the infant is never left unattended on the
scale to prevent injuries or falls. Weight measurements
in this age group should be taken to the nearest 10 g
or 0.5 ounces. Once the measurement is obtained, the FIGURE 8-9. Weight measurement in an older child.
shoes should also be removed. The provider should and MUAC (Eissa & Gunner, 2004; Neumann, Gewa,
make sure that the child is not holding on to the scale & Bwibo, 2004). Skinfold thickness indirectly mea-
beam, a parent’s hand, or the wall, all of which result sures the amount of adipose tissue and is most often
in inaccurate readings. The weight should be measured measured at the triceps, subscapular, and abdominal
to the nearest 100 g or 0.25 pounds, recorded in the regions. To measure triceps skinfold thickness, the
child’s chart and on the age- and gender-specific CDC provider should use special calipers, such as Lange
growth charts (2 to 20 years). calipers. To begin, the provider should ask the child
to flex his or her arm 90 degrees. The provider then
Body Mass Index marks a place on the upper arm that is midway be-
The body mass index (BMI) measurement is considered tween the olecranon process and the acromium on
the standard of care for the early recognition of over- the posterior aspect of the upper arm. Next, the pro-
weight and obesity in children, a serious and prevalent vider gently grasps the skin away from the underly-
problem (Dennison & Boyer, 2004). The BMI provides ing muscle and places the caliper jaws onto the skin-
a guideline by which to determine a healthy weight for fold. The provider should wait 2 to 3 seconds and
the child based on height. The provider should calcu- then take a reading. The calipers measure in millime-
late and plot the BMI in all children beginning at age ters (mm); the measurement should be taken to the
2 years. This calculation is done by dividing the child’s nearest 0.1 mm (CDC, 2005). Two readings should be
weight in kilograms by the height in meters squared. done and averaged for a final reading (Hockenberry
The BMI can also be calculated by dividing the child’s & Barrera, 2007).
weight in pounds by the height in inches squared, then MUAC is the measurement of the circumference
multiplying that result by 703. Table 8-8 lists the BMI of the upper arm, measured at the midpoint between
interpretation standards for children. The BMI should the tip of the shoulder and the tip of the elbow (olec-
be plotted for children older than age 2 years, using ranon process and the acromium). MUAC is used in
the 2000 age- and gender-specific growth charts from children 8 and older (CDC, 2005) to estimate the
the CDC. If the child’s BMI is above the 85th percen- amount of subcutaneous fat present in the upper arm.
tile, further assessment is necessary (see Chapter 10 for Excess fat in the upper arm can indicate overweight
a detailed discussion of BMI). or obesity; a decline in subcutaneous fat in the up-
per arm can indicate malnutrition (Eissa & Gunner,
Skinfold Thickness and Mid-upper Arm 2004; Neumann, Gewa, & Bwibo, 2004). To measure
MUAC, the child should be standing upright, shoul-
Circumference
ders relaxed, and arms hanging to the side; the arm
Two indirect measurements of adiposity in children
should not be flexed. The provider should place the
are skinfold thickness and mid-upper arm circumfer-
tape measure around the MUAC and obtain a reading
ence (MUAC). Both obesity and chronic undernutri-
in centimeters (cm), measured to the nearest 0.1 cm
tion can be reflected in changes in skinfold thickness
(CDC, 2005). Both skinfold measurements and MUAC
values are used to triage children for further evalua-
tion of nutritional status.
TABLE 8-8
Interpretation of Body Mass Length
Index (BMI) Standards for To measure linear growth, the recumbent height (i.e.,
Children 2 to 20 Years of Age length) in children under 2 rather than standing height
should be measured. Most children 2 or younger will
AGE- AND GENDER- not cooperate or be able to stand long enough for the
SPECIFIC BMI provider to obtain an accurate standing height. Also,
CLASSIFICATION PERCENTILES children in this age group have physiologic lordosis,
Underweight BMI ⬍5th percentile
which makes a standing height less accurate. For length
measurements to be accurate, proper positioning of
Healthy weight BMI ⱖ5th ⱕ85th the child is imperative. It is important to note that the
percentile birth to 36 months CDC growth charts are standard-
Overweight BMI ⱖ85th ⱕ95th ized for recumbent height.
percentile Length is measured with the child on the examina-
tion table in the supine position and the body fully
Obese BMI ⱖ95th percentile extended. The provider should be sure to hold the
child’s head midline, straighten the child’s legs, and
Source: Centers for Disease Control and Prevention. (2009b). dorsiflex the feet. The distance between the top of the
About BMI for children and teens. Retrieved January 20, 2007,
from http://www.cdc.gov/nccdphp/dnpa/bmi/childrens_BMI/ child’s head and the soles of the feet is then mea-
about_childrens_BMI.htm#What%20is%20BMI%20percentile. sured. A measuring board is the most accurate way
TABLE 8-9
Normal Linear Growth Patterns
in Children
LENGTH IN
CENTIMETERS
AGE (CM)(AVERAGE)
Birth 50 cm
Birth to 6 months 66 to 67 cm
6 to 12 months 75 cm
Second year growth 10 cm/year
FIGURE 8-10. Measurement of recumbent height (length) in Third year growth 8 cm/year
an infant, using a measuring board.
Fourth year growth 7 cm/year
Seventh year growth 6 cm/year

to measure length in an infant or toddler. When us-
ing a measuring board (Fig. 8-10), the provider places Annual growth until puberty 5 to 6 cm/year
the child’s head at the top of the board and the heels
firmly at the bottom; the measurement is then taken Source: Halac, I., & Zimmerman, D. (2004). Evaluating short
stature in children. Pediatric Annals, 33(3), 170–176.
to the nearest 0.5 cm or 0.25 inch. If a measuring
board is unavailable, an alternative is to use the pa-
per that lines the examination table by marking the
paper at the top of the child’s head and at the bottom for-length should be plotted for children young-
of the child’s heels and then measure the distance beer than 2 using the CDC age- and gender-specific
tween the two marks. This measurement technique growth charts.
also requires that the child’s body be fully extended.
Once the measurement is obtained, the provider Weight-for-Stature
should plot it on the age- and gender-specific CDC Weight-for-stature is defined as weight compared to
growth chart. height (stature) regardless of a child’s age (CDC, 2009).
Weight-for-stature is calculated on children 2 and
Height older. Weight-for-stature should be plotted on the CDC
Height is the measurement of linear growth while the growth chart in children from 77 to 121 cm (CDC,
child is standing upright. A standing height should 2009a) to show the relationship between weight and
be obtained if the child is older than 2. Height can be height (Ariza, Greenberg, & Unger, 2004). Although
measured using a scale with a measuring bar or a wall- weight-for-stature is less cumbersome to use than BMI,
mounted unit (stadiometer), which provides the most the BMI is preferred because it measures changes in the
accurate measurement. To measure a child’s standing weight–height in relationship to age and can be used
height, the provider should first ask the child to re- until age 20 (Flegal, Wei, & Ogden, 2002). BMI-for-
move his or her shoes and any hats or hair ornaments age and weight-for-stature measurements do not yield
that would interfere with the measurement. The child identical results and are not interchangeable (Flegal,
should stand straight, look straight ahead, and have his Wei, & Ogden, 2002).
or her head, shoulders, buttocks, and heels touching
the wall or stadiometer. The provider should make sure Arm Span
that the child is not slouching. The height measurement In some instances, exact height cannot be determined
should be taken to the nearest 0.1 cm (0.25 inch) and in a child because the child cannot stand or recline
recorded on the age- and gender-specific CDC growth completely because of contractures, spinal abnor-
chart for that child. Table 8-9 summarizes normal lin- malities (e.g., scoliosis, myelomeningocele), limb de-
ear growth patterns in children. formities, or amputations. Arm-span measurement,
which is nearly equal to height in children, can be
Weight-for-Length used as an alternative to longitudinal measurement;
Weight-for-length reflects body weight in comparison it can also be used as a predictor of height (Halac &
to length regardless of the child’s age (CDC, 2009a). Zimmerman, 2004). Arm-span measurement is also
This comparison is used to determine overweight and useful in identifying children with growth abnormali-
underweight in infants and young children. Weight- ties. Measurement of arm span is done by asking the
child or adolescent to extend both arms outward, can yield inaccurate results. The tape measure should
then measuring the distance from the tip of the be placed in the same position in neonates, although
middle finger across the chest to the tip of the other this may not reflect the largest measurement because
middle finger. In children of European ancestry, the of cranial molding or swelling. Once the measurement
arm-span measurement should be 1 cm less than the is obtained, the provider should plot it on the stan-
child’s height; in adolescents, the arm-span measure- dardized age and gender-specific CDC growth chart for
ment should equal the height (Kemp, 2005). Children head circumference. The head circumference measure-
and adolescents of Asian ancestry have proportionally ment should fall between the 5th and 95th percentile,
shorter arms than those of European and African an- be consistent with the child’s previous measurements,
cestry; children of African ancestry have significantly and be comparable to the child’s height and weight
longer arms (Kemp, 2005). The arm-span measurement percentile measurements. A head circumference mea-
exceeds the height with conditions such as Marfan’s surement that exceeds two standard deviations above
syndrome, vertebral abnormalities, and homocystin- the mean for age and sex, exceeds the 95th percen-
uria (Halac & Zimmerman, 2004). Short arm spans are tile on the growth charts, or increases too rapidly is
found in children with skeletal dysplasias (Halac & defined as macrocephaly. A large head could be simply
Zimmerman, 2004). familial (the provider should measure both parents’
head circumferences) or a result of a more serious
Head Circumference etiology such as hydrocephaly, subdural hematoma,
Measurement of head circumference is a routine part brain tumors, or other causes of increased intracranial
of growth assessment in children 3 and younger and pressure. An increased head circumference in children
at any time the provider deems necessary (e.g., with 2 or older may indicate separation of the cranial su-
noticeable increased head circumference, abnormal tures, a sign of increased intracranial pressure.
growth patterns, provider concern about neurologic A head circumference that measures less than two
functions or developmental milestone achievement). standard deviations below the mean for age and sex,
To measure the head circumference, the provider measures less than the 5th percentile on the growth
should use a paper or metal measuring tape and place charts, or that is increasing too slowly is termed micro-
it around the child’s head at its greatest circumference; cephaly. A small head in an infant or child may indicate
the area is just above the eyebrows and the pinna, a slowly growing brain, intrauterine growth retarda-
and around the occipital prominence (the occipital tion, or craniosynostosis (premature closure of cranial
frontal circumference [OFC]) (Fig. 8-11). Cloth mea- sutures). Children with microcephaly commonly have
suring tapes should not be used as they stretch and neurologic problems and developmental delays. With
the success of the American Academy of Pediatrics’
Back to Sleep campaign, more infants are presenting
with plagiocephaly, specifically occipital flattening
that can be helped by placing the infant prone while
awake. Plagiocephaly affects OFC measurements and
should be noted.
Chest Circumference
Measurement of chest circumference is not routinely
done unless the provider suspects abnormal growth
in an infant, particularly if the infant’s head is of ab-
normal size. Because of cephalocaudal development
(see Chapter 2), the head circumference normally ex-
ceeds the infant’s chest circumference by 2 cm from
birth until age 6 months. Between the ages of 6 and
24 months, the head and chest circumference should
be about equal. By age 2, the head and chest circum-
ference should be equal, with the chest continuing
to grow faster than the head throughout childhood.
After age 2, the chest circumference should always be
larger than the head circumference. To measure the
chest circumference, the provider should place the
tape measure around the chest across the nipple line.
FIGURE 8-11. Measurement of head circumference in an
infant. The tape measure should be placed around the point Measurement of chest circumference is not plotted on
of largest circumference of the head. any growth chart.
SUMMARY Hagan, J., Shaw, J., & Duncan, P. (Eds). (2007). Bright futures: Guide-
lines for health supervision of infants, children and adolescents. (3rd
ed.). Elk Grove Village, IL: American Academy of Pediatrics.
Obtaining accurate objective data during the pediat- Halac, I., & Zimmerman, D. (2004). Evaluating short stature in
children. Pediatric Annals, 33(3), 170–176.
ric physical examination is essential to developing an Hebbar, K., Fortenberry, J. D., Rogers, K., Merritt, R., & Easley, K.
accurate problem list and corresponding management (2005). Comparison of temporal artery thermometer to stan-
plan. Accurate measurements are particularly impor- dard temperature measurements in pediatric intensive care
unit patients. Pediatric Critical Care Medicine, 6(5), 557–561.
tant when dealing with the pediatric population. It is Hockenberry, M. J., & Barrera, P. (2007). Communication and
also very important for the pediatric health care pro- physical assessment and developmental assessment of the
vider to be proficient in performing the four major child. In Hockenberry, M. J., & Wilson, D. Nursing care of in-
fants and children. (8th ed.). (p. 169). St. Louis: Mosby Elsevier.
examination techniques and to be knowledgeable Kemp, S. (2005). Growth failure. Retrieved November 11, 2009,
about the physical and psychosocial developmental from http://www.emedicine.com/PED/topic902.htm.
stages in children. King, R. C. (1983). Refining your assessment techniques. RN,
February, 43–47.
Koutlas, T. C., Marziarz, D. M., Reade, C., & Love, K. (2009). Co-
arctation of the aorta and Interrupted aortic arch: Surgical
perspective. Retrieved November 11, 2009, from http://www
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Algren, C. L., & Arnow, D. (2007). Pediatric variations of nurs- Avery’s neonatology: Pathophysiology and management of the new-
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Mosby Elsevier. of children’s fears of medical experiences across two cultures.
Andrews, M. M., & Boyle, J. S. (2008). Transcultural concepts in nurs- Journal of Pediatric Health Care, 18(6), 302–307.
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Ariza, A. J., Greenberg, R. S., & Unger, R. (2004). Childhood over- Advanced pediatric clinical assessment: Skills and procedures.
weight: Management approaches in young children. Pediatric (pp. 70–146). Philadelphia: Lippincott Williams & Wilkins.
Annals, 33(1), 33–38. National High Blood Pressure Education Program Working Group
Braun, C. A. Accuracy of pacifier thermometers in young chil- on High Blood Pressure in Children and Adolescents. (2004).
dren. Pediatric Nursing, 32(5), 413–418. The fourth report on the diagnosis, evaluation, and treatment
Carlson, S. E. (2005). Feeding after discharge: Growth, develop- of high blood pressure in children and adolescents. Pediatrics,
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R., & Zlotkin, S. H. (Eds.). Nutrition of the preterm infant: Sci- Nativio, D. G. (2005). Understanding fever in children. The Amer-
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Cincinnati: Digital Publishing Inc. Neumann, C. G., Gewa, C., & Bwibo, N. O. (2004). Child nutrition
Centers for Disease Control and Prevention. (2005). National in developing countries. Pediatric Annals, 33(10), 658–674.
Health and Nutrition Examination Survey. Anthropometry Schmitt, B. D. (1984). Preschoolers who refuse to be examined.
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November 11, 2009, from http://www.cdc.gov/nchs/data/ 138(5), 443–446.
nhanes/nhanes_05_06/BM.pdf. Tufts, G. (2004). Primary care of the premature infant. The Ameri-
Centers for Disease Control and Prevention. (2009). Growth can Journal for Nurse Practitioners, 8(10), 25–28; 31–32; 37–42.
chart home page. Retrieved November 11, 2009, from http:// U.S. Department of Health and Human Services. (2009). Mater-
www.cdc.gov/growthcharts/background.htm. nal Child Health Bureau training module—Using the CDC
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the CDC growth charts. Retrieved November 11, 2009, from with special health care needs. Retrieved November 11, 2009,
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Dennison, B. A., & Boyer, P. S. (2004). Risk evaluation in pediatric
ADDITIONAL RESOURCES
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Annals, 33(1), 25–30. http://www.med.ucla.edu/wilkes/intro.html
Duderstadt, K. (2006). Assessment parameters. In Duderstadt, This site offers audio clips for listening to heart and breath sounds.
K. Pediatric physical examination: An illustrated handbook. Centers for Disease Control
(pp. 11–22). St. Louis: Mosby Elsevier. http://www.cdc.gov/growthcharts/background.htm
Eissa, M. A., & Gunner, K. B. (2004). Evaluation and manage- This portion of the Centers for Disease Control web site provides
ment of obesity in children and adolescents. Journal of Pediat- the growth charts for children for weight, length, height, weight
ric Health Care, 18(1), 35–38. for length, weight for stature, and BMI. These charts were revised
Engel, J. K. (2006). Body temperature, pulse and respirations. In in 2000 to be more representative of the ethnic diversity and
Engel, J. K. Pediatric assessment. (5th ed.) (pp. 75–87). St. Louis: current feeding practices in children in the United States. These
C. V. Mosby. charts also include percentile curves up to age 20 years and
First, L. R. (2004). Fever update 2004: A topic that keeps getting measurements inclusive of the 3rd and 97th percentiles. The
hotter. Presented at the Masters of Pediatric Meeting. Jan. 28– CDC web site also has self-study materials related to using the
Feb. 3. Bal Harbour, FL. CDC growth charts and BMI assessment and interpretation.
Flegal, K. M., Wei, R., & Ogden, C. (2002). Weight-for-stature com-
pared with body mass index–for-age growth charts for the Unit- Condition-specific Growth Charts
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American Journal of Clinical Nutrition, 75(4), 761–766. text/page1a.htm
IHDP Growth Charts for Premature Infants This site provides information on what to do with broken glass
http://depts.washington.edu/growth/cshead circumferencen/ mercury thermometers, gives suggestions for alternatives to
text/page4a.htm mercury thermometers, and tells the consumer how to dispose
of old mercury glass thermometers.
Measurement of Skinfold Thickness
http://www.cdc.gov/nchs/data/nhanes/nhanes_05_06/BM.pdf The R.A.L.E. Repository
http://www.rale.ca/
The Environmental Protection Agency This web site provides digital recordings of normal and
http://www.epa.gov/region1/eco/mercury/spillstherm.html abnormal respiratory sounds.
CHAPTER
The Health Supervision
9 Visit: Wellness
Examinations in
Children ELLEN M. CHIOCCA
A crucial element of pediatric health assessment is health screening, teaching, anticipatory guidance, and
health supervision. This involves the determination appropriate referrals.
of a child’s physical and psychosocial health and well-
ness, assessment of the knowledge base of the parent
or caregiver, and the delivery of clinical preventive INFLUENCES ON PEDIATRIC
services. Wellness care for children lays the founda-
tion for good health as an adult. Many of the health
WELL-CHILD CARE
problems that are prevalent in American adults, such
The highest quality preventive health care must be
as obesity, diabetes, heart disease, and mental health
accessible, affordable, comprehensive, and culturally
disorders, begin in childhood. The health supervi-
sensitive (Hagan, Shaw, & Duncan, 2008). Pediatric
sion visit allows the pediatric health care provider
preventive health services must also be delivered by
to monitor a child’s health status within the context
qualified professionals with pediatric expertise, such as
of his or her family and community, deliver health
pediatricians, pediatric nurse practitioners, and pediat-
promotion and screening, conduct school or sports
ric specialists and subspecialists.
examinations, prevent disease, and intervene before
Access to care is defined as having a regular source
problems arise.
of comprehensive, age-appropriate pediatric health
care without financial barriers such as inadequate or
no insurance, a scarcity of pediatric health care pro-
WELLNESS CARE FOR CHILDREN viders (including mental and dental specialists), and
a scarcity of hospitals that provide pediatric expertise
With the advent of immunizations and antibiotics in (Pincus, Thomas, Keyser, Castle, Dembrowsky, Firth,
the 20th century, the prevalence of physical illness in et al., 2005). Socioeconomic factors that affect acces-
children has decreased; however, a “new morbidity” sibility to health care, such as poverty, homelessness,
has emerged as a cluster of psychosocial health con- and a lack of health insurance or transportation, can
cerns among children. Chief among these are school adversely affect health outcomes in children (Pincus et
and learning problems, mood disorders (e.g., anxiety, al., 2005). For example, children with private health
depression), adolescent suicide and homicide, firearms insurance are more likely than children with limited
in the home, school violence, drug and alcohol abuse, or no health insurance to receive consistent preven-
human immunodeficiency virus (HIV) and acquired tive health care services (Gresenz, Rogowski, & Escarce,
immunodeficiency syndrome (AIDS), the prevalence 2006). Uninsured children are more likely to use the
of sedentary lifestyles and childhood obesity, and the emergency room (ER) for routine care than children
media’s influence on sexuality and interpersonal vio- with private insurance; in fact, access to consistent pe-
lence (American Academy of Pediatrics [AAP], 2001). diatric health care is associated with a marked decrease
Other concerns include behavior disorders, family and in the use of the ER for health care services ( Johnson
relationship instabilities, and unsafe communities. Be- & Rimsza, 2004).
cause of this shift in focus, pediatric health supervision Access to quality pediatric health care may also be
visits are essential to provide physical and psychosocial affected by certain provider factors. Numerous screening
161
recommendations—coupled with the requisite health conduct health supervision, promote breastfeeding,
teaching, an overwhelming number of patients on monitor immunization status, conduct developmental
a given clinic day, and limited clinic hours—can surveillance and health screenings, and provide age-
adversely affect the preventive services that are offered. appropriate, individualized anticipatory guidance and
A scarcity of pediatric health care providers, especially education regarding nutrition, physical activity, safety,
in rural areas (Lindeke & Jukkala, 2005), or providers parenting, discipline, and psychosocial issues. An im-
who are unable to communicate with the child or fam- portant role for the pediatric health care provider is to
ily because of language barriers also hamper access to encourage all families to establish a medical home.
adequate health care (Mullin & Ambrosia, 2005; Pincus
et al., 2005). Many African-American and Hispanic
children in the United States do not have regular ac-
cess to health care because they are uninsured. Unin- THE PEDIATRIC HEALTH
sured families or families for whom English is a second SUPERVISION VISIT
language also experience barriers to health care (Mullin
& Ambrosia, 2005; Pincus et al., 2005). However, a Various evidence-based, well-child health assessment
recent study found that children with special health guidelines exist, including the AAP’s Bright Futures
care needs, including African-American and Hispanic Guidelines for Health Supervision of Infants, Children
children, received more health teaching and health and Adolescents, the American Medical Association’s
screening than children without special health care Guidelines for Adolescent Preventive Services (GAPS), and
needs (Houtrow, Kim, Chen, & Newacheck, 2007). Healthy People 2010 (see Additional Resources). These
Personal beliefs about what constitutes health care guidelines are particularly helpful in assisting the pe-
may affect access to health care for children; for diatric provider in ensuring that all age-appropriate
example, some parents and caregivers may not view components of the well-child visit are completed in as
preventive services as valuable. This also includes much depth as possible.
health beliefs about the importance of oral health.
Kelly and colleagues (2005) found that in low-income
families, parents’ health beliefs about oral health fo- TIMING AND FREQUENCY OF VISITS
cused on episodic and emergency dental care. These
Current recommendations by the AAP suggest that the
families also face financial constraints, transportation
frequency of pediatric health supervision visits be in
difficulties, and discrimination, which hamper their
accord with the Recommendations for Preventive Pediat-
access to dental care for their children.
ric Health Care (AAP, 2007). The timing and content of
Culture plays a role in pediatric preventive health
these visits are delineated in the periodicity schedule
care because of its influence on the beliefs of families
for well-child visits, published by the American Acad-
about what constitutes health and illness; in addition,
emy of Pediatrics, a link to which can be found in the
families may use traditional healing practices rather
Additional Resources section at the end of the chapter.
than traditional preventive health care. Families that
Because childhood is a time of rapid growth and
rely on traditional healers often seek formal health care
change, health supervision well-child visits are more
only when a person is already ill (see Chapter 4 for a
frequent when the child is very young and growth and
discussion of the role of culture on health and illness).
development are rapid. More or fewer visits may be
necessary, depending on the child’s health status or
the family’s circumstances.
THE MEDICAL HOME Some pediatric health care providers advocate
changing the recommended timing of the well-child
Ideally, the pediatric health supervision visit is con- visits because the periodicity schedule has been tradi-
ducted with a consistent pediatric health care provider tionally linked to the schedule of childhood immuniza-
or group of providers, often referred to as the “medical tions. It is thought that this contributes to the low rate
home.” The medical home is defined by The American of attendance at well-child health maintenance visits,
Academy of Pediatrics (AAP) as “a model of delivering as many parents view these visits as synonymous with
primary care that is accessible, continuous, compre- “baby shots” and nothing else (Schor, 2004). Some
hensive, family-centered, coordinated, compassionate, experts propose identifying priority themes for each
and culturally effective” (AAP, 2008, p. 184). By pro- visit, according to the child’s current developmen-
viding an ongoing, consistent source of health care tal stage; for example, the 5-year visit could focus on
for the child, a medical home avoids fragmentation of school readiness and the importance of reading. This
care and allows for adequate follow-up of all health approach allows the parent to come prepared for the
assessments. It also allows the pediatric health care visit with specific questions for the provider and al-
provider to establish a relationship with the child lows the provider to fine-tune assessments and priori-
and family and presents increased opportunities to tize the content of the well-child visit (Schor, 2004).
C HA P T ER 9 Th e He alth Sup e r vis io n Vis it: We lln e s s Ex am in atio ns in C hildr en • 163
COMPONENTS When providing preventive health care services to

Regardless of the timing and frequency of the pediat- children, there are several assessment areas or domains
ric health supervision, each visit should contain specific as part of the history that are essential to include.
components. These include the history, identification of These assessments help formulate interventions and
parental concerns, physical examination, developmen- individualize child–parent education and anticipatory
tal surveillance, observation of parent–child interac- guidance. Specific assessment areas include:
tions, health screening, determination of immunization • Nutrition (see Chapter 10)
status, anticipatory guidance, and child–family educa- • Risk for overweight and obesity (see Chapter 10)
tion (Hagan, Shaw, & Duncan, 2008). The health care • Daily physical activity (see Chapters 6 and 10)
provider assesses parental knowledge about nutrition, • Elimination patterns (see Chapter 6)
discipline, illness and injury prevention, temperament, • Sleep patterns (see Chapter 6)
and growth and development. In addition, the health • Age-appropriate safety and risk of injury (see Chapters
care provider assesses the quality of physical care, paren- 6 and 7)
tal nurturing, and stimulation that the child receives. • Social and family relationships (see Chapter 6)
All assessments are geared to the child’s age and devel- • Behavior (see Chapters 2 and 24)
opmental stage. Many of these assessment areas overlap • Growth and development (see Chapters 2 and 6)
with the Bright Futures health-promotion themes, which Other areas to assess involve evaluating the parent’s
are listed in Box 9-1. discipline practices, including the parent’s beliefs about
discipline and the discipline practices they employ.
History Specific questions should be asked about shaking and
All children new to a pediatric health care provider’s corporal punishment, both of which can seriously
practice require a comprehensive and complete ini- harm an infant or child physically and emotionally
tial history. At each subsequent health supervision (see Chapter 23). Table 9-1 provides some examples of
visit, the provider obtains an interval history, which age-specific assessments in these areas.
updates the child’s health status since the last visit A mental health assessment is necessary for all age
(see Chapter 6 for a detailed explanation of these groups, including screening for risk factors that predis-
histories). Part of the history is obtained by using pose the child to mental health problems. Examples
questionnaires that the parent or older child can an- of some of these risk factors are listed in Box 9-2 (see
swer before the clinical interview. Appropriate topics Chapter 24 for details about mental health assessments
for screening questionnaires include diet, nutrition, in children). The National Association of Pediatric Nurse
exercise, and age-appropriate safety precautions. At Practitioners’ (NAPNAP) KySS Guide to Child and Adoles-
each visit, the provider must always remember to cent Mental Health Screening: Early Intervention and Health
elicit any parental–child concerns, inquire about Promotion (Melnyk & Moldenhauer, 2006) provides age-
family life, and evaluate the child in the context of specific questionnaires with which to screen children
the community in which he or she lives. for emotional and mental health issues (see Additional
Resources). Pediatric providers must also screen mothers
for postpartum depression because of the adverse effects
of maternal depression on young children (Chaudron,
Szilagyi, Campbell, Mounts, & McInerny, 2007).
BOX 9-1 Pediatric health care providers assess for spiritual
Bright Future Health health in the child and family. This may include as-
Promotion Themes sessments involving the child and family’s connection
with a greater power, purpose and meaning in life, or
• Family support
links to any faith-based groups.
• Child development
The health care encounter presents an excellent
• Mental health opportunity for the provider to evaluate parental
• Healthy weight knowledge about disease prevention for their child. This
• Healthy nutrition includes determining knowledge about simple hand-
• Physical activity washing, covering mouths when coughing and sneez-
• Oral health ing, and the importance of immunizations.
• Healthy sexual development and sexuality Assessment of oral health begins at the 6-month
• Safety and injury prevention visit, continuing at the 12-month, 18-month, 2-year,
• Community relationships and resources 30-month, and 3-year visits (Hagan, Shaw, & Duncan,
2008). The provider determines if the child has a “den-
tal home,” which should be established soon after
Source: Hagan, J. F., Shaw, J. S., & Duncan, P. M. (Eds). (2008). Bright
futures: Guidelines for health supervision of infants, children and adoles- the first tooth eruption or by 12 months (American
cents. (3rd ed.). Elk Grove Village, IL: American Academy of Pediatrics. Academy of Pediatric Dentistry, 2007).
TABLE 9-1
164
Age-Specific Well-Child History Assessments
GROWTH &
NUTRITION ELIMINATION SAFETY SLEEP PSYCHOSOCIAL DEVELOPMENT
Infants Breast-fed or formula- How many wet diapers Rear-facing car seat use? Does infant sleep Who is primary See Chapter 2,
fed? Type of formula? a day? Number of Any smokers in the home? supine? Any co- caregiver? Who lives in Table 2-3.
Do parents know stools a day? Character Is infant protected against sleeping? the home?
hunger/satiety cues? of stools? falls? Is infant rocked to Any maternal
Bottle propping? Bottle Is infant fed any foods that sleep? postpartum depression?
in bed? Juice? Amount are choking hazards? Tummy time? Are infant’s needs met
a day? Is infant put to sleep prone? consistently?
When were solids Does parent or caregiver How is parent/infant
introduced? Type? avoid having infant near hot attachment?
Frequency and liquids? Is father involved? Any
amount? Are there smoke detectors in smokers/substance
Has child had first the home? abusers in the home?
dental visit by 12 Is home baby-proofed (e.g., Any domestic violence?
months of age? electrical wall socket covers, Does older infant have
door latches, etc.)? security object?
Do family members employ Frequency of ER visits?
frequent hand-washing with For what reason?
young infant, especially
during cold and flu season?
Any guns in the home?
Toddlers Does the child drink Has toilet training Is car seat used in rear seat Does child have Does child have security See Chapter 2,
from a cup or bottle? begun? At what age? of vehicle? Is house baby- consistent bedtime? object? Table 2-3.
Type or amount of Frequency or character proofed (electrical wall Hour of bedtime and Does toddler have
milk a day? of stools? socket covers, door latches, rising? Does child sleep tantrums? Any biting,
Amount of juice a day? medications out of reach)? through the night? hitting, or other
Typical meals? Has crib mattress been Where does toddler aggressive behavior?
Snacks? lowered? sleep? How many Type of rules and
Do parents brush Supervised around water? naps? discipline?
child’s teeth? Does Near streets? Sunscreen used? Does caregiver or parent
child suck thumb or Smoke detectors in home? read to child each day?
pacifier? Has child Any smokers in the home? Number of hours of TV
visited the dentist? Any Guns in the home? watched a day? Type
rewarding with food? of programs watched?
How many hours of TV Exposure to media
watched a day? violence/sexuality?
Any smokers/substance
abusers in the home?
Any domestic violence?
GROWTH &
Preschool Typical meals? Type of Is toilet training Is child still in car seat (until Does child still nap? Is child in preschool or See Chapter 2,
child snacks? complete or 40 lbs)? Booster seat? Is home Consistent bedtime? daycare? Table 2-3.
Does child eat breakfast continuing? child-proofed? Nightmares? Does caregiver or parent
each day? Problems with Is child aware of “stranger Does child sleep read to child each day?
Amount of juice or urination or danger”? through night? Number of hours of TV
soda each day? Use defecation? Does child wear a helmet Any nightmares/night watched a day? Type
food as reward? Does Bedwetting? when riding a bicycle? terrors? of programs watched?
child still use sippy Is child aware of street safety? Exposure to media
cup? How much time Water safety? violence or sexuality?
spent a day watching Animal safety? Type of discipline?
TV? Does the child Has child been taught about Any smokers/substance
get at least 30 min of “good touch/bad touch”? abusers in the home?
exercise a day? Guns in the home? Any domestic violence?
Does child brush teeth
at least twice a day?
Visit dentist? Does
child suck thumb?
School-aged Typical meals? Type of Problems with Is child in booster seat if Consistent bedtime? Family relationships? See social
child snacks? urination or ⬍80 lbs? Does child always Nightmares? Any smokers or assessments.
Does child eat breakfast defecation? wear a seatbelt? Does child sleep substance abusers in the
each day? Bedwetting (WNL until Is child aware of “stranger through night? home? Any domestic
Amount of juice or 6 yrs)? danger”? violence?
soda each day? Use Rushes to bathroom Does child wear a helmet Peer relationships?
food as reward? How when returns home when riding a bicycle? Does child have a best
much time spent a day from school (may Is child aware of street safety? friend?
watching TV, browsing indicate bullying at Water safety? Type of discipline?
the Internet, or playing school)? Animal safety? Reports of bullying? How
video games? Does the UTIs/constipation (may Has child been taught about does child handle anger?
child get at least 30 indicate bullying at “good touch/bad touch”? School performance?
min of exercise a day? school) (Governo & Guns in the home? Homework issues?
Does child brush teeth Siewers, 2008)? Learning disabilities?
at least twice a day? School failure or refusal?
Visit dentist? School phobia?
Involved in
extracurricular activities?
(continued)
165
TABLE 9-1
166
Age-Specific Well-Child History Assessments (Continued)
GROWTH &
Adolescents Typical meals? Chronic diarrhea, Does teen always wear a Bedtime? Hour of Who lives in home? See social
Fast food or soda intake which may indicate seatbelt? Does teen smoke, waking? How are these people assessments
a day? laxative intake? use drugs, drink alcohol, Difficulty falling related?
Meal skipping, fad Rushes to bathroom or engage in risk-taking asleep? Difficulty Recent changes in
diets, or eating when returns home behaviors, such as fast waking up for school? family? Any smokers or
disorders? from school, which driving? Falling asleep in class? substance abusers in the
Recent change in may indicate bullying Is the teen involved with Does teen nap home? Any domestic
appetite? How much at school? Internet activities that could each day? May violence?
time spent a day UTIs or constipation, be unsafe? Any guns in the need evaluation for How is school going?
watching TV, browsing which may indicate home? depression, substance Does teen have friends?
the Internet, or playing bullying at school abuse, or sleep cycle What does teen do for
video games? Does the (Governo & Siewers, disorder if teen naps fun? How does teen
teen get at least 30 min 2008)? UTIs may also for ⬎3 hours each day) handle anger?
of exercise a day? indicate STIs. (Reitman, 2007). Bullying?
School phobia?
Learning disabilities?
ADHD?
Recent changes in teen’s
academic progress?
Difficulty with
homework?
Teen skipping classes?
Life plan and goals?
Do academic abilities
match grades?
Reports of interpersonal
violence or gang
involvement? Is teen
sexually active? Does
teen use condoms?
Evidence of depression
or risk-taking behaviors?
Changes in relationships
with others?
Thoughts of hurting
him or herself? Hurting
others?
ADHD, attention deficit hyperactivity disorder; ER, emergency room; STIs, sexually transmitted infections; UTIs, urinary tract infections; WNL, within normal limits.
pregnancy. This must be done in a sensitive, private,

BOX 9-2
and confidential manner; Chapter 20 discusses these
Risk Factors for Child assessments in detail.
Behavioral and Mental Health
Problems
Identifying Parent and Child Concerns
• Chronic medical illness An essential component of the pediatric health super-
• Poverty vision visit is soliciting concerns of the parents or child
• Homelessness at the beginning of the encounter. This is a vital part
• Exposure to domestic violence of developing a meaningful relationship with the child
• Maternal depression and family, recognizing that they are the experts on
their own health. This enhanced communication fos-
• Parental separation or divorce
ters a strong provider–child–family relationship, the
• Substance abuse in family member
goal of which is to promote health and prevent illness
• Chronic physical or mental illness in family member
and injury.
• Parental knowledge deficits
• Child social skills deficits
Physical Examination
• School failure
At each health supervision visit, an essential compo-
• Learning disability
nent is the complete, head-to-toe physical examination.
Depending on the child’s age, the provider must be
Source: Ollendick, T. H., & Hersen, M. (1998). Handbook of child certain to focus on specific areas in the physical assess-
psychopathology. (3rd ed). New York: Plenum Press. ment. These age-specific areas are listed in Table 9-2
(see Chapter 8 for details about the pediatric physical
examination).
Other assessments include questions about feeding
practices, such as bottle-propping (i.e., if the infant is
placed in bed with a bottle containing milk or sweet- Developmental Surveillance and
ened drinks), if the child has a “companion” bottle Behavioral Assessment
or sippy cup that is carried throughout the day, and Developmental and behavioral assessment encomp-
if the companion bottle contains sweetened drinks. asses developmental surveillance, psychosocial/behavioral
The provider also asks about the child’s oral care rou- assessment, developmental screening, and autism screen-
tine, which should begin in infancy, including ques- ing (Hagan, Shaw, & Duncan, 2008). Developmental
tions about whether the older child brushes his or her surveillance and psychosocial/behavioral assessment
teeth at least twice a day. The assessments conducted should occur at every health maintenance visit in
at these visits help the provider determine the level of partnership with the parent. More frequent assess-
risk to the child’s oral health and the level of parental ments may be needed between health maintenance
education that is needed. visits if the parent raises a concern. These assessments
The provider should ask parents and children must be done by an experienced pediatric health care
school-aged and older about the use of sunscreen, par- provider, preferably one who sees the child regularly
ticularly in the summer and with prolonged exposure to have an ongoing perspective of the child’s develop-
to the sun in winter, as with skiing or any other out- ment. Formal developmental screening is conducted,
door sport. The provider also asks if the child is kept using a standardized developmental evaluation tool
out of the sun during peak intensity or if the child (see Chapter 2, Table 2-4); this takes place at the 9-
wears protective clothing or a hat during prolonged month, 18-month, and 30-month health mainte-
sun exposure (see Chapter 7). nance visits. Autism screening occurs at the 18-month
During each health supervision visit, the provider and 24-month well-child visit in all children or when
asks if the child is exposed to environmental tobacco the parent expresses a concern (Gupta, Hyman, &
smoke (ETS) in the form of secondhand cigarette or Johnson, 2007). This is done by evaluating behavioral
cigar smoke in the home, car, or homes of extended symptoms, using the criteria for autism spectrum dis-
family, friends, or child care providers. The child’s so- orders outlined in the Diagnostic and Statistical Manual
cial situation can change between health supervision of Mental Disorders, 4th edition, text revision (DSM-
visits, so this must be reassessed at each visit. When IV-TR) or by using one of the autism screening tools
the parent is out of the room, preteens and adolescents listed in Chapter 2, Table 2-4 (Cole, 2008).
are screened for tobacco use. Screening for drug and alcohol use is an important
Adolescents, and in some cases preadolescents, are part of behavioral assessment in the adolescent. Bright
asked about sexual activity. All adolescent girls who Futures recommends that teens be asked about alcohol
report a late menstrual period, amenorrhea, or sexual or drug use at all visits beginning at age 11 and sug-
activity without contraception should be tested for gests screening by asking the questions, “Have you
TABLE 9-2
Focus of Physical Examination by Age Health Supervision Visit
AGE ASSESSMENT AREAS AGE ASSESSMENT AREAS
Newborn • Length, weight, head circumference 6 months • Length, weight, weight-for-length,
• Maturity head circumference
• Cranial molding, birth trauma • Symmetrical pupillary light reflex
• Skin lesions, jaundice • Skin
• Fontanelles • Skull (positional plagiocephaly)
• Umbilical cord • Conjugate gaze
• Congenital anomalies • Red reflex
• Red reflex • Ocular mobility
• Placement of ears • Responds to sounds
• Dysmorphic features • Cardiac murmurs
• Cardiac murmurs • Femoral pulses
• Femoral pulses • Muscle tone
• Genitalia; descent of testes • Parachute reflex
• Hips, feet, spine • Grasp, transfer
• Grasp, suck, walk, Moro reflexes; • Hip abduction
muscle tone • Teeth
• Genitalia/testes
3 to 5 days • As newborn visit plus: 9 months • Same as 6-month visit

• Assess for dacryocystitis
2 to 4 weeks • Length, weight, head circumference 12 months • Length, weight, weight-for-length,

• Congenital anomalies head circumference
• Red reflex • Symmetrical pupillary light reflex
• Blink reflex • Conjugate gaze
• Reacts to sound • Cover/uncover test
• Cardiac murmurs • Check teeth for caries
• Assess abdomen for masses • Red reflex
• Hips, tibial torsion, metatarsus • Hips
adductus • Gait
• Genitalia • Testes
• Grasp, suck, walk, Moro reflexes
2 months • Length, weight, weight-for-length, 15 months • Length, weight, weight-for-length,

head circumference head circumference
• Congenital anomalies • Symmetrical pupillary light reflex
• Skull (positional plagiocephaly) • Conjugate gaze
• Skin • Cover/uncover test
• Cardiac murmurs • Teeth
• Red reflex; pupils • Gait
• Reacts to sound • Hips
• Hips
• Genitalia
• Grasp, suck, Moro reflexes
• Tone
4 months • Length, weight, weight-for-length, 18 months • Length, weight, weight-for-length,

head circumference head circumference
• Skull (positional plagiocephaly) • Cover/uncover test
• Skin • Red reflex
• Red reflex, pupils • Conjugate gaze
• Symmetrical pupillary light reflex • Hips
• Cardiac murmurs • Gait
• Femoral pulses
• Hip click
• Metatarsus adductus
• Muscle tone
AGE ASSESSMENT AREAS AGE ASSESSMENT AREAS

24 months • Standing height, weight, weight-for- 8 years • Same as 7-year visit
height, head circumference, BMI
• Red reflex
• Cover/uncover test
• Conjugate gaze
• Teeth
• Gait
• Speech
30 months • Standing height, weight, weight-for- 9 years • Height, weight

height, head circumference • BMI
• BMI • Blood pressure
• Red reflex • Skin (abuse, tattoos, piercings)
• Cover/uncover test • Forward bending test
• Conjugate gaze • Sexual maturity rating
• Coordination
• Speech
3 years • Height, weight 10 years • Same as 9-year visit

• BMI
• Blood pressure
• Funduscopic examination
• Speech
• Teeth
4 years • Height, weight 11 to 14 years • Height, weight

• BMI • BMI
• Blood pressure • Blood pressure
• Gait • Skin (acanthosis nigricans, acne,
• Fine motor skills tattoos, piercings, abuse, self-injury)
• Speech • Breasts (female: sexual maturity
rating; male: gynecomastia)
• Genitalia (female: sexual maturity
rating, inspect for evidence of STI;
perform pelvic exam based on sexual
history [see Chapter 20]; male: sexual
maturity rating, inspect for evidence of
STI, examine testicles for hydroceles,
hernias, varicocele, or masses)
• Forward bending test
5 years • Height, weight 15–17 years • Same as 11–14-year visit

• BMI
• Blood pressure
• Funduscopic examination
• Teeth
• Fine motor skills
• Gait
• Speech
6 years • Same as 5-year visit 18–21 years • Same as 11–14-year visit; clinical
breast exam should be performed on
all girls after 20 years of age
7 years • Height, weight

• BMI
• Blood pressure
• Hips, knees, gait
• Teeth
• Sexual maturity rating
BMI, body mass index; STI, sexually transmitted infection.

Source: Hagan, J. F., Shaw, J. S., & Duncan, P. M. (Eds). (2008). Bright futures guidelines for health supervision of infants, children and adolescents.
(3rd ed.). Elk Grove Village, IL: American Academy of Pediatrics.
ever had an alcoholic drink?” and “Have you ever used disorders and hemoglobinopathies most often occurs
marijuana or any other drug to get high?” (Levy & before the neonate is discharged from the hospital af-
Knight, 2003) and following any affirmative responses ter birth, but no later than 1 week of age if the child
with a drug- or alcohol-screening tool. One such tool was born at home or remains hospitalized in the neo-
that is developmentally appropriate for adolescents natal intensive care unit (NICU). A normal result must
and has been used in the primary care setting with be documented by 2 months at the latest; abnormal
demonstrated validity is the CRAFFT Screening Test, a results require retesting and referrals to the appropri-
six-item screening tool similar to the CAGE assessment ate pediatric subspecialist (Kaye, 2006).
tool used in adults (Knight, Sherritt, Shrier, Harris, &
Chang, 2002). A positive response to two or more of Measurements. At each health supervision visit,
the six items in this test suggests a problem with drugs length or height and weight are measured; the head
or alcohol and requires immediate action. circumference is also obtained on children 2 and younger
(AAP, 2007). Weight-for-length is obtained on children
Observation of Parent–Child Interaction 18 months and younger and, beginning at 2 years, a
The provider observes the quality of physical care, pa- standing height is obtained. Beginning at 2 years, the
rental nurturing, and developmental stimulation that standing height and weight are used to calculate the
the child receives. Observations of parent–child inter- body mass index (BMI). All measurements are then plot-
action are specific to the child’s age and developmen- ted on the age- and sex-appropriate percentile charts
tal level. Examples include observing whether: (a) the (see Appendix B). Blood pressure is measured as part
parent recognizes and responds to the infant’s needs, of routine health screening beginning at 3 years. In-
(b) the parent talks to the child, (c) the parent and fants and children younger than 3 who have acute
child treat each other respectfully, and (d) the parent or chronic conditions that may affect blood pressure
has behavioral expectations for the child that are de- should have their blood pressure measured (Nation-
velopmentally appropriate. al High Blood Pressure Education Program Working
Group on High Blood Pressure in Children and Ado-
lescents, 2004). See Chapter 8 for a detailed discussion
Health Screening of blood pressure and anthropometric measurements
Bright Futures: Guidelines for Health Supervision of In- in children and Chapter 10 for a discussion of calcu-
fants, Children and Adolescents (3rd ed.) has published lating the BMI in children.
recommendations for health screening in children,
from birth to age 21, which are evidence-based and Hearing. It is important to identify hearing loss in a
were extensively reviewed by experts (Hagan, Shaw, young child because of the consequences of delayed
& Duncan, 2008). These screening recommendations language acquisition in children with auditory deficits.
form the basis for the 2007 American Academy of Pe- It is best to identify hearing loss before 3 months; this is
diatrics (AAP) Recommendations for Preventive Pediatric achieved through universal newborn screening through
Health Care (AAP, 2007). Conduction of health screen- auditory brainstem response (ABR) (see Chapter 14).
ing is based on these recommendations and on risk Universal objective hearing screening should take place
assessment for selective screening. again at the 4-year, 5-year, 6-year, 8-year, and 10-year
visits. At all other health maintenance visits, subjective
Newborn Metabolic and Hemoglobinopathy assessment is conducted by eliciting parental concerns
Screening. Newborn screening for metabolic disor- about the child’s speech or hearing; conducting devel-
ders and hemoglobinopathies is critical to diagnosing opmental surveillance, including speech and auditory
these conditions in a timely manner and beginning skills; and reviewing middle-ear status, according to the
referral, disease management, and genetic counsel- American Academy of Pediatrics (AAP) pediatric peri-
ing as needed (Kaye, 2006). The conditions for which odicity schedule (AAP, 2007a). If the risk assessment is
newborns are screened vary from state to state; each positive, appropriate referrals are made for diagnostic
pediatric health care provider should become familiar audiologic assessment.
with the conditions for which his or her population
is screened. There are 29 primary conditions and 25 Vision and Eye Exams. Age-appropriate eye examina-
secondary conditions currently identifiable through tions are essential beginning at birth. Various clinical
newborn screening. Examples of primary conditions assessments, as well as objective visual acuity measure-
include biotinidase deficiency, congenital adrenal hy- ments detect eye and vision problems so that appropri-
perplasia, congenital hypothyroidism, cystic fibrosis, ate referral and treatment are initiated. Evaluation of
galactosemia, homocystinuria, maple syrup urine dis- vision begins with an ocular history, obtained from the
ease, medium-chain acyl-coenzyme A dehydrogenase parent (see Chapter 15). From birth to 9 months, the
deficiency, phenylketonuria, sickle cell disease and provider assesses children for eye problems according
other hemoglobinopathies, and tyrosinemia (Tarini to the recommendations in Bright Futures Guidelines,
& Freed, 2007). Newborn screening for metabolic 3rd ed. Beginning at the 12-month visit through the
30-month visit, the provider assesses both pupils for the

BOX 9-3
red reflex, performs the cover/uncover test, and tests for
Assessing Risk of Lead
ocular mobility (see Chapter 15). An age-appropriate
objective vision examination is added (see Chapter 15),
Poisoning in Asymptomatic
along with ophthalmoscopic examination of the optic Children
nerve and retinal vessels at the 3-year (if the child is co- Does your child:
operative), 4-year, 5-year, 6-year, 8-year, 10-year health
• Live in or regularly visit a house or child care facility
supervision visit, and once during early adolescence built before 1950?
(11–14 years), middle adolescence (15–17 years), and
• Live in or regularly visit a house or child care facility
late adolescence (18–21 years). This vision screening is built before 1978 that has been renovated or
also performed any time the children, parents, or teach- remodeled within the last 6 months?
ers express concern about vision (AAP, 2007b). • Have a sibling or playmate who has had lead poisoning?
Hematocrit or Hemoglobin. The purpose of obtain-

Source: American Academy of Pediatrics, Committee on Environmental
ing a hemoglobin or hematocrit is to screen for ane- Health. (2009). Screening for elevated blood lead levels. Pediatrics,
mia, most commonly iron-deficiency anemia (Lee & 116(4), 1036–1046.
Truman, 2005), although hemoglobinopathies, such as
sickle cell disease and thalassemia, also cause anemia in listed in Box 9-3. Because most children with lead poi-
children. Premature or low-birth-weight infants, term soning are asymptomatic, universal blood lead screen-
infants older than 6 months, infants who consume ing is conducted at 12 months and 24 months of age,
non–iron-fortified or low-iron formula, infants who regardless of risk, but especially for children who meet
are given cow’s milk before 12 months of age, children high-risk criteria or those on Medicaid. Then screen-
who adhere to a strict vegetarian diet (without iron ing assessment is conducted at the 6-month, 9-month,
supplements), menstruating girls, and children living 12-month, 18-month, 2-year, 3-year, 4-year, 5-year,
in poverty are at risk for iron-deficiency anemia. The and 6-year visits. Some states require that all children
AAP (2007) recommends that infants and children be receive lead screening regardless of type of insurance.
screened for anemia, depending on these risk factors;
however, anemia screening should be done univer- Tuberculosis Screening. Tuberculosis (TB) has a dif-
sally at 12 months. Anemia screening should also be ferent presentation in children than in adults, espe-
done on all preterm and low-birth-weight infants and cially in children 4 and younger. These children have
those who are fed non–iron-fortified or low-iron for- a higher incidence of converting from TB infection to
mula at the 4-month visit. At the 18-month, 2-year, TB disease because of their immature immune systems
3-year, 4-year, and 5-year visits, and all annual health (Selekman, 2006). However, children 12 and younger
maintenance visits until 21 years of age, the provider with active pulmonary TB are rarely infectious because
conducts an anemia risk assessment by investigating they do not produce sputum, have fewer pulmonary
whether any of the above risk factors are present and, tubercle bacilli, and lack the force necessary to expel
if so, conducts anemia screening. Specific questions these bacilli through coughing (AAP, 2009a). In chil-
about excessive bleeding in menstruating girls are in- dren, TB screening is selective, based on a risk assess-
cluded in this screening, and adolescents who report a ment protocol called “targeted testing,” which aims to
history of extensive blood loss are screened for anemia identify children at high risk for contracting TB (Pedi-
(Wu, Lesperance, & Bernstein, 2002). atric Tuberculosis Collaborative Group, 2004). This risk
is determined by asking the parent the screening ques-
Lead Screening. Lead poisoning is one of the most tions listed in Box 9-4; this assessment should occur
prevalent pediatric health problems in the United at the 1-month, 6-month, 12-month, and 18-month
States (Marcus, 2007). The most common sources of visits, then annually from 2 years to 21 years. Children
lead exposure in the United States are lead-based paint with a positive screen should be tested for TB using the
in older homes, household dust, contaminated soil and Mantoux tuberculin skin test. Children infected with
drinking water, lead crystal, and lead-glazed ceramics HIV and incarcerated adolescents should also receive
and pottery (Marcus, 2007). Young children are espe- an annual tuberculin skin test (AAP, 2009a).
cially vulnerable to lead poisoning because their bod-
ies absorb lead more readily because of their greater Dyslipidemia. The current epidemic of childhood
intake of dietary fat and, in some cases, decreased in- obesity contributes to the risk for hyperlipidemia in
take of calcium and iron. Lead damages heme synthe- children, an important risk factor for coronary artery
sis, causing a decreased number of red blood cells and disease as they grow into adulthood. In 2008, the AAP
hemoglobin, resulting in anemia. High lead levels in published revised guidelines for lipid screening in chil-
children can also cause central nervous system toxicity dren (Daniels, Greer, & AAP Committee on Nutrition,
and renal failure. A lead risk assessment is conducted 2008). The first lipid screening should take place af-
by using a questionnaire; appropriate questions are ter age 2, but no later than age 10, in the context of
at the 85th percentile or higher, even without any other

BOX 9-4
risk factors (Barlow & the Expert Committee, 2007).
Tuberculosis Risk Assessment
Questionnaire Sexually Transmitted Infections. All sexually active
youth should be screened annually for Chlamydia tra-
• Has a family member or close contact had
tuberculosis? chomatis; even asymptomatic males and females who
report the use of barrier protection should be screened
• Has a family member had a positive tuberculin skin test?
(AAP, 2009a). An annual screen for gonorrhea should
• Was your child born in a high-risk country (i.e.,
be done on all sexually active youth as well (U.S. Pre-
countries other than the United States, Canada,
Australia, New Zealand, or those in Western Europe)? ventive Services Task Force [USPSTF], 2005). A hu-
man immunodeficiency virus (HIV) screen should be
• Has your child traveled to or been in contact with any
person from a high-risk country for more than 1 week? obtained based on a positive risk assessment, using
a screening questionnaire. Risk factors include past
or present injection drug use, males who have sex
Source: American Academy of Pediatrics. (2009a). Tuberculosis. In
Pickering, L. K., Baker, C. J., Kimberlin, D. W., & Long, S. S. (Eds). Red
with males, males and females who have unprotected
Book: 2009 report of the Committee on Infectious Diseases. (28th ed.). sex with multiple partners, males and females who
(pp. 680–701). Elk Grove Village, IL: American Academy of Pediatrics. exchange sex for money or drugs or have sex with
partners who do; anyone being treated for a sexually
the health supervision visit. Criteria to screen these transmitted infection (STI), anyone being treated in
children are listed in Box 9-5. Overweight and obese a high-prevalence clinical setting (e.g., STI clinics,
children require dyslipidemia screening irrespective of correctional facilities, homeless shelters, TB clin-
family history or other risk factors. ics, clinics that serve males who have sex with other
Screening children for dyslipidemia consists of ob- males, and adolescent health clinics that have a high
taining a fasting lipid profile (i.e., total cholesterol, low- prevalence of STIs), or anyone who requests an HIV
density lipoprotein [LDL], high-density lipoprotein test (USPSTF, 2007). In 2006, the Centers for Disease
[HDL], and triglyceride). Only the total cholesterol and Control and Prevention (CDC) recommended that all
HDL yield usable results if a nonfasting sample is ob- persons aged 13–64 be routinely screened for HIV un-
tained (Hagan, Shaw, & Duncan, 2008). If values are less the prevalence of HIV infection in the patient’s
within normal limits on initial screening, a fasting lipid demographic population is documented to be less
profile should be repeated in 3–5 years (Daniels, Greer, than 1 per 1000 patients screened (CDC, 2006). The
& AAP Committee on Nutrition, 2008). USPSTF recommends selective screening for syphilis
The AAP recommends universal screening for dyslipid- for commercial sex workers, persons who exchange
emia at one health maintenance visit in late adolescence. sex for drugs, those who live in a correctional facility,
All adults 20 and older should have a fasting lipid pro- and males who have sex with other males and engage
file every 5 years (Grundy, Cleeman, Bairey Merz, Brewer, in high-risk sexual behavior (USPSTF, 2004).
Clark, Hunninghake, et al., 2004). Other populations of
children who should be screened include those with a BMI Cervical Dysplasia. The USPSTF highly recommends
annual screening for cervical cancer in females who
are sexually active and have a cervix, with screening
BOX 9-5 via cervical cytology (Pap smear) beginning 3 years
Criteria for Lipid Screening in after the onset of sexual activity, or at age 21, which-
Children ever comes first (USPSTF, 2003).
Targeted lipid screening in children includes children Immunization Status. At every pediatric health care
and adolescents with: encounter, the health care provider reviews the child or
• Positive family history of dyslipidemia or premature adolescent’s immunization status and updates any im-
(ⱕ55 years of age for men and ⱕ65 years of age for munizations as necessary. A schedule of recommended
women), cardiovascular disease, or dyslipidemia immunizations is published annually by the AAP Com-
• Unknown family history mittee on Infectious Disease (ACIP). A current sched-
• Overweight (BMI ⱖ85th percentile, ⬍95th percentile) ule of immunizations for children can be found on the
• Obesity (BMI ⱖ95th percentile) CDC/ACIP or AAP web sites (see Additional Resources).
• Hypertension (blood pressure ⱖ95th percentile)
• Cigarette smoking Anticipatory Guidance. Anticipatory guidance is
• Diabetes mellitus
provided at each well-child, health supervision visit.
It educates the parents or caregivers about their child’s
next stage of development so that they know what to
Source: Daniels, S. R., & Greer, F. R. and the American Academy
of Pediatrics, Committee on Nutrition. (2008). Lipid screening and expect. Examples include teaching safety related to the
cardiovascular health in childhood. Pediatrics, 122(1), 198–208. mobility of a curious toddler or an adolescent who has
just learned to drive, nutrition for the physiologically

BOX 9-6
anorexic toddler, sleep position for the newborn and
High-Risk Behaviors to Assess
infant, toilet-training challenges, a school-aged child’s
adjustment to his or her parent’s divorce, or speech
With the Preparticipation
and language abilities in the bilingual child. Specific Sports Examination
educational topics are based on the assessment find- • Alcohol use
ings obtained during the history, physical examina- • Substance abuse
tion, developmental assessment, and health screening.
• Driving while intoxicated
All teaching must be in the family’s language and be
• Lack of seat belt use
culturally appropriate. Written materials must be at an
appropriate literacy level for the parent or caregiver. • Reckless driving
• Steroid and other performance-enhancing drug use
• Smoking
• Unprotected sexual activity
THE PREPARTICIPATION SPORTS
EXAMINATION
The preparticipation sports examination (PPE) is a
common reason that school-aged children and adoles-
cents seek primary health care. In some instances, the
sports physical may be the child’s only contact with a
BOX 9-7
health care provider. For this reason, it is important for American Heart Association’s
the pediatric health care provider to be sure that the Recommendations for
child and parent are aware that the PPE is not a sub- Preparticipation Cardiovascular
stitute for a pediatric health supervision visit, as the Screening
focus is on screening the child or adolescent’s risk for
injury, illness, or sudden death as a result of the child’s FAMILY HISTORY
participation in a particular sport. The provider should • Premature, sudden cardiac death before age 50
take the opportunity during the PPE to evaluate the because of heart disease in more than one
child’s overall health and to discuss high-risk behav- relative
iors (Box 9-6) (McCarthy, 2006). • Heart disease with disability in close family member
before age 50
• Confirmed family history of hypertrophic or dilated
HISTORY cardiomyopathy, long Q-T syndrome or other
The PPE begins with a thorough history. Questions ion channelopathies, Marfan syndrome, or other
should focus on a positive child or family history of cer- concerning arrhythmias
tain medical conditions that can affect the child’s sports
PERSONAL HISTORY
participation, as well as current illnesses, infections, or
conditions that would preclude sports participation. • Diagnosed heart murmur
Preparticipation cardiovascular screening is especially • Exertional chest pain or discomfort
important to determining the risk for sudden cardiac • Unexplained syncope or near syncope
death. The most common causes of sudden cardiac (non-neurocardiogenic)
death in athletes are hypertrophic cardiomyopathy, • Unexplained dyspnea or fatigue, associated with
structural coronary anomalies, Marfan syndrome, con- exercise
genital anomalies of the coronary arteries, atherosclerot- • Systemic hypertension
ic coronary disease, and myocarditis (McCarthy, 2006).
The family history is an essential portion of the cardi- PHYSICAL EXAMINATION
ac history, as many of these conditions are inherited. • Heart murmur (evaluated supine and standing)
Box 9-7 summarizes the American Heart Association’s • Bilateral femoral pulse assessment to exclude
recommendations for preparticipation cardiovascular coarctation of the aorta
screening of competitive athletes (Maron, Thompson, • Inspect for stigmata of Marfan syndrome
Ackerman, Balady, Berger, Cohen, et al., 2007).
• Brachial blood pressure measurement while sitting,
Additional questions focus on neurologic, respira- preferably in both arms
tory, integumentary, genitourinary, or musculoskeletal
problems. The health history and physical examina-
tion form used by the Ohio High School Athletic As- Source: Maron, B. J., Thompson, P. D., Ackerman, M. J., et al. (2007).
Recommendations and considerations related to pre-participation
sociation (2008) provides a comprehensive history for screening for cardiovascular abnormalities in competitive athletes: 2007
the preparticipation examination (Fig. 9-1). update. Circulation, 115(12), 164.
Ohio High School Athletic Association

Preparticipation Physical Evaluation
DATE OF EXAM:______________________________ Page 1 of 4
Name ___________________________________________________ Sex ___________ Age _______ Date of Birth ____________________________
Grade______ School ____________________ Sport(s) ______________________________________________________________________________
Address ______________________________________________________________________________ Phone ________________________________
Personal Physician____________________________________________________________________________________________________________
In case of emergency, contact: Name ________________________Relationship ________________
Phone (H) __________________(W)_____________________(Cell)_____________________(Cell)__________________________
History
This section is to be carefully completed by the student and his/her parent(s) or legal guardian(s) before participation in interscholastic athletics in
order to help detect possible risks.
Explain "YES" answers in the space provided. Circle Yes No

questions you don't know the answer to. 25. Do you cough, wheeze, or have difficulty breathing during or after exercise?
26. Is there anyone in your family who has asthma?
1. Has a doctor ever denied or restricted your participation in Yes No 27. Have you ever used an inhaler or taken asthma medicine?
sports for any reason? 28. Were you born without or are you missing a kidney, an eye, a testicle, or
2. Do you have an ongoing medical condition (like diabetes or asthma)? any other organ?
3. Are you currently taking any prescription or nonprescription 29. Have you had infectious mononucleosis (mono) within the last month?
(over-the-counter) medicines or pills? 30. Do you have any rashes, pressure sores, or other skin problems?
4. Do you have allergies to medicines, pollens, foods, or stinging insects? 31. Have you had a herpes skin infection?
5. Do you think you are in good health? 32. Have you ever had a head injury or concussion?
6. Have you ever passed out or nearly passed out DURING exercise? 33. Have you been hit in the head and been confused or lost your memory?
7. Have you ever passed out or nearly passed out AFTER exercise? 34. Have you ever had a seizure?
8. Have you ever had discomfort, pain, or pressure in your chest 35. Do you have headaches with exercise?
during exercise? 36. Have you ever had numbness, tingling, or weakness in your arms or
9. Does your heart race or skip beats during exercise? legs after being hit or falling?
10. Has a doctor ever told you that you have (check all that apply): 37. Have you ever been unable to move your arms or legs after being hit or
High Blood Pressure A heart murmur falling?
High Cholesterol A heart infection 38. When exercising in the heat, do you have severe muscle cramps or
11. Has a doctor ever ordered a test for your heart? (for become ill?
example, ECG, echocardiogram) 39. Has a doctor told you that you or someone in your family has sickle cell
12. Has anyone in your family died for no apparent reason? trait or sickle cell disease?
13. Does anyone in your family have a heart problem? 40. Have you had any problems with your eyes or vision?
14. Has any family member or relative died of heart problems or 41. Do you wear glasses or contact lenses?
of sudden death before age 50? 42. Do you wear protective eyewear, such as goggles or a face shield?
15. Does anyone in your family have Marfan syndrome? 43. Are you happy with your weight?
16. Have you ever spent the night in a hospital? 44. Are you trying to gain or lose weight?
17. Have you ever had surgery? 45. Has anyone recommended you change your weight or eating habits?
18. Have you ever had an injury, like a sprain, muscle or ligament 46. Do you limit or carefully control what you eat?
tear, or tendinitis, that caused you to miss a practice or 47. Do you have any concerns that you would like to discuss with a doctor?
game? If yes, circle affected area below: FEMALES ONLY
19. Have you had any broken or fractured bones or dislocated 48. Have you ever had a menstrual period?
joints? If yes, circle below: 49. How old were you when you had your first menstrual period?
20. 50. How many periods have you had in the last 12 months?
Have you had a bone or joint injury that required x-rays, MRI,
CT, surgery, injections, rehabilitation, physical therapy, a
brace, a cast, or crutches? If yes, circle below: Explain "Yes" Answers Here: (Attach additional sheets as needed)
Upper Hand /
Head Neck Shoulder Arm Elbow Forearm Fingers Chest
Upper Lower Foot /
back back Hip Thigh Knee Calf/shin Ankle Toes
21. Have you ever had a stress fracture?

22. Have you been told that you have or have you had an x-ray
for atlantoaxial (neck) instability?
23. Do you regularly use a brace or assistive device?
24. Has a doctor ever told you that you have asthma or allergies?
I (we) hereby state, to the best of my (our) knowledge, my (our) answers to the above questions are complete and correct.
Signature: Signature: Date: ______________
Athlete Parent or Guardian (If athlete is under 18)
The student has family insurance Yes No; If yes, family insurance company name and policy number: ________________________________________________
NOTE: CONSENT AND HIPAA RELEASE FORMS THAT MUST BE SIGNED BY BOTH THE PARENT AND THE STUDENT ARE ON A SEPARATE SHEET.
NOTE: HISTORY AND ALL CONSENT FORMS MUST BE COMPLETED PRIOR TO PHYSICAL EXAMINATION
Modified from American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American
Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine, 2004. Rev. 03/06
FIGURE 9-1. Preparticipation physical examination form. (Source: Ohio High School Athletic Association.
Preparticipation physical examination. Retrieved November 7, 2009, from http://www.ohsaa.org/
medicine/PPE.pdf, with permission.) (continued)
Page 2 of 4
Physical Examination Form
The section below is to be completed by physician or staff after history and consent forms are completed.
Student’s Name____________________________________________ Birth Date______________________________________
Height______ Weight_________ % Body Fat (optional)_________ Pulse_______ BP______/______, ______/______, ______/_____
Vision R 20/ __________ L 20/ __________ Corrected: Y N Pupils: Equal ________ Unequal _______
Follow-Up Questions on More Sensitive Issues (Optional)

1. Do you feel stressed out or under a lot of pressure?
2. Do you ever feel so sad or hopeless that you stop doing some of your usual activities for more than a few days?
3. Do you feel safe?
4. Have you ever tried cigarette smoking, even 1 or 2 puffs? Do you currently smoke?
5. During the past 30 days, did you use chewing tobacco, snuff, or dip?
6. During the past 30 days, have you had at least 1 drink of alcohol?
7. Have you ever taken steroid pills or shots without a doctor's prescription?
8. Have you ever taken any supplements to help you gain or lose weight or improve your performance?
9. Questions from the Youth Risk Behavior Survey (http://www.cdc.gov/HealthyYouth/yrbs/index.htm) on guns, seatbelts, unprotected sex, domestic violence, drugs, etc.
Notes:
MEDICAL Normal Abnormal findings Initials*

Appearance
Eyes/ears/nose/throat
Hearing
Lymph nodes
Heart
Murmurs
Pulses
Lungs
Abdomen
Genitalia (males only)
Skin
MUSCULOSKELETAL
Neck
Back
Shoulder/arm
Elbow/forearm
Wrist/hand/fingers
Hip/thigh
Knee
Leg/ankle
Foot/toes
*Multiple-examiner set-up only.
Notes:
Clearance
Cleared without restriction
Cleared, with recommendations for further evaluation or treatment for:
Not cleared for: All Sports Certain sports: Reason:

Recommendations:
Emergency Information:
Allergies:
Other Information:
Name of Physician: (print/type/stamp) (M.D., D.O., D.C.) Date:
If the Physician's Assistant (P.A.) or Advanced Nurse Practitioner (A.N.P.) performed the exam, name and address of collaborating physician or
physician group:
Address: Phone:
Signature of Physician:
Page 3 of 4
OHSAA AUTHORIZATION FORM
I hereby authorize the release and disclosure of the personal health information of _______________________________ ("Student"),
as described below, to ____________________________________ ("School").
The information described below may be released to the School principal or assistant principal, athletic director, coach, athletic trainer,
physical education teacher, school nurse or other member of the School's administrative staff as necessary to evaluate the Student's
eligibility to participate in school sponsored activities, including but not limited to interscholastic sports programs, physical education
classes or other classroom activities.
Personal health information of the Student which may be released and disclosed includes records of physical examinations performed
to determine the Student's eligibility to participate in school sponsored activities, including but not limited to the Pre-participation
Evaluation form or other similar document required by the School prior to determining eligibility of the Student to participate in
classroom or other School sponsored activities; records of the evaluation, diagnosis and treatment of injuries which the Student
incurred while engaging in school sponsored activities, including but not limited to practice sessions, training and competition; and other
records as necessary to determine the Student's physical fitness to participate in school sponsored activities.
The personal health information described above may be released or disclosed to the School by the Student's personal physician or
physicians; a physician or other health care professional retained by the School to perform physical examinations to determine the
Student's eligibility to participate in certain school sponsored activities or to provide treatment to students injured while participating in
such activities, whether or not such physicians or other health care professionals are paid for their services or volunteer their time to the
School; or any other EMT, hospital, physician or other health care professional who evaluates, diagnoses or treats an injury or other
condition incurred by the student while participating in school sponsored activities.
I understand that the School has requested this authorization to release or disclose the personal health information described above to
make certain decisions about the Student's health and ability to participate in certain school sponsored and classroom activities, and
that the School is a not a health care provider or health plan covered by federal HIPAA privacy regulations, and the information
described below may be redisclosed and may not continue to be protected by the federal HIPAA privacy regulations. I also understand
that the School is covered under the federal regulations that govern the privacy of educational records, and that the personal health
information disclosed under this authorization may be protected by those regulations.
I also understand that health care providers and health plans may not condition the provision of treatment or payment on the signing of
this authorization; however, the Student's participation in certain school sponsored activities may be conditioned on the signing of this
authorization.
I understand that I may revoke this authorization in writing at any time, except to the extent that action has been taken by a health care
provider in reliance on this authorization, by sending a written revocation to the school principal (or designee) whose name and address
appears below.
Name of Principal: ________________________________________________

School Address: ________________________________________________
This authorization will expire when the student is no longer enrolled as a student at the school.
NOTE: IF THE STUDENT IS UNDER 18 YEARS OF AGE, THIS AUTHORIZATION MUST BE SIGNED BY A PARENT OR
LEGAL GUARDIAN TO BE VALID. IF THE STUDENT IS 18 YEARS OF AGE OR OVER, THE STUDENT MUST SIGN THIS
AUTHORIZATION PERSONALLY.
____________________________________________________________________________________________________
Student’s Signature Birth date of Student, including year
____________________________________________________________________________________________________
Name of Student's personal representative, if applicable
I am the Student's (check one): _______ Parent _______ Legal Guardian (documentation must be provided)
____________________________________________________________________________________________________
Signature of Student's personal representative, if applicable Date
A copy of this signed form has been provided to the student or his/her personal representative
THE STUDENT SHALL NOT BE CLEARED TO PARTICIPATE IN INTERSCHOLASTIC ATHLETICS UNTIL THIS FORM HAS BEEN
SIGNED AND RETURNED TO THE SCHOOL
Page 4 of 4
2009-2010 Ohio High School Athletic Association Eligibility and Authorization Statement
This document is to be signed by the participant from an OHSAA member school and by the participant’s parent.
I have read, understand and acknowledge receipt of the OHSAA brochure entitled “Your Athletic Eligibility,”
which contains a summary of the eligibility rules of the Ohio High School Athletic Association. I understand that
a copy of the OHSAA Handbook is on file with the principal and athletic administrator and that I may review it,
in its entirety, if I so choose. All OHSAA bylaws and regulations from the Handbook are also posted on the
OHSAA web site at www.ohsaa.org.
I understand that an OHSAA member school must adhere to all rules and regulations that pertain to the
interscholastic athletics programs that the school sponsors, but that local rules may be more stringent than
OHSAA rules.
I understand that participation in interscholastic athletics is a privilege not a right.
Student Code of Responsibility
As a student athlete, I understand and accept the following responsibilities:

I will respect the rights and beliefs of others and will treat others with courtesy and consideration
I will be fully responsible for my own actions and the consequences of my actions
I will respect the property of others
I will respect and obey the rules of my school and laws of my community, state and country
I will show respect to those who are responsible for enforcing the rules of my school and the laws of
my community, state and country
I understand that a student whose character or conduct violates the school’s Athletic Code or School
Code of Responsibility is not in good standing and is ineligible for a period of time as determined by
the principal
Informed Consent – By its nature, participation in interscholastic athletics includes risk of injury and
transmission of infectious disease such as HIV and Hepatitis B. Although serious injuries are not common and the
risk of HIV transmission is almost nonexistent in supervised school athletic programs, it is impossible to eliminate
all risk. Participants have a responsibility to help reduce that risk. Participants must obey all safety rules, report all
physical and hygiene problems to their coaches, follow a proper conditioning program, and inspect their own
equipment daily. PARENTS, GUARDIANS OR STUDENTS WHO MAY NOT WISH TO ACCEPT RISK
DESCRIBED IN THIS WARNING SHOULD NOT SIGN THIS FORM. STUDENTS MAY NOT PARTICIPATE IN
AN OHSAA-SPONSORED SPORT WITHOUT THE STUDENT’S AND PARENT’S/GUARDIAN’S SIGNATURE.
I understand that in the case of injury or illness requiring transportation to a health care facility, that a
reasonable attempt will be made to contact the parent or guardian in the case of the student-athlete being a minor,
but that, if necessary, the student-athlete will be transported via ambulance to the nearest hospital.
To enable the OHSAA to determine whether the herein named student is eligible to participate in interscholastic
athletics in an OHSAA member school I consent to the release to the OHSAA any and all portions of school record
files, beginning with seventh grade, of the herein named student, specifically including, without limiting the
generality of the foregoing, birth and age records, name and residence address of parent(s)or guardian(s),
residence address of the student, academic work completed, grades received and attendance data.
I consent to the OHSAA’s use of the herein named student’s name, likeness, and athletic-related information in
reports of contests, promotional literature of the Association and other materials and releases related to
interscholastic athletics.
By signing this we acknowledge that we have read the above information and that we consent to the herein
named student’s participation.
*Must Be Signed Before Physical Examination
__________________________________________________________________________________________________________________
Student’s Signature Birth date Grade in School Date
__________________________________________________________________________________________________________________
Parent’s or Guardian’s Signature Date
Rev. 3/08
FIGURE 9-1. Preparticipation physical examination form. (Source: Ohio High School Athletic
Association. Preparticipation physical examination. Retrieved November 7, 2009 from http://www.
ohsaa.org/medicine/PPE.pdf, with permission.)
PHYSICAL EXAMINATION active sports include hypertrophic cardiomyopathy,

The physical examination for the PPE focuses on long QT interval syndrome, concussion, significant
assessing the cardiovascular, respiratory, and mus- knee injury, sickle cell disease, and uncontrolled sei-
culoskeletal systems and the paired organs. The zures (Kurowski & Chandran, 2000).
cardiovascular examination includes auscultation
with a focus on provocative maneuvers to screen for
hypertrophic cardiomyopathy. Other components
LABORATORY AND DIAGNOSTIC
of the physical examination include the 2-minute EXAMINATION
orthopedic screening examination, which involves In the absence of identified risk factors or positive
12 steps to evaluate musculoskeletal alignment, flex- findings on the history, specific screening tests such
ibility, and proprioception, all of which determine as electrocardiography, treadmill stress testing, and
musculoskeletal abnormalities and injury sequelae urinalysis are not indicated (Kurowski & Chandran,
(Table 9-3). Additional portions of the PPE are listed 2000). Menstruating females may need to be screened
in Table 9-4. Medical conditions that would limit or for iron-deficiency anemia. Urine drug screening or
preclude a child or adolescent from participating in HIV testing may be required, depending of the type of
TABLE 9-3
The 2-Minute Musculoskeletal Screening Examination
INSTRUCTION TO ATHLETE EXAMINATIONS AREA EVALUATED
Stand facing, then away from Examiner inspects symmetry of trunk Acromioclavicular joints; general
examiner, with arms at sides. and upper extremities. habitus
Look at ceiling and then the floor; Examiner observes forward flexion, Cervical spine motion
touch ears to shoulders. extension, rotation, and lateral flexion
of the neck.
Shrug shoulders. Examiner’s hands remain on athlete’s Trapezius strength

shoulders to provide resistance while
athlete shrugs shoulders.
Stretch both arms out at side 90 Examiner’s hands are placed on top Deltoid strength
degrees, then lift arms a few inches. of athlete’s forearms to resist shoulder
abduction.
Perform full internal and external Examiner observes internal and Range of motion in glenohumeral
rotation of arm external rotation of the athlete’s joint
shoulders.
Extend and flex elbow. Examiner observes elbow motion. Range of motion in elbow
With arms at sides, flex elbows 90 Examiner observes elbow and wrist Range of motion in elbow and wrist
degrees, and pronate and supinate motion.
palms.
Clench fists then spread fingers apart. Examiner observes hand and finger Range of motion in hands and fingers
motion, strength, and deformities
Stand with back to examiner; with Examiner observes for thoracic Scoliosis, hip motion, and hamstring
knees straight, and touch toes. curvature and shoulder and hip tightness
asymmetry.
Stand facing examiner and tighten, Examiner inspects lower extremities Symmetry, knee effusions, and ankle
then relax quadriceps. for alignment and symmetry. effusions
“Duck walk” four steps away and Examiner observes strength and Range of motion in hip, knee, and
toward examiner. balance. ankle
Rise onto toes, then lean back on Examiner observes strength and Calf symmetry; leg strength
heels. balance.
TABLE 9-4
Components of Preparticipation Physical Examination
AREA OF EXAMINATION COMMENTS
Blood pressure Results are compared to norm for child’s age, height, and sex.
General appearance Excessive height and excessive long-bone growth (i.e., arachnodactyly, arm span more
than height, pectus excavatum) suggest Marfan syndrome.
Eyes Vision defects that demonstrate at least one eye with ⬎20/40 corrected vision are
assessed. Lens subluxations, severe myopia, retinal detachments, and strabismus are
associated with Marfan syndrome.
Cardiovascular The point of maximal impulse is palpated for increased intensity, suggesting
hypertrophy and failure, respectively. With the patient supine and standing or straining
during Valsalva’s maneuver, the patient is auscultated. A diminished femoral pulse
suggests coarctation of the aorta.
Respiratory Accessory muscle use or prolonged expiration is inspected, and patient is auscultated for
wheezing. Exercise-induced asthma requires exercise testing for diagnosis.
Abdominal Examiner palpates for hepatic or splenic enlargement.
Genitourinary Examiner assesses for hernias, varicoceles, and testicular masses; these findings do not
usually preclude sports participation, but teen should be aware of symptoms of hernia
incarceration and complications of injury to testicles. A testicular mass needs a referral.
Musculoskeletal Examiner conducts 2-minute orthopedic screening examination.
Skin Examiner inspects for evidence of molluscum contagiosum, herpes simplex infection,
impetigo, tinea corporis, or scabies, which would temporarily prohibit participation in
sports where direct skin-to-skin contact occurs (e.g., wrestling, martial arts).
Source: Kurowski, K., & Chandran, S. (2000). The preparticipation athletic evaluation. American Family Physician, 61(9), 2683–2690, 2696–2698.
sport and organization sponsoring the sport; screening revisited: a renewed commitment to the psychosocial aspects
of pediatric care. Pediatrics, 108(5), 1227–1230.
should be encouraged if the child or adolescent has
American Academy of Pediatrics Committee on Practice and Ambu-
any identified risk factors. latory Medicine Bright Futures Steering Committee Recommen-
dations for Preventive Pediatric Health Care. (2007). Pediatrics,
120(6), 1376. Retrieved July 5, 2008, from http://aappolicy.aap-
publications.org/cgi/content/full/pediatrics;120/6/1376.
SUMMARY American Academy of Pediatrics Joint Committee on Infant
Hearing. (2007a). Year 2007 position statement: principles
and guidelines for early hearing detection and intervention
The well-child, health supervision visit presents an programs. Pediatrics, 120(4), 898–921.
excellent opportunity for the pediatric health care American Academy of Pediatrics Committee on Practice and
Ambulatory Medicine, Section on Ophthalmology, American
provider to improve the health of children through Association of Certified Orthoptists, American Association
developing meaningful relationships with the child for Pediatric Ophthalmology and Strabismus and American
and family while promoting health and wellness, Academy of Ophthalmology. (2007b). Statement of reaffirma-
tion: eye examination in infants, children, and young adults
identifying health issues early, and educating chil- by pediatricians. Pediatrics, 120(3), 683–684.
dren and families in the context of a medical home. American Academy of Pediatrics Medical Home Initiatives for
Children with Special Health Care Needs Project Advisory
Committee. (2008). The medical home). Pediatrics, 122(2),
450 (doi:10.1542/peds.2008-1427).
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emy of Pediatrics. www.ahrq.gov/clinic/3rduspstf/cervcan/cervcanrr.htm.
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Preventive health care for children with and without special infection: recommendation statement. Rockville, MD: Agen-
health care needs. Pediatrics, 119(4), 821–828. cy for Healthcare Research and Quality (AHRQ). Retrieved No-
Kurowski, K., & Chandran, S. (2000). The preparticipation ath- vember 7, 2009, from http://www.ahrq.gov/clinic/3rduspstf/
letic evaluation. American Family Physician, 61(9), 2683–2690, syphilis/syphilrs.htm.
2696–2698. U.S. Preventive Services Task Force. (2005). Screening for gonor-
Johnson, W. G., & Rimsza, M. E. (2004). The effects of access to rhea: recommendation statement. Publication No. 05-0579-
pediatric care and insurance coverage on emergency depart- A. Rockville, MD: Agency for Healthcare Research and Quality
ment utilization. Pediatrics, 113(3), 483–487. (AHRQ). Retrieved November 7, 2009, from http://www.ahrq
Kaye, C. I. (2006). Introduction to the newborn screening fact .gov/clinic/uspstf05/gonorrhea/gonrs.htm.
sheets. Pediatrics, 118(3), 1304–1312. U.S. Preventive Services Task Force. (2007). Screening for HIV:
Kelly, S. E., Binkley, C. J., Neace, W. P., & Gale, B. S. (2005). Barriers recommendation statement. Publication No. 05-0580-A. Rock-
to care-seeking for children’s oral health among low-income ville, MD: Agency for Healthcare Research and Quality (AHRQ).
caregivers. American Journal of Public Health, 95(8), 1345–1351. Retrieved November 7, 2009, from http://www.ahrq.gov/clin-
Knight, J. R., Sherritt, L., Shrier, L. A., Harris, S. K., & Chang, ic/uspstf05/hiv/hivrs.htm.
G. (2002). Validity of the CRAFFT Substance Abuse Screening Wu, A. C., Lesperance, L., & Bernstein, H. (2002). Screening for
Test among adolescent clinic patients. Archives of Pediatrics iron deficiency. Pediatrics in Review, 23(5), 171–178.
and Adolescent Medicine, 156(6), 607–614.
Kurowski, K., & Chandran, S. (2000). The preparticipation ath-
letic evaluation. American Family Physician, 61(9), 2683–2690,
2696–2698. ADDITIONAL RESOURCES
Lee, M., & Truman, J. T. (2005). Acute anemia. Retrieved Novem- The following are suggested resources, some of which include
ber 7, 2009, from http://med.javeriana.edu.co/pediatria/revis/ evidence-based health screening guidelines with the goal of
eMedicine%20-%20Anemia,%20Acute%20%20Article%20by prevention, early identification, and health promotion for
%20Margaret%20Lee,%20MD.htm. infants, children, and adolescents:
Levy, S., & Knight, J. R. (2003). Office management of substance
abuse. Adolescent Health Update, 15(3), 1–9. American Academy of Pediatrics
Lindeke, L., & Jukkala, A. (2005). Rural NP practice barriers and http://www.aap.org
strategies: one state’s story. American Journal for Nurse Practi- For current immunization schedule: American Academy of
tioners, (9), 11–18. Pediatrics Red Book: http://www.aapredbook.org
Marcus, S. (2007). Lead toxicity. Retrieved July 14, 2008, from Bright Futures
http://www.emedicine.com/EMERG/topic293.htm. http://www.brightfutures.aap.org
Maron, B. J., Thompson, P. D., Ackerman, M. J., Balady, G., Berger, A program of the American Academy of Pediatrics; the goal is
S., Cohen, D., et al. (2007). Recommendations and consider- to promote health and wellness in children through theory and
ations related to preparticipation screening for cardiovascular evidence-based health supervision guidelines. Bright Futures
abnormalities in competitive athletes: 2007 update. Circula- also provides educational tools to assist pediatric health care
tion, 115(12), 1643–1655. providers in fine-tuning their clinical skills for the health
McCarthy, V. M. (2006). Getting into the game: keys to perform- supervision visit.
ing an efficient sports physical. Advance for Nurse Practitioners,
14(6), 67–69. Bright Futures: Guidelines for Health Supervision of Infants,
Melnyk, B. M., & Moldenhauer, Z. (2006). The KySS guide to child Children and Adolescents (3rd ed.).
and adolescent mental health screening: Early intervention and http://brightfutures.aap.org
A comprehensive guide to the current recommendations for Healthy People 2010

well-child, health supervision standards. http://www.healthypeople.gov/
Bright Futures periodicity schedule: http://brightfutures.aap.org/ A set of health objectives, the goal of which is to improve the
pdfs/Guidelines_PDF/20-Appendices_PeriodicitySchedule.pdf quality and length of life in the United States and to eliminate
health disparities.
Pedicases
http://www.pedicases.org National Association of Pediatric Nurse Practitioners
A web site affiliated with Bright Futures that comprises 30 case (NAPNAP)
studies that simulate situations that the pediatric health care http://www.napnap.org
provider may encounter during health supervision visits. The Professional membership association for pediatric nurse prac-
focus is on health promotion, disease prevention, behavior, titioners; the goal is to provide optimal health care to children
growth, and development and adolescent health. through research, scholarship, and practice. Position state-
ments relative to pediatric health supervision and wellness care
Pediatrics in Practice include, all available online:
http://www.pediatricsinpractice.org
A Bright Futures–based health promotion curriculum designed NAPNAP Position Statements on:
to help pediatric health care providers enhance their health Access to Care
promotion skills in the areas of health, child and family Pediatric Health Care Home
partnership, family-centered communication, health School-based Health Care
promotion, time management in clinical practice, education, Age Parameters for Pediatric Nurse Practitioner Practice
advocacy, and cultural competency. Supporting Infant and Family Well-being in the First Year of Life
Immunizations
The National Center of Medical Home Initiatives for Prevention of Tobacco Use in the Pediatric Population
Children with Special Needs Supporting Grandparents Raising Grandchildren
http://www.medicalhome.org Breastfeeding
Devoted to pediatric medical home principles and resources. Prevention of Unintentional Injuries in Children
Agency for Healthcare Research and Quality Integration of Mental Health Care in Pediatric Primary Care
http://www.ahcpr.gov Settings
Provides evidence-based clinical practice guidelines for both NAPNAP HEAT (Healthy Eating and Activity Together)
disease management and preventive services; it includes the Initiative
Guide to Clinical Preventive Services (2007), which is the U.S. Evidence-based clinical practice guidelines for identifying and
Preventive Services Task Force’s (USPSTF) recommendations on preventing overweight in children.
health screening, counseling, and prevention.
NAPNAP KySS (Keep Your Children/Yourself Safe and Secure)
Centers for Disease Control and Prevention Initiative
http://www.cdc.gov A national program launched by NAPNAP, which aims to
For current immunization schedule: http://www.cdc.gov/vaccines promote the mental health of children and adolescents
Also has health statistics on lead poisoning, tuberculosis, and through health promotion, screening, and early, evidence-
sexually transmitted infections. based interventions. Emphasis is on physical safety (injury
Guidelines for Adolescent Preventive Services (GAPS) and violence prevention, motor vehicle safety; prevention
http://www.ama-assn.org/ama/upload/mm/39/gapsmono.pdf of tobacco, drug and alcohol use; physical, emotional,
Guidelines for health supervision visits for adolescents between and sexual abuse; sexually transmitted infections), and
the ages of 11 and 21 years; published by the American Medical emotional safety (coping, problem-solving skills, self-esteem
Association. building).
CHAPTER
Assessment of
10 Nutritional Status
JOANNE KOUBA AND ELLEN M. CHIOCCA
Assessment of nutritional status is always a necessary situations, by a nutrition support service. This allows
first step in the delivery of nutrition services to chil- for an efficient and appropriate allocation of resources
dren in the acute, primary, long-term, and community within the health care or community agencies.
environments. This assessment provides information for
development of the initial and subsequent nutritional
diagnoses, guides the development of nutrition inter- ASSESSMENT OF PEDIATRIC
ventions, and provides benchmarks for evaluation.
NUTRITIONAL STATUS
Assessment of pediatric nutritional status attempts to
NUTRITION SCREENING identify the nutritional problems in a child. The types
of data collected depend on the patient’s profile and
Nutrition screening identifies risk or concern for the resources of the health care environment. This
nutrition problems. Typical information required for often involves a combination of subjective and objec-
screening, such as height or length, weight, head cir- tive measures and a careful synthesis by the health
cumference (when a child is younger than 3), special care provider. A registered dietitian (RD) is typically
diets, food allergies or intolerances, growth problems, the health care professional who completes a nutri-
weight loss, feeding skills, extended periods on liquid tional assessment. This assessment should result in a
diets or full dietary restriction (NPO), and feeding plan for nutrition intervention and serial evaluations.
problems, are generally easily obtained from the child’s Many registered dietitians who work exclusively with
parents, caregivers, nurses, case workers, or other staff pediatric populations have a specialty certification in
and should be tailored to the specific audience (Hagan, this area; that is, most are board-certified specialists
Shaw, & Duncan, 2008b; Halac & Zimmerman, 2004; in pediatric nutrition and are certified through the
Samour & King, 2005). Depending on the age and reli- Commission on Dietetic Registration. The following
ability, the child may also be able to provide informa- sections cover the various parameters used in nutri-
tion used in nutrition screening. tional assessment.
Additional data may be included based on specific
concerns; for example, information on the physical ac-
tivity of a pediatric diabetic patient or bowel habits of a ANTHROPOMETRICS
cystic fibrosis patient. Criteria for various levels of nu- Assessment of nutritional status in infants, children,
trition risk based on screening should be defined by or- and adolescents should include anthropometric mea-
ganizational policy. Those at low or moderate risk may surements, which are used to measure childhood
have services delivered by technical level staff such as growth (Hagan, Shaw, & Duncan, 2008b; National
a dietetic technician. Services may include anticipa- Center for Health Statistics, 2007). Growth and devel-
tory guidance for normal nutrition, wellness, or disease opment during childhood depends on optimal nutri-
prevention. Patients at high risk require a higher level tion, health, and environmental conditions. Environ-
of care—usually involving nutritional assessment— mental factors that can influence development range
provided by a registered dietitian or, in complex from the family’s economic situation, cultural food
182
C H A P T E R 10 A s s e s s m e n t o f Nutritional S tatus • 183
practices, work patterns of caregivers, school foods, TABLE 10-1

and physical activity opportunities or challenges
Summary of Centers
(Halac & Zimmerman, 2004; Kavey, Daniels, Lauer,
Atkins, Hayman, Taubert, et al., 2003; Samour & King,
for Disease Control and
2005). Health conditions that may influences growth Prevention Pediatric Growth
include chromosomal abnormalities (e.g., Down syn- Charts
drome), metabolic disorders (e.g., phenylketonuria), GENDER
neurologic disorders (especially those resulting in a AND AGE GENDER CHART
nonambulatory status [e.g., spinal bifida]), or chronic
medication use (e.g., corticosteroid use) (Lucas, Feucht, Birth to Boys Weight-for-length
& Greiger, 2004). Problems in any of these areas can 36 months Weight-for-age
Length-for-age
impair childhood growth and development. Nurses Head circumference-
and caregivers should consider these various factors for-age
when assessing pediatric growth and development by
using anthropometrics. In conjunction with other di- Birth to Girls Weight-for-length
36 months Weight-for-age
etary and biochemical data, anthropometric data can Length-for-age
explain growth patterns, help establish nutrition care Head circumference-
goals, and evaluate health care services. for-age
Fundamental anthropometric measures of children
2 to 20 years Boys BMI-for-age
include height and weight. Body weight reflects energy
of age Weight-for-age
deficits most readily and to a greater extent than stature Stature-for-age
in times of undernutrition (Hagan, Shaw, & Duncan,
2008b). Head circumference should also be used to 2 to 20 years Girls BMI-for-age
assess growth from birth to 36 months (National Center of age Weight-for-age
Stature-for-age
for Health Statistics, 2007). Accurate measurements are
important, as small errors can result in large inaccuracies 2 to 5 years Boys Weight-for-stature
when calculating body mass index (BMI). The Centers of age
for Disease Control and Prevention (CDC) have devel-
2 to 4 years Girls Weight-for-stature
oped growth charts for various anthropometric indices.
of age
These and other valuable information on this topic are in
Appendix B. These growth charts synthesize age, gender,
weight, stature, and other measures and are appropriate
for most children. The CDC growth charts were first
If a child experiences a deviation from the expected
developed in 1977 and revised in 2000. There are
growth pattern by either falling outside the expected
16 gender- and age-specific charts that include two broad
percentile ranges or experiences large or abrupt changes
age categories, birth to 36 months and 2 to 20 years, for
in the growth curve, then further evaluation is war-
each gender. These are summarized in Table 10-1.
ranted since this may indicate a nutritional, health, or
Each growth chart is available in either an indivi-
other psychosocial problem (National Center for Health
dual or clinical format. The individual format is sim-
Statistics, 2007; Story, Holt, & Sofka, 2002). Changes in
pler than the clinical format and includes English and
weight indices usually reflect changes in recent nutri-
metric units. This is the chart that is most appropriate
ent intake. Inadequate stature measures usually indicate
for parents or caregivers. The clinical format includes
chronic nutrition or health problems.
space for serial assessment data and includes two sets
of curves per page except for the body mass index-for-
age (BMI-for-age) and weight-for-stature charts. Charts CENTERS FOR DISEASE CONTROL
mostly commonly used are those that display the 5th
through 95th percentiles. An alternative set displays
AND PREVENTION GROWTH CHARTS
the 3rd through 97th percentiles that some health Body Mass Index-for-Age
care providers prefer. The 10th, 25th, 50th, 75th, and The BMI-for-age and gender is currently recommended
90th are displayed on each, in addition to the 85th by the CDC as the most appropriate assessment of
on the BMI-for-age charts. The recent revisions of the weight status rather than the previously used weight-
CDC growth charts were developed, using a larger and for-stature measure for children and adolescents
more nationally representative sample of the current (Hagan, Shaw, & Duncan, 2008b; National Center for
pediatric population in the United States, including Health Statistics, 2007; U.S. Department of Health and
data from several cycles of the National Health and Human Services [USDHHS], 2007). This index com-
Nutrition Examination Survey. bines weight and height at various ages in each gender
to assess weight status as underweight, overweight, highly restrictive diets, or eating disorders (Halac &
or obese. A child or adolescent whose gender-specific Zimmerman, 2004; National Center for Health Statis-
BMI-for-age is equal to the 95th percentile or more is tics, 2007; Nevin-Folino, 2003). Nonnutritional reasons
categorized as obese. Those with a BMI-for-age equal to for short stature include genetic disorders and develop-
the 85th percentile or more but less than the 95th per- mental problems that impair long bone growth (e.g.,
centile for the appropriate gender are considered to be cerebral palsy, spina bifida, malabsorption syndromes)
“overweight.” Children who are in either of these cat- (Halac & Zimmerman, 2004). In some children, low
egories should receive further medical assessment and stature-for-age may be a genetic manifestation and may
nutrition counseling for weight management (Barlow not reflect abnormal growth (Baer & Harris, 1997).
& Dietz, 2007; Rosenbaum, 2007).
Underweight is considered to be a gender-specific Weight-for-Age
BMI-for-age less than the 5th percentile. The adult Weight-for-age is used in early infancy to monitor
BMI criteria are not used to assess weight in chil- weight and in older children to monitor weight-for-
dren and adolescents. Children or adolescents who length. It is not used to assess weight status but rather
are underweight should be evaluated for eating dis- to monitor changes in health or nutritional status.
orders, cancer, diabetes, thyroid disease, infections, Infants who are exclusively breast-fed experience
and gastrointestinal or other health problems (Halac somewhat different growth patterns. They tend to gain
& Zimmerman, 2004; Nevin-Folino, 2003; Samour weight more rapidly in the first 3 months and then
& King, 2005). After the BMI is calculated, it should weigh less than formula-fed infants at the end of the
be plotted on the gender-specific BMI-for-age chart first year (Hagan, Shaw, & Duncan, 2008b).
to determine the approximate percentile for weight
assessment.
Weight-for-Length
An in-depth medical assessment is recommended
Weight-for-length (or stature) is not dependent on
for overweight children aged 2 to 20 (Barlow & Dietz,
age and assesses weight status in infants and young
2007). For children and adolescents who are catego-
children. A child whose weight-for-length exceeds the
rized as overweight, continued screening should in-
95th percentile is considered overweight. Similarly, a
clude a careful family health history for type 2 diabetes
child whose weight-for length is less than the 5th per-
mellitus, obesity, and cardiovascular diseases, as well
centile is considered underweight.
as the child’s blood pressure and lipid levels. If an at-
risk child is found to be positive for a family history
of elevated blood pressure, lipids, or BMI, then an in- Head Circumference-for-Age
depth medical assessment is indicated. Head circumference-for-age is a critical measure for
infants younger than 36 months; it reflects brain size
and may identify hydrocephalus or microcephaly (i.e.,
Weight-for-Stature
which indicates the need for neurologic evaluation).
Weight-for-stature charts continue to be included as Developmental problems are a concern for those with
optional tools for children aged 2–5 years. The period head circumference indices that are less than the 5th
from 24 to 36 months is considered transitional. percentile or more than the 95th percentiles (Lucas,
Health care providers may measure recumbent length Feucht, & Greiger, 2004). Serial data for anthropometric
(supine) or stature (standing height). This is noted indices are particularly useful in assessing growth and
by the overlap between the two age categories. De- development in children with special conditions.
pending on which measure is obtained, the corre-
sponding growth chart should be used. For example,
if the recumbent length is measured in a girl who is SPECIAL CONDITIONS
30 months of age, then the weight-for-length chart
When assessing certain groups of infants, children, and
for girls, infant to 36 months is used. If that same girl
adolescents, the CDC growth charts are not appropriate.
has stature measured, then it is appropriate to use the
These include very-low-birth-weight (VLBW) infants,
BMI-for-age growth chart for girls since her standing
those with genetic disorders, or those with chronic ill-
height is obtained.
nesses. Alternative growth charts have been developed
for some of these populations (Lucas, Feucht, & Greiger,
Stature-for-Age 2004). For children who cannot stand up straight, lin-
The stature-for-age (or length) index is useful to as- ear growth can be approximated using sitting height,
sess linear growth for shortness or tallness. Short stat- arm span, and knee height. However, because these al-
ure, or stunting, is defined as stature-for-age less than ternative growth charts have often been developed us-
the 5th percentile. Reasons for short stature should be ing small reference populations, reliability and validity
evaluated. Short stature may be because of inadequate may be a concern. Whenever assessing a special popula-
intake of key nutrients secondary to food insecurity, tion as one of those mentioned above, it is advisable to
use the child as his own reference, comparing current all racial and ethnic groups. Practitioners should use
to past measures. It is also preferable to use multiple caution when assessing growth patterns of VLBW
indices such as head circumference, length-for-age, and infants, exclusively breast-fed infants, or other specific
weight-for-age, rather than a single parameter. groups such as children with genetic disorders. Nurses
It should be noted that VLBW infants were not and other health care providers need to interpret the
included in the reference data used to develop the findings from anthropometric assessment, using the
growth charts because their growth patterns are CDC growth charts, with insight and care. One para-
different from infants with birth weights over 2500 meter can never provide a complete assessment relative
mg. To assess growth in VLBW infants, the Infant to the health or nutritional status of a child. A combi-
Health and Development Program (IHDP) charts or nation of objective measures (e.g., anthropometrics,
the CDC growth charts are appropriate postdischarge biochemistry) and subjective measures (e.g., diet his-
(Lucas, Feucht, & Greiger, 2004; Nevin-Folino, 2003). tory) must be included. However, like a cumulative
The CDC advises health care providers to make several grade point average for a college student, BMI-for-age
adjustments when assessing these infants. First, when or stature-for-age measurements do provide some his-
assessing the VLBW infant with these charts, postnatal torical depth for the practitioner.
age should be corrected for gestational age from birth
to 24 months with either chart. In addition, growth
patterns of VLBW infants are similar on either chart BIOCHEMICAL MARKERS
except for weight-for-length, which shows a smaller
Laboratory values are rarely used alone in the assessment
decrease in growth on the IHDP charts than the CDC
of nutritional status. However, as objective measures they
charts. When using the CDC charts, VLBW infants will
are valuable in confirming suspected nutrient deficits or
fall in lower percentiles in length and weight-for-age.
excesses when medical, social, and diet histories suggest
They will show some catch-up growth in length-for-age
problems. The four commonly used general categories
and head circumference-for-age for age but will plot
of biochemical measures that are included in nutritional
in lower percentiles for weight-for-age and weight-for-
screening/assessment are summarized below.
length. These infants are often heavier for length until
65 cm in length and then become thinner for length
than non-VLBW infants. In general, the IHDP charts Serum Proteins
reflect growth patterns in VLBW infants compared to Normal laboratory values for commonly used protein
the CDC growth charts except in the weight-for-length measures are summarized in Table 10-2 (Nevin-Folino,
category (National Center for Health Statistics, 2007; 2003; Samour & King, 2005). Serum albumin is the
Nevin-Folino, 2003). most commonly measured protein because of its rela-
The CDC growth charts are important tools for tive availability and reasonable cost. A low serum al-
health care providers to assess the growth of infants, bumin level may indicate depressed hepatic albumin
children, and adolescents up to 20 years of age in production as a consequence of low dietary protein
TABLE 10-2
Serum Proteins Used in Assessing Nutritional Status
PARAMETER NORMAL VALUE HALF-LIFE FACTORS TO CONSIDER
Albumin Preterm: 2.5–4.5 g/dL 18–20 days Inflammation, infection, trauma, liver
Term: 2.5–5.0 g/dL disease, gastrointestinal losses, and
1–3 months: 3.0–4.2 g/dL fluid retention
3–12 months: 2.7–5.0 g/dL
⬎1 year: 3.2–5.0 g/dL
Transferrin 180–260 mg/dL 8–9 days Inflammation, liver disease, fluid

retention, and iron deficiency
Prealbumin 20–50 mg/dL 2–3 days Liver disease, infection, trauma,

hyperthyroidism, and cystic fibrosis
Retinol-binding protein 30–40 g/dL 12 hours Liver disease, infection, zinc

deficiency, vitamin A deficiency and
renal disease
Source: Bessler, S. (2005). Nutritional assessment. In Samour, P. Q., & King, K. (Eds.). Handbook of pediatric nutrition. (3rd ed.). (p. 16).
Sudbury, MA: Jones and Bartlett Publishers.
intake (Samour & King, 2005). However, albumin is • Fed non–iron-fortified formulas for over 2 months
not the most sensitive or specific indicator of protein • Fed cow’s milk before 12 months of age
status. The 14-day half-life of albumin creates a lag • Breast-fed without iron from supplemental foods
between inadequate protein intake and a low serum after 6 months
level. The same is true for repletion. Once nutritional • Given more than 24 oz of cow’s milk a day
support is started, it may take several weeks to observe • Taking medication that interferes with iron ab-
a rise in albumin. Nonnutritional factors can also lead sorption (e.g., antacids, calcium, phosphorus) or
to abnormal albumin levels despite adequate protein have chronic inflammatory disorders, infections,
intake. These include liver or renal disease, fluid reten- or blood loss
tion or deficits, infection, and malabsorption. Health • From 2–5 years of age:
care providers should consider these factors when
• With inadequate iron intake
evaluating albumin and other proteins. Transferrin,
• Who experience food insecurity because of family
retinal-binding protein, and pre-albumin are some-
income or neglect
times preferred for the assessment of protein status, as
• With special medical conditions
they reflect more recent changes. However, measuring
these proteins is more expensive and also subject to • From 5–12 years of age and adolescent males from
the nonnutritional factors mentioned above. 12–18 years of age:
• With known risk factors, such as inadequate iron
intake or previous iron-deficiency anemia
Iron Status • With special medical conditions
Iron deficiency is the most common nutritional de- • From 12–21 years of age for adolescent females, who
ficiency in children in the United States because need annual screening:
of the demands of this nutrient for normal growth
from infancy through adolescence (Looker, 2002). • Because of known risk factor (e.g., extensive blood
The prevalence of iron deficiency is estimated at 3% loss, menstrual blood loss)
overall in U.S. children (CDC, 2007; Looker, 2002). • Because of inadequate iron intake or previous iron-
Iron deficiency results in cognitive deficits, delays in deficiency anemia.
psychomotor development, behavioral problems, im- The concern and importance of iron to support both
paired growth, fatigue, increased infections, and an physical growth and cognitive development make iron
increased risk of lead toxicity (Borgona-Pignatti & status evaluation an important part of a nutritional as-
Marsella, 2008; Hagan, Shaw, & Duncan, 2008b). For sessment. Measurement of hemoglobin and hematocrit
certain population groups, such as children from low- is often used to assess iron status in acute and primary
income households, iron deficiency is more prevalent. care, community, or school settings. Low levels should
Risk factors include preterm or low-birth-weight, non– alert the health care provider to potential nutritional
iron-fortified formula for more than 2 months, cow’s deficits and always warrant further evaluation (Hagan,
milk before 1 year, high consumption of cow’s milk, Shaw, & Duncan, 2008b; Nevin-Folino, 2003). However,
blood loss, chronic infection, or inflammatory disor- hemoglobin and hematocrit are often normal until iron
der (CDC, 2007). Children from a migrant, refugee, or stores are depleted and iron deficiency is advanced.
low-income family or a recipient of the Women, In- In addition, blood loss, infections, inflammatory con-
fant, and Children’s (WIC) Special Supplemental Feed- ditions, and other vitamin deficiencies can lead to low
ing Program are at risk for iron deficiency. levels of hemoglobin and hematocrit. Any child with
According to CDC guidelines, all infants and children iron deficiency should also be assessed for lead toxicity
should be assessed for iron-deficiency anemia (CDC, based on the CDC guidelines as the two are often con-
2007). Those with risk factors or at high risk should nected (Hagan, Shaw, & Duncan, 2008b).
be screened with laboratory tests. Universal screening
is completed for those at high risk at 9–12 months, Cholesterol and Triglycerides
6 months later, and every year from 2–5 years for chil-
For children (⬎2 years) with a parent who has hyper-
dren from low-income families who are eligible for
cholesterolemia (⬎240 mg/dL) or a family history of
WIC or are from migrant or refugee families.
premature cardiovascular disease (⬍55 years in par-
Selective screening should be completed for children
ent or grandparent), assessment of serum lipids is
(CDC, 2007):
advised (Grundy, Cleeman, Bairey Merz, Brewer, Clark,
• Younger than 6 months of age who were preterm or Hunninghake, et al., 2004; Hagan, Shaw, & Duncan,
low-birth-weight and were fed noniron formulas 2008b; Nevin-Folino, 2003). Acceptable lipid levels
• Younger than 9–12 months and 6 months later who for children are summarized in Table 10-3. Elevated
were: lipid levels should be considered in conjunction with
• Preterm or low-birth-weight weight status, family history of cardiovascular disease
TABLE 10-3
Lipid Guidelines for Children
PARAMETER OPTIMAL BORDERLINE UNDESIRABLE
Total cholesterol ⬍170 mg/dL 170–199 mg/dL ⬎200 mg/dL
Low-density lipoprotein ⬍110 mg/dL 110–129 mg/dL ⬎130 mg/dL
High-density lipoprotein ⱕ35 mg/dL ⬍35 mg/dL
Triglycerides ⱖ150 mg/dL ⬍150 mg/dL
Source: Kavey, R. W., Daniels, S. R., Lauer, R. M., Atkins, D. L., Taubert, K., et al. (2003). American Heart Association Guidelines for Primary
Prevention of Atherosclerotic Cardiovascular Disease Beginning in Childhood. Circulation, 107, 1562–1566.
or diabetes, and dietary factors to minimize the risk metabolism can contribute problems with nutrition.
of premature chronic disease risk in the child. Conditions that interfere with normal food intake in-
clude cancer and its treatment, cerebral palsy, autism,
Glucose congenital heart diseases, cleft palate, or use of cer-
Similar to the recommendations for lipid screening in tain medications (Halac & Zimmerman, 2004; Lucas,
children, the American Diabetes Association recom- Feucht, & Greiger, 2004; Nevin-Folino, 2003; Samour
mends glucose screening in children at risk for diabetes & King, 2005). Any problem that involves the ability to
based on the overweight status of the child; positive chew and swallow foods properly and appetite changes
family history for diabetes; symptoms of insulin resis- should be examined closely. Cystic fibrosis, inflamma-
tance such as acanthosis nigricans, polycystic ovarian tory bowel diseases, celiac disease, or draining abscesses
syndrome, or dyslipidemia; or belonging to an ethnic contribute to nutrient losses (Lucas, Feucht, & Greiger,
group with a high prevalence of diabetes, such as Native 2004). Any problems with vomiting, diarrhea, flatu-
Americans, African Americans, Hispanic Americans, or lence, and indigestion may interfere with the adequacy
Pacific Islanders (American Diabetic Association, 2006). of nutrients. Increased nutrient needs can result from
If a child is found to have a fasting glucose of 100 mg/dL fever, infection, burns, cancer, or recent surgical proce-
or more, further evaluation is necessary. dures (Nevin-Folino, 2003). Additional indicators that
should alert the health care provider to potential nu-
trition concerns might be family unemployment, in-
DISEASE-SPECIFIC BIOCHEMICAL adequate housing, or lack of health insurance (Hagan,
Shaw, & Duncan, 2008b). Parents or other caregivers
MARKERS are usually the appropriate individuals to interview
In some children, additional biochemical measures are about food intake patterns, as children are often too
needed, depending on the specific disorders, such as young to discuss these issues reliably.
renal or malabsorptive problems, suspected nutrient Nutrition-focused physical assessment should in-
deficiencies or the resources that are available. The clude observation of general appearance and review
laboratory at each facility should be consulted to obtain of systems, including an oral examination (Halac &
details on the age-adjusted standards for each value. Zimmerman, 2004; Lucas, Feucht, & Greiger, 2004;
Samour & King, 2005). Subcutaneous fat stores
should be assessed for general nutritional status. Four
CLINICAL EVALUATION areas commonly observed are the shoulders, triceps,
Clinical evaluation should be incorporated into the chest, and hands. Loss of fullness or loose skin may
nutritional assessment along with analysis of anthro- indicate wasting. In addition, muscle wasting can be
pometric, biochemical, and dietary data. This involves assessed by anthropometric measures or also by ob-
a general evaluation of relevant clinical information, servation of the quadriceps femoris (anterior thigh)
including the past medical and surgical histories, a or deltoid muscle (shoulder) area (Lee & Nieman,
nutrition-focused physical examination, and psycho- 2009). Ascites or edema should be considered when
social factors. assessing weight status and protein status. General-
The child’s medical and surgical histories should ized cachexia should alert the practitioner to the need
be carefully reviewed in terms of relevance to nutri- for a more thorough assessment.
tion. Any disorder or disease that causes an inability Physical findings that would be relevant in a nutri-
to ingest or absorb adequate nutrients or an increased tional assessment are summarized in Table 10-4. Many
TABLE 10-4
Physical Findings Related to Nutritional Problems
POSSIBLE POSSIBLE
SYSTEM OR NORMAL PHYSICAL NUTRIENT NUTRIENT
TISSUE APPEARANCE FINDING DEFICIENCY EXCESS
Hair Shiny, not easily Alopecia, Protein/calorie
pluckable, evenly Easily pluckable, Protein, essential
distributed Dyspigmented fatty acids
Protein
Sparse Protein, biotin, zinc Vitamin A
Epithelial
Skin Smooth, without Xerosis and scaling Essential fatty acids Vitamin A
rashes, swelling, or Vitamin A
scales Zinc
Follicular Vitamin A, C
hyperkeratosis
Ecchymoses, Vitamin C, K
petechiae
Purpura Vitamin C, K
Desquamation in sun Niacin

exposed areas
Yellow pigmentation Carotene

without sclerae
involvement
Nails Koilonychia, spoon Iron

shaped
Mouth and lips Pink and moist with Angular stomatitis Riboflavin
intact skin (inflammation at Niacin
corners of mouth) Pyridoxine
Cheilosis (inflamed, Riboflavin

ulcerated lips) Niacin
Pyridoxine
Tongue Pink and moist, with Glossitis (inflamed Riboflavin

intact skin tongue) scarlet, Pyridoxine
painful, and rough Niacin
Folate
Cobalamin
Atrophic lingual Riboflavin

papillae (smooth Niacin
tongue) Folate
Cobalamin
Iron
Hypogeusesthesia Zinc
Gums Pink, moist, and Bleeding, swollen, Ascorbic acid

smooth receding (vitamin C)
Eyes Pink membranes Conjunctival pallor Iron

Folic acid
Cobalamin (B12)
POSSIBLE POSSIBLE
SYSTEM OR NORMAL PHYSICAL NUTRIENT NUTRIENT
TISSUE APPEARANCE FINDING DEFICIENCY EXCESS
Bright, shiny, and Bitot’s spots, xerosis, Vitamin A
clear and night blindness
Intact blood vessels Corneal B vitamins

vascularization,
fissures of eyelid
corners
Papilledema Vitamin A
Musculoskeletal Well developed Costochondral Vitamin D

Some fat stores junction enlargement
Normal movement “Beading” on ribs
(rachitic rosary)
Bowed legs, bone
pain
Hemorrhages on Ascorbic acid

extremities
Muscle wasting and Protein-calorie

reduced strength
General Edema Protein

Thiamin
Poor skin turgor Fluid/dehydration
Pallor/anemia Iron
Folic acid
Cobalamin (B12)
Poor wound healing Protein, vitamin C,

and zinc
Neurologic Psychologically stable Mental confusion Niacin, cobalamin,

Normal reflexes and dementia and pyridoxine
Confabulations and Thiamin
disorientation
Peripheral Niacin, cobalamin, Pyridoxine

neuropathy and pyridoxine
Tetany Calcium
Magnesium
Headache Vitamin A
Drowsiness, lethargy, Vitamins A and D

vomiting
Cardiomegaly, Thiamin
heart failure, and Phosphorus
tachycardia
Gastrointestinal Symmetrical, flat Hepatomegaly and Protein-calorie Vitamin A

distention
Distention and flatus Lactose intolerance

of the abnormal conditions noted in this table are non- of high-calorie foods. However fraught with error,
specific and may be secondary to other reasons besides insight into dietary patterns assists in the analysis
nutrient deficits or excesses, making further biochemi- of suspected nutrient deficits, the need for anticipa-
cal evaluation necessary to substantiate a deficiency tory guidelines to prevent nutrition problems, and
(Samour & King, 2005). In addition, suspected nutrient the response to nutrition interventions.
problems should be accompanied by an evaluation of Assessment of food and nutrient intake is often
the diet. framed within a “diet history,” which combines several
Malnutrition is often categorized as kwashiorkor or components, depending on the health care setting,
marasmus. Protein deficiency is the primary problem in specific medical conditions, or age of the child. The
kwashiorkor. Clinical manifestations include decreased following discussion reviews the methods, applica-
serum protein levels; pedal edema, which may extend tions, and strengths or limitations of each.
to the upper body; and dull hair that is easily plucked.
Weight, adipose tissue, and skeletal muscle may ap-
pear to be relatively normal. In contrast, marasmus DIETARY QUESTIONNAIRE
is characterized by severe energy deficits that result In addition to assessment of daily food intake, using
in severe loss of weight, skeletal muscle, and adipose food recalls, records, or frequency tables, a general
tissue. Children suffering from marasmus appear set of questions is completed as part of a dietary
wasted, and linear growth is commonly stunted. These evaluation. For pediatric populations, this should be
classical definitions of malnutrition are more com- geared to the age of the child or the child’s medi-
monly used in developing countries; in developed cal condition. For all ages, these include questions
countries, malnutrition is often termed “cachexia” or about food allergies, aversions, or intolerances; a his-
“mixed protein-calorie malnutrition.” tory of dietary restrictions for medical, cultural, or
other reasons; a history of weight changes; and vi-
tamin, mineral, or dietary supplement use (Hagan,
DIETARY EVALUATION Shaw, & Duncan, 2008, 2008b; Halac & Zimmerman,
2004; Nevin-Folino, 2003). In addition, general ques-
Food and eating provide people not only with nutri- tions should provide some idea about the household
ents to foster normal growth and protect against some dynamics related to food shopping and prepara-
diseases, but also with a pleasurable aspect of life that tion, family meal times, resources for the household
allows them to express caring, culture, creativity, and food, and participation in food programs (e.g., WIC,
personal preferences. Our behaviors associated with National School Lunch program).
eating are integral to daily routines, family connec- In infants, a feeding history from birth should be
tions, social interactions, celebrations, and even solace. completed with quantity, quality, and composition
For these reasons, assessment of nutritional status is of daily feeding episodes, number of wet diapers, and
incomplete without consideration of dietary patterns. some description of the feeding relationship with par-
This includes details about types of foods, prepara- ents or caregivers (Halac & Zimmerman, 2004; National
tion methods, amounts, and the patterns of meals and Center for Health Statistics, 2007). As the infant makes
snacks. Cultural patterns, religious observations, so- the transition to solid foods, dietary intake assessment
cioeconomic influences or other lifestyle practices are should include feeding skills such as chewing, hand-
important factors that influence dietary quality and to-mouth movement, weaning from bottle to cup,
nutrient intake (Hanson, Nuemark-Sztainer, Eisenberg, and the incorporation of a broad range of appropri-
Story, & Wall, 2005; Samour & King, 2005). ate foods. Patterns of sleep, activity, and elimination
Depending on the child’s age and medical circum- should also be included for infants.
stances, a dietary evaluation can be easy or difficult. The foods provided by childcare providers and
Whenever assessing dietary intake, it is important to schools need to be considered for children who at-
remember that these data are subjective and prone tend these programs. Young children who are out of
to error and bias because of memory lapse, lack of the home from early morning through late afternoon
knowledge about food composition, preparation are likely to receive two meals and two snacks; thus,
methods, portions, and social desirability. For ex- more than 60% of their nutrient intake is taken from
ample, an overweight 14-year-old girl when asked nonfamily members. Children in these situations are
about the meatloaf that she ate for lunch may hon- very dependent on the child care providers, whether
estly not know whether it was made from beef, pork, home-based or agency-based, for dietary quality. The
turkey, or soy. In addition, she may neglect to men- same is true for school-aged children who may re-
tion that she ate it with gravy if she has been told ceive both breakfast and lunch at school. In addition,
to avoid gravies to reduce caloric intake. She may snacks offered informally from teachers or as part of
have experienced negative feedback from a previous social events provide sources of energy and nutrients
health care provider as a result of reporting intake for this group.
BOX 10-1 BOX 10-3

Interview Questions Interview Questions for Parents
for Infants (Newborn to of Formula-fed Infants
4 Months of Age)
What infant formula do you use?
How do you think feeding is going? Is the formula iron-fortified?
Do you have any questions about breast or formula How do you prepare the formula?
feeding your child? How do you store the formula after preparation?
How does your infant let you know that he or she is How do you clean the nipples, bottles, and other
hungry? equipment used to mix the formula?
How do you know when he or she has had enough? Do you have any concerns about feeding your infant?
How often does your infant eat? What is the source of water for mixing with the
Have you noticed any changes in eating? formula?
How do you feel about the way your infant is growing?
Are you concerned about having enough money to buy Source: Hagan, J. F., Shaw, J. S., & Duncan, P. M. (2008). Infancy. In
food or formula? Hagan, J. F., Shaw, J. S., & Duncan, P. M. (Eds.). Bright futures: Guidelines
for health supervision of infants, children and adolescents. (3rd ed.).
What is the source of water for drinking or cooking? (pp. 253–380). Elk Grove Village, IL: American Academy of Pediatrics.
Source: Hagan, J. F., Shaw, J. S., & Duncan, P. M. (2008). Infancy. In

Hagan, J. F., Shaw, J. S., & Duncan, P. M. (Eds.). Bright futures: Guidelines
for health supervision of infants, children and adolescents. (3rd ed.). TWENTY-FOUR-HOUR RECALL
(pp. 253–380). Elk Grove Village, IL: American Academy of Pediatrics. This retrospective method asks the client to recall,
usually verbally, all foods and beverages consumed in
the previous 24-hour period (Samour & King, 2005).
Adolescence is characterized by increasing indepen-
The client typically recites the dietary intake in chron-
dence (Hagan, Shaw, & Duncan, 2008). This often in-
ologic order while the interviewer records this in-
cludes part-time employment, which creates the financial
formation either by hand or with the aid of a nutrient
resources and consequently more opportunities to be away
from the family for meals. Each phase of childhood creates
environmental circumstances that require inquiry relative
to dietary patterns and nutrient intake. Additional inter- BOX 10-4
view questions are summarized in Boxes 10-1 to 10-7. Interview Questions
for Young Children
(4–12 Months of Age)
BOX 10-2
Interview Questions for Have you given your child any food besides breast milk
Mothers of Breast-fed Infants or formula?
If so, what has the child eaten? Has there ever been a
Do you need help with breast-feeding? reaction?
Do you have any concerns about feeding your infant? Does your child seem interested in food?
Does your infant attach to your breast and suck well? Who else feeds the child besides parents?
Do you hear him or her swallowing when Does the child have teeth yet? How many?
breast-feeding? Can the child feed her- or himself any food? If so, what
Have you had any problems with your breasts or food?
nipples? Does the child use his or her fingers, spoon, bottle, or
Do you restrict any foods in your diet? cup?
Do you drink any wine, beer, or other alcohol? Does the child put any nonfoods in the mouth?
Do you use any drugs? Has your child tried to drink from a cup? Was she or he
Do you know your HIV status? successful?
Are you planning to return to work or school? If so, will Has your child ever choked or gagged on food?
you express milk?
How do you plan to store your breast milk after Source: Hagan, J. F. , Shaw, J. S., & Duncan, P. M. (2008). Infancy. In
expressing it? Hagan, J. F., Shaw, J. S., & Duncan, P. M. (Eds.). Bright futures: Guidelines
(pp. 253–380). Elk Grove Village, IL: American Academy of Pediatrics;
Source: Hagan, J. F., Shaw, J. S., & Duncan, P. M. (2008). Infancy. In Hagan, J. F., Shaw, J. S., & Duncan, P. M. (2008). Early childhood: 1–4
Hagan, J. F., Shaw, J. S., & Duncan, P. M. (Eds.). Bright futures: Guidelines years. In Hagan, J. F., Shaw, J. S., & Duncan, P. M. (Eds.). Bright futures:
for health supervision of infants, children and adolescents. (3rd ed.). Guidelines for health supervision of infants, children and adolescents. (3rd
(pp. 253–380). Elk Grove Village, IL: American Academy of Pediatrics. ed.). (pp. 381–461). Elk Grove Village, IL: American Academy of Pediatrics.
BOX 10-5 BOX 10-7

Interview Questions for Early Interview Questions for
Childhood (2–4 Years of Age) Adolescents (11–20 Years
of Age)
Do you have any concerns about your child’s eating or
growth? FOR THE ADOLESCENT:
What do you do if your child does not like a particular
What meals do you usually eat each day? How many
food?
snacks?
Do you have the appropriate equipment for feeding him
How often do you skip meals?
or her (e.g., high chair, booster)?
What do you usually eat or drink in the morning?
Do you have any concerns about food served away
Around noon? Afternoon?
from home?
Evening?
What is your child’s eating pattern or routine?
Did you drink any milk yesterday?
How much juice does he or she drink each day?
How many times did you eat fruit or vegetables
Is your child still using a bottle?
yesterday?
Does your child eat meals with the family?
Are there any foods you will not eat? If so, which ones?
Of what do your child’s snacks consist?
How much soda do you drink each day? What type?
What changes would you like to make in your eating
Source: Hagan, J. F. , Shaw, J. S., & Duncan, P. M. (2008). Early child-
habits?
hood: 1–4 years. In Hagan, J. F., Shaw, J. S., & Duncan, P. M. (Eds.).
Bright futures: Guidelines for health supervision of infants, children and
adolescents. (3rd ed.). (pp. 381–461). Elk Grove Village, IL: American
FOR THE PARENT:
Academy of Pediatrics. Do you think your child eats healthy foods?
How often does your family eat meals together?
analysis software program. Reviewing the food list Do you have any concerns about your child’s eating and
several times with prompts by the interviewer usually growing?
elicits details related to quantity, brand name, cook-
ing methods, or condiments, which are often missed. Source: Hagan, J. F. , Shaw, J. S., & Duncan, P. M. (2008). Adolescence. In
Strategies to improve completeness of the diet recall Hagan, J. F., Shaw, J. S., & Duncan, P. M. (Eds.). Bright futures: Guidelines
(pp. 515–575). Elk Grove Village, IL: American Academy of Pediatrics.
BOX 10-6
Interview Questions include visual cues, using measuring cups or food
for School-aged Children models for portion estimates or mentally rehearsing
(5–10 Years of Age) daily events to improve memory of food intake. This
method requires a low literacy level and is an insig-
FOR THE CHILD:
nificant burden on the client; however, the previous
Where did you eat yesterday? At school? At home? At a 24-hour period may not be typical for patients in acute
friend’s house? care facilities, and it relies on memory, which is vari-
What do you usually eat or drink in the morning? able (Samour & King, 2005).
Around noon? Afternoon? No matter how accurate a 24-hour recall may be, it
Evening? may not reflect the child’s usual intake because of the
Did you drink any milk yesterday? day-to-day variability of children’s meals. A large num-
How many times did you eat fruit or vegetables ber of 24-hour recalls represent the eating patterns of
yesterday? a certain age group when aggregated and nutrient in-
FOR THE PARENT: take is averaged, but for any individual, interpretation
of one 24-hour recall should be done with an under-
Do you think your child eats healthy foods? standing of the above limitations. Since the client is
What does your child eat for snacks? Where does she or being asked to recall foods consumed in the past, the
he eat them? dietary patterns will not be changed, which is a possi-
Do you have any concerns about your child’s eating and bility when social desirability alters food intake when
growing? diet records are collected. In young pediatric patients,
a 24-hour recall is often completed with the parent or
Source: Hagan, J. F. , Shaw, J. S., & Duncan, P. M. (2008). Middle other significant caregiver, which leads to additional
childhood. In Hagan, J. F., Shaw, J. S., & Duncan, P. M. (Eds.). Bright futures:
Guidelines for health supervision of infants, children and adolescents. (3rd ed.). limitations in lack of knowledge about foods served if
(pp. 463–514). Elk Grove Village, IL: American Academy of Pediatrics. the child regularly consumes meals away from home.
FOOD RECORDS OR DIARIES year complex. Comparisons of FFQs to diet records

An alternative method of diet analysis is to ask the reveal that they overestimate nutrient intakes (Samour
child, parent, or caregiver to write down all foods and & King, 2005). An example of the National Institute
beverages consumed over a period of days. The value of of Health Diet History Questionnaire can be found at
this method is that there is less error because of omis- their web site (National Institute of Health, 2007).
sion and improved representation of food intake if
both weekend and weekdays are included. Limitations
include the need for a literate client (or parent) who
CALORIE COUNTS
is willing to devote time to this activity, and the pos- For inpatients, food and nutrient intake can be assessed
sibility that the process of keeping a food diary may using the “calorie-count” method (Samour & King,
itself alter food intake. In theory, food records that are 2005). In this case, food consumption is observed,
longer (7 compared to 3 days) may be more complete. estimated, and recorded. This can be completed by hos-
However, these longer food records often become less pital staff (from the nursing or nutrition departments),
complete as the client becomes less interested in the the patient, or family members. An analysis provides
task (Samour & King, 2005). Food records provide the an estimation of key nutrient intakes and may be use-
health care provider with more insight into food pat- ful for decisions about adding oral supplements or al-
terns and meal cycles, as they encompass more than ternative methods of nutritional support. Observation
the day prior to a hospital admission, as is the case of at mealtimes may be useful to assess feeding technique
the 24-hour recall. In addition, this method is often and the developmental level of the child (Hagan, Shaw,
used for self-assessment in monitoring behavioral & Duncan, 2008b; Lucas, Feucht, & Greiger, 2004).
change over time. The most accurate food records are This method is not indicative of dietary quality, nutri-
preceded by a training session with both the child and ent intake, or food patterns at home. In addition, food
parents or caregivers so that details about brand name, intake may be altered as a consequence of the reasons
label descriptors, food preparation, or composition are that caused inpatient admission, facility schedules, or
complete and accurate. testing procedures.
FOOD FREQUENCY QUESTIONNAIRES EVALUATION AND

Food frequency questionnaires (FFQs) can be included INTERPRETATION OF DIETARY
in a diet history as a method to evaluate intake by INTAKE INFORMATION
food group. The format of a FFQ is generally like a
“checklist,” which includes a listing of food groups, Information obtained from the methods described
sometimes subdivided, and asks how many servings above can be assessed for both quality and quantity.
a day, week, or month are consumed by the client. An optimal quality dietary pattern may be indicated
This may reveal the intake of specific food groups that by acceptable responses for the appropriate interview
were not identified on the 24-hour recall or recorded questions in Boxes 10-1 through 10-7, and include in-
in food diaries. For example, yogurt intake may have dications of regular meal and snack consumption of
been absent from a 24-hour recall, but a FFQ may indi- nutrient-dense foods with positive family interactions
cate that the child consumes yogurt four times a week, that support anticipated growth and health problems
which would improve the calcium intake assessment. without other concerns, which means no battles at
Detailed FFQs have been developed with a focus on mealtime and no force feeding of broccoli. Eating disor-
certain nutrients, such as calcium or fat. Others pro- ders are thought to be generated by demanding parents
vide a general checklist of food-group intake. FFQs do or kids feeling guilty about eating an extra tablespoon
not require as much time to complete as diet records, of potatoes. Common concerns include childhood
and they can be completed without an interviewer. overweight, dependency on bottle-feeding, skipping
However, they may require cognitive restructuring meals, or the regular omission of any food group.
of food groups, and they do not yield a qualitative The quantity of nutrients and food groups con-
description of meal patterns; for example, a portion sumed can be estimated using computerized nutrient
of the questionnaire asks the person to estimate how analysis. Programs for this purpose range from free,
many times a week or month berries are consumed. online applications such as the MyPyramid Track-
This requires the person to think about their intake er, which is available from the U.S. Department of
of strawberries, blueberries, blackberries, or raspberries Agriculture (USDA), to those that are used for research
over a 12-month period. Most people consume these purposes (USDA, 2007).
more frequently in summer months than winter The Dietary Reference Intakes (DRIs), which en-
months, making a value representative of the entire compass six categories, are commonly used reference
standards in the United States (National Academy of Breast-feeding is the recommended source of nutri-
Sciences, 2004). These include eight different catego- ents for infants, unless there is a contraindication.
ries that cover childhood and adolescence. The Rec- Developmentally, it is usual for breast-fed infants to
ommended Dietary Allowance (RDA) is the nutrient locate the mother’s breast, attach to the nipple, and
intake recommended to meet the nutrient needs of nurse. During the first week, breast-fed infants should
healthy individuals within a specific group as defined be eating 8 to 12 times daily with five or more wet
by age, gender, or other condition. The RDA has a large diapers and three to four stools daily (Hagan, Shaw, &
“safety net” included beyond the minimum amount Duncan, 2008b). Ideally, infants should receive only
to prevent deficiency. Intakes that are estimated to be breast milk for the first 6 months, and breast-feeding
somewhat below the RDA do not automatically indi- should continue until at least 12 months or when the
cate a deficiency, but they may signal a need for further mother and the infant no longer wish to continue.
evaluation, especially when considering the subjective The mother should be encouraged to seek breast-
nature of dietary data. The Adequate Intake (AI) cat- feeding support if needed. Breast-feeding should occur
egory is used for nutrients lacking adequate scientific in a relaxed space with about 20–45 minutes devoted
evidence to establish an RDA. Rather, these values are to each session. The infant should complete eating at
considered to be the goals for intake of that nutrient. one breast and then be moved to the other. Turning
The Estimated Average Requirement (EAR) is the esti- the head from the nipple, closing the mouth, or be-
mated nutrient intake necessary to meet 50% of the coming interested in other activities in the room are
defined group. The Estimated Energy Requirement signs that the infant is full and finished eating. Infants
(EER) provides a goal for calorie, or energy, intake con- younger than 4 weeks should not be allowed to sleep
sistent with normal health, development, and physi- for more than 4 hours without feeding (Hagan, Shaw,
cal activity. Guidelines for carbohydrate, protein, and & Duncan, 2008b).
fat goals are provided by the Acceptable Macronutrient For formula-fed infants, formula should be prepared
Distribution Range (AMDR) with consideration for according to manufacturer’s directions. Formula pre-
disease prevention and nutrient adequacy. Finally, the pared for more than 24 hours and stored in the
Tolerable Upper Limit (TUL) nutrient levels are those refrigerator should be discarded. Ready-to-feed or con-
at which danger of toxicity may result if exceeded centrated formulas that have been in the refrigerator
consistently. more than 48 hours should be discarded (Hagan, Shaw,
To assess food-group intake, key goals from the & Duncan, 2008b). Formula should not be heated by
Dietary Guidelines for Americans 2005 and MyPyramid microwave, as overheating is common, which may
can be used (USDA, 2007; USDHHS & USDA, 2005). In burn the infant. A safe water supply is essential for
general, children are advised to consume 6 oz of grains, formula feeding.
with at least 50% from whole grain sources, 2.5 cups Infants younger than 1 should receive only breast
of vegetables, 1 cup of fruit, 2–3 cups of low-fat dairy, milk or iron-fortified infant formula. Cow, goat, or
and 5 oz of lean protein sources daily (Hagan, Shaw, & soy milk should not be used before the first birthday,
Duncan, 2008b; USDA, 2007; USDHHS & USDA, 2005). even mixed in cereals. Reduced-fat milk should not
Additional advice is provided to encourage healthy be given until the infant is 2 or older. Infants can
weight through regular physical activity and limiting be offered juice in a cup after 6 months with a dai-
the intake of sugars and fats. ly limit of 4–6 oz (Hagan, Shaw, & Duncan, 2008b;
Halac & Zimmerman, 2004). Honey, even in processed
foods, should not be given to infants because honey
INFANTS can be a source of spores that cause botulism toxic-
This section summarizes key concepts of expected ity (Kleinman, 2009). Care should be taken to pre-
eating patterns and routines for infants. Whenever vent choking as more foods are added to the infant’s
possible, observation of parent–infant interaction diet. Hard candy, grapes, hot dogs, marshmallows,
should be included in the nutritional assessment. peanut butter, raw carrots, or raisins should never be
This interaction should be affectionate and comfort- given to infants or children younger than 3 years of
able (Hagan, Shaw, & Duncan, 2008b). When con- age (Hagan, Shaw, & Duncan, 2008b). Parents and
sidering dietary patterns for infants, deviation from caregivers should always observe infants and children
the key concepts may indicate the need for further during eating to avoid choking episodes. In addition,
evaluation or intervention. infants should not be fed in the car.
Approximately 60% of U.S. infants are breast-fed It is expected that infants will initially lose about
initially (Hagan, Shaw, & Duncan, 2008b). However, by 6% of their birth weight but regain this weight with-
6 months of age, only 25% continue to be breast-fed. in the first 10–14 days. By 6 months of age, infants
One of the goals of Healthy People 2010 is to increase should double their birth weight, and by 1 year, they
breast-feeding to 75% initially with 50% of infants should triple it (Halac & Zimmerman, 2004; Nevin-
still being breast-fed by 6 months (USDHHS, 2000). Folino, 2003). On average, infants are expected to gain
about 5–7 oz a week until they are 4–6 months of age been fed a non–iron-fortified formula for more than
(Hagan, Shaw, & Duncan, 2008b). This high-growth 2 months; had been fed cow’s milk before 12 months;
velocity slows down to about 3–5 oz a week from 6–18 consumed more than 24 oz of cow’s milk daily; are
months of age. Length should increase by about 50% from a low income, migrant, or refugee family; or are
in the first year. On average, infants should gain about a participant of the WIC Special Supplement Feed-
1 inch a month in the first 6 months (Hagan, Shaw, & ing Program (CDC, 2007). In addition, any infant
Duncan, 2008b). This growth declines to an average with medical problems, such as chronic infections
increase of about 1/2 inch/month from 6–12 months. or inflammatory disorders, should be screened for
During the first 6 months, when growth velocity is anemia.
high, energy needs are about 108 kcal/kg/day (Hagan, To reduce the risk of dental caries, prolonged
Shaw, & Duncan, 2008b). With a decline in growth in and frequent bottle-feeding with high-carbohy-
the second half of the first year, energy needs are de- drate–containing liquids should be avoided. Infants
creased to 100 kcal/kg/day on average (Hagan, Shaw, should not be put to bed with a bottle that contains
& Duncan, 2008b). Low-birth-weight and preterm in- carbohydrates. After 6 months, the infant should
fants younger than 6 months should be evaluated for be receiving water from a fluoridated source (at 0.3
the need for iron supplements if they are not breast- ppm), or fluoride supplements should be considered
fed or are receiving iron-fortified formula, as they were to reduce dental caries risk (Hagan, Shaw, & Duncan,
born with lower iron stores (CDC, 2007). 2008b). By 12–14 months, infants should be weaned
By 4–6 months, infants generally show signs of from a bottle and drinking from a cup.
developmental readiness for the introduction of other
foods. Parents and caregivers should note which foods
are introduced and report this during health care YOUNG CHILDREN (AGES 2–5)
visits. These include coordinated swallowing (more Parents or caregivers should continue to add new
than reflexive sucking), cooperation during feeding, foods to the diet of young children. Developmentally,
sitting with support, and good control of the head children from 12–18 months can grasp and release
and neck (Hagan, Shaw, & Duncan, 2008b). The in- foods with their fingers, hold a spoon and cup, and
fant must be ready to progress with transitional feed- want foods that others are eating. Children who are
ing. Choking risk is increased in infants who are not 2–3 years old can hold a cup, chew foods better than
developmentally ready. During this period, infants a 1-year-old child, and express their food likes and
continue to consume breast milk or formula, in addi- dislikes (Hagan, Shaw, & Duncan, 2008b). By age 4,
tion to foods with modified consistency that are added children can use a fork, hold a cup by the handle,
to the diet. Initially, an infant cereal without sugar or pour liquids from small containers, request favorite
salt is offered. One single food at a time is added so foods, and begin to be influenced by media sources,
that tolerance can be monitored to identify any food including television and advertisements (Christakis
allergies or intolerances (Nevin-Folino, 2003). At 7-day & Zimmerman, 2007; Institute of Medicine, 2006).
intervals, another food is incorporated into the diet. Between the ages of 4 and 5, children begin to cut
Generally, infant cereals, vegetables, and fruits are the their food with a knife and fork, are more adept at
first food groups included. Pureed or finely chopped drinking from a cup, continue to be influenced by
meats are added within a couple of months. All foods media messages directed at food choices, and may
are modified for consistency as tolerated by the infant. be interested in food preparation (Hagan, Shaw, &
Meal patterns include five or six small meals plus breast Duncan, 2008b).
milk or formula. Fat should not be restricted in the diets of children
By 6–12 months, infants should be chewing in a younger than 2. After 2 years, the diet can be slowly
more coordinated fashion, manipulating food with changed to incorporate more whole grains, fruits,
their fingers, drinking from a cup, starting to use uten- vegetables, low-fat dairy products, and lean meats. The
sils, attempting to feed themselves, and erupting teeth. dietary pattern should include three meals and three
To ensure an adequate iron supply, any formula and snacks a day. Parents’ responsibilities should include
cereals should be iron-fortified. Breast-feeding should purchasing and preparing healthy foods that are devel-
continue. Vitamin C food sources should be included opmentally appropriate for meals and snacks, provid-
to enhance iron absorption (Hagan, Shaw, & Duncan, ing appropriate utensils, and establishing regular eat-
2008b; Nevin-Folino, 2003). ing periods during the day (Hagan, Shaw, & Duncan,
At 9 months, infants should be offered soft, moist 2008b). Young children need to eat every 2–3 hours
foods such as pasta with sauce, meatloaf, soft cooked during waking periods. Children who are 2–3 years old
vegetables, fruit, and soft cheeses, following the same should eat the same number of servings shown on the
eating schedule as the rest of the family. In addition, MyPyramid as older children, although the portion is
iron-deficiency screening should be completed on about two thirds of the suggested portion. By age 4,
infants who were preterm or low-birth-weight; had the serving sizes are similar.
Choking precautions should be maintained for Adolescent young men and physically active women
young children, including staying with the child require the maximum suggested servings from the
during meals and snacks and making sure the child MyPyramid guideline (Hagan, Shaw, & Duncan,
is seated when eating; there should be no eating in 2008b; USDA, 2007; USDHHS & USDA, 2005). Low-
the car in addition to avoiding the foods listed above. fat dairy products should be emphasized to maximize
When the child is older than 3, some of the above- bone density, and lean protein sources should be en-
mentioned food is modified to make it safer by cutting couraged for adequate iron intake.
or chopping. The prevalence of overweight adolescents, especial-
Juice should be limited to 4–6 oz a day to prevent ly among minority youth, has escalated in the United
dental caries and to discourage children from filling up States in the last three decades (CDC, 2006; Rosen-
on juice at the expense of more nutrient-dense foods baum, 2007). In addition, there is a growing concern
such as fruits, vegetables, whole grains, and low-fat that lifestyle practices are increasingly contributing to
dairy. Optimal dietary patterns in this age group also morbidity and mortality. Considering the long latency
include appropriate parental use of food. For example, period between intermediate factors (such as obesity
food should not be used as a reward, bribe, punish- and physical inactivity) with chronic diseases (such
ment, pacifier, or entertainment. Use of food for these as diabetes mellitus and coronary heart disease), the
purposes may encourage overeating and rejection of rise in the number of overweight adolescents is an
healthy foods (Hagan, Shaw, & Duncan, 2008b). ongoing concern. In addition, when adolescents are
overweight, they are likely to engage in unsafe weight-
loss strategies (Rosenbaum, 2007). These factors make
SCHOOL-AGED CHILDREN weight status and related practices important indica-
tors for assessment during adolescence.
(AGES 5–10) Disordered eating patterns are estimated to affect
Meals and snacks should continue to be offered to 1%–2% of adolescent girls (Hagan, Shaw, & Duncan,
school-aged children ( Hagan, Shaw, & Duncan, 2008a). 2008b). Criteria for anorexia nervosa include refusal to
They should eat the minimum number of servings maintain a desirable body weight, excessive fear of gain-
from each food group as outlined in the MyPyramid ing weight, amenorrhea, and denial of underweight
guideline. Regular consumption of nutrient-dense (American Psychiatric Association [APA], 2000). Crite-
foods should be encouraged, whereas frequent intake ria for bulimia nervosa include recurrent binge eating
of high-sugar and high-fat foods (e.g., sugar-sweetened characterized by the consumption of large amounts
beverages, butter, salad dressing, candy, cookies, chips) of food in private, lack of control when eating, and
should be discouraged (Hagan, Shaw, & Duncan, 2008b). recurrent inappropriate methods to prevent weight
Breakfast is a good way to begin the intake of high- gain from binge episodes (such as vomiting or laxative
quality foods and should be a regular habit. In an effort abuse) (APA, 2000). If an eating disorder is suspected, a
to prevent overweight, parents and caregivers should be comprehensive evaluation by an interdisciplinary team
role models for optimal dietary patterns. “Screen time” with expertise in this area should be completed. Eating
should be limited to 2 hours daily to minimize media disorders are serious conditions that have negative im-
suggestions related to unhealthy food choices and to plications for nutritional status and overall health.
encourage more active use of leisure time (American
Academy of Pediatrics, 2001; Christakis & Zimmerman,
2007). Extreme measures, such as weight-loss diets and CHILDREN WITH MEDICAL
forbidding foods, are not advised for this age group CONDITIONS
(Hagan, Shaw, & Duncan, 2008b).
For children or adolescents with medical disorders,
specific recommendations may be made for medi-
cal nutrition therapy. These recommendations may
ADOLESCENTS (AGES 11–19) range from carbohydrate counting for glucose con-
Adolescence is characterized by increasing indepen- trol in children with diabetes mellitus or a gluten-free
dence and less reliance on the family; peer influ- diet for those with celiac disease. Unique situations
ences grow. At the same time, the adolescent experi- such as these require complex nutrition assessment
ences growth spurts that require nutrient-dense diets with individualized nutritional education and coun-
(Spear, 2002). Adolescent diets have been noted to seling by a RD.
be lacking in folate, vitamin A, iron, calcium, and Children and adolescents with special dietary
zinc, which results from inadequate intake of fruits, needs still require adequate nutrients for growth and
vegetables, and dairy products (Kant, 2003; Moore, development but with additional modifications for
Braid, Falk, & Klentrov, 2007; Rosenbaum, 2007). disease management. This presents extraordinary
(3rd ed.). (pp. 515–575). Elk Grove Village, IL: American

challenges that are achievable only when families and Academy of Pediatrics.
health care providers work together. Hagan, J., Shaw, J., & Duncan, P. (2008a). Middle childhood. In
Hagan, J. F., Shaw, J. S., & Duncan, P. M. (Eds.). Bright futures:
Guidelines for health supervision of infants, children and adoles-
cents. (3rd ed.). (pp. 463–514). Elk Grove Village, IL: American
Academy of Pediatrics.
SUMMARY Hagan, J., Shaw, J., & Duncan, P. (2008b). Promoting healthy nu-
trition. In Hagan, J. F., Shaw, J. S., & Duncan, P. M. (Eds.).
Since the growth and development of children are Bright futures: Guidelines for health supervision of infants, children
and adolescents. (3rd ed.). (pp. 121–145). Elk Grove Village, IL:
dependent on optimal diet and adequate nutrient American Academy of Pediatrics.
intake, health care should include screening of nutri- Halac, I., & Zimmerman, D. (2004). Evaluating short stature in
tional status. If the screening indicates some risk for children. Pediatric Annals, 33(3), 170–176.
Hanson, N. I., Neumark-Sztainer, D., Eisenberg, M. E., Story, M.,
nutrition problems, then a complex nutrition assess- & Wall, M. (2005). Associations between parental report of
ment should be completed. This includes observation the home food environment and adolescent intakes of fruits,
and analysis of anthropometric, biochemical, clinical, vegetables and dairy foods. Public Health Nutrition, 8, 77–85.
Institute of Medicine. (2006). Food marketing to children and youth:
and dietary information. Common parameters used Threat or opportunity? Washington, DC: National Academies
for these purposes were reviewed. Key concepts for Press.
interpretation based on age group were summarized. Kant, A. K. (2003). Reported consumption of low-nutrient-
density foods by American children and adolescents. Archives
Ensuring that both healthy children and those with of Pediatric Adolescent Medicine, 157, 789–796.
special needs because of medical conditions receive an Kavey, R. W., Daniels, S. R., Lauer, R. M., Atkins D. L., Hayman
optimal diet to foster growth and manage disease is L. L., Taubert K., et al. (2003). American Heart Association
guidelines for primary prevention of atherosclerotic cardio-
complex and requires a collaborative interdisciplinary vascular disease beginning in childhood. Circulation, 107,
approach. 1562–1566.
Kleinman, R. D. (Ed). (2009). Pediatric nutrition handbook. (6th ed).
Elk Grove Village, IL: American Academy of Pediatrics.
Lee, R. D., & Nieman, D. C. (2009). Nutritional assessment.
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tions. (2001). Children, adolescents and television. Pediatrics, Morbidity and Mortality Weekly Report, 51(40), 897–899.
107(2), 423–426. Lucas, M. L., Feucht, S. A., & Greiger, L. E. (2004) Children with
American Diabetic Association. (2006). Diagnosis and classifica- special care needs: Nutrition care handbook. Chicago: American
tion of diabetes mellitus. Diabetes Care, 29(1), S43–S48. Dietetic Association.
American Psychiatric Association (APA). (2000). Diagnostic and Moore, M., Braid, S., Falk, B., & Klentrou, P. (2007). Daily calcium
statistical manual of mental disorders. (4th ed.). Washington, intake in male children and adolescents obtained from the
DC: American Psychiatric Association. rapid assessment method and the 24-hour recall method.
Barlow, S. E., & Dietz, H. W. (2007). Obesity evaluation and Nutrition Journal, 24(6), doi:10.1186/1475-2891-6-24.
treatment: Expert committee recommendations. Pediatrics, National Academy of Sciences, Institute of Medicine, Food and
119(2), 405. Nutrition Board. (2004). Dietary reference intakes: Recom-
Bessler, S. (2005). Nutrition assessment. In Samour, P. O., & King, mended intakes for individuals, vitamins. Dietary reference
K. (Eds.) Handbook of pediatric nutrition. (3rd ed.). (p. 16). intakes: Recommended intakes for individuals, elements.
Sudbury, MA: Jones and Bartlett Publishers. Dietary reference intakes: Tolerable upper intake levels, vita-
Borgona-Pignatti, C., & Marsella, M. (2008). Iron deficiency in mins. Dietary reference intakes: Tolerable upper intake levels,
infancy and childhood. Pediatric Annals, 37(5), 322–338. elements. Dietary reference intakes: Acceptable macronutrient
Centers for Disease Control and Prevention, Epidemiology Pro- distribution ranges. Dietary reference intakes: Recommended
gram Office. (2007). Iron deficiency. Retrieved November 28, intakes for individuals, macronutrients. Dietary reference in-
2009, from http://www.cdc.gov/nccdphp/dnpa/nutrition/ takes: Estimated average requirements for groups. Retrieved
nutrition_for_everyone/iron_deficiency/index.htm. April 29, 2007, from http://www.iom.edu/Object.File/Mas-
Centers for Disease Control and Prevention. (2006). Update: ter/21/372/0.pdf, pages 1–7.
Prevalence of overweight among children, adolescents, and National Center for Health Statistics. (2007). CDC growth charts:
adults–United States, 2003–2004. Retrieved November 28, United States. Hyattsville, MD. Retrieved April 29, 2007, from
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Christakis, D. A., & Zimmerman, F. J. (2007). Children and tele- Retrieved January 30, 2007, from http://riskfactor.cancer.gov/
vision: A primer for pediatricians. Contemporary Pediatrics, DHQ/forms/files/shared/dhq1.
24(3), 31–42. Nevin-Folino, N. L. (Ed.). (2003). Pediatric manual of clinical dietetics.
Daniels, S. R., Arnett, D. K., Eckel, R. H., Gidding, S. S., Hayman, Chicago, IL: American Dietetic Association.
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gov/mypyramid/results.html? U.S. Department of Health and Human Services (USDHHS).
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USDHHS. Surgeon General.
CHAPTER
Newborn
11 Assessment PAT HUMMEL
Assessment of the newborn infant is challenging information, necessitating an interview with the fa-
because of the infant’s vulnerability during the transi- ther, a close relative, or a friend. This information
tion from intrauterine to extrauterine life and during should be confirmed at a later time with the mother
the neonatal period (Leone & Finer, 2006). Perinatal of the infant. Reviewing medical records may provide
and neonatal risk factor assessment and a systematic valuable information, but these reviews should also
physical assessment by a skilled health care provider be confirmed, when possible, through interviews.
confirm normality and detect abnormalities, guiding Ideally, the provider should interview both parents,
the infant’s subsequent care. Providers require an either together or individually.
understanding of neonatal anatomy and physiology as
well as the skills to accomplish a comprehensive infant
assessment. Newborn assessment, including a compre- FAMILY HISTORY
hensive history and a detailed physical examination, is To assess the family history, providers should inquire
reviewed in this chapter. about known inherited diseases in the family, such
The health care provider must obtain a thorough his- as cystic fibrosis, hemophilia, or muscular dystrophy,
tory, usually from a parent. Details of the genetic back- and the presence of other disorders, such as mental
ground, pregnancy, and delivery allow the provider retardation or heart defects. Previous neonatal or in-
to focus on potential problems identified by the his- fant deaths must be documented, including the cause
tory. The provider must have a thorough knowledge of these deaths, if known. The family history must
of normal variants encountered during physical assess- include, at minimum, information about both par-
ment of the newborn. Early detection of congenital ents, grandparents, parents’ siblings, and siblings of
abnormalities is important for treatment and referral. the infant.
Infant outcomes are enhanced by early identification A genogram should be constructed if the infant
of problems with the transition to extrauterine life, presents with a congenital anomaly or a disease that
enabling timely intervention. is known or thought to be genetically transmitted.
Referral to a specialist in genetic diseases is impor-
tant; a complete history and genogram assist with the
COMPREHENSIVE HISTORY analysis of recurrence risk and alert family members to
potential problems.
A comprehensive history is an important aspect of the
newborn assessment as it is instrumental in identify-
ing risk factors that may impact the infant’s health MATERNAL HEALTH HISTORY
status. The comprehensive history includes a family The health status of the mother, including acute
history, maternal health history, obstetric history (in- and chronic health problems that may impact the
cluding pregnancy and labor), and the birth and neo- neonate’s health, should be reviewed (Table 11-1).
natal histories. The history is usually obtained from Chronic conditions such as diabetes, hypertension,
a parent through an interview and through medical and asthma, and acute conditions, such as a cur-
record review. The provider should determine the rent infection or trauma, may impact infant health.
reliability of the information. The postpartum mother Medications taken before and during pregnancy
recovering from anesthesia may be unable to provide should be documented as some may be teratogenic.
199
TABLE 11-1
Maternal Health and Fetal Risk Assessment
AREAS OF ASSESSMENT COMPONENTS/RISKS/PROBLEMS
Maternal physical General health assessment
examination Pregnancy health assessment
Urinalysis For protein, glucose, blood, infection, and ketones
Screening tests Rubella, rapid plasma reagin, hepatitis B, blood type, antibody status, human
immunodeficiency virus, gonorrhea, Chlamydia, and Pap smear
Maternal age Adolescent:

• Pre-eclampsia and eclampsia
• Intrauterine growth restriction
• Maternal malnutrition
35 years of age or older:
• Pregnancy-induced hypertension
• Diabetes
• Obesity
• Chromosomal abnormalities
• Increased pre-existing medical conditions
• Increased cesarean section rate
• Increased placenta previa
Past medical history • Chronic hypertension

• Renal disease
• Diabetes mellitus
• Heart disease
• Endocrine (thyroid) problems
• Cancer
• Sickle cell
• Pulmonary disease
• Gastrointestinal or liver disease
• Blood and clotting disorders
• Substance abuse
Family history History of genetic disease that may affect mother or fetus
Ethnic background Population risks for genetic disease:

• Cystic fibrosis: North American Caucasians of European ancestry and Ashkenazi Jews
• Sickle cell disease: African Americans, Africans, Hispanics, Mediterraneans, Middle
Easterners, and Caribbean Indians
• Tay-Sachs: Ashkenazi Jews, French Canadians, Cajuns
• Beta-thalassemia: Chinese, Southeast Asians, Mediterraneans, Pakistanis, Bangladeshis,
Middle Easterners, and Africans
• Alpha-thalassemia: Chinese, Southeast Asians, and Africans
• Bloom’s syndrome, Canavan’s disease, familial dysautonomia, Fanconi’s anemia,
Gaucher’s disease, Niemann-Pick disease: Ashkenazi Jews
Source: Mehta, S. H., & Sokol, R. J. (2007). Methods of assessment for pregnancy at risk. In DeCherney, A. H., Nathan, L., Goodwin, T. M., &
Laufer, N. (Eds.). Current diagnosis & treatment in obstetrics & gynecology. (10th ed.). (pp. 249–258). New York: Lange Medical Books/McGraw-Hill.
The extremes of reproductive age (e.g., adolescents, infant’s health, assists the provider in obtaining ac-
women over 35) can be associated with medical curate information.
conditions that are dangerous for the mother (e.g.,
pre-eclampsia, eclampsia, placenta previa).
A social history includes the mother’s marital sta- OBSTETRIC HISTORY
tus and financial and social support systems. Tobac- An obstetric history includes maternal data, includ-
co, alcohol, and illegal substance use by the mother ing age, gravida, and parity (Table 11-2). Gravida and
should be noted. These questions should be raised parity information is often noted in a shortened form.
with every mother, without personal bias. A non- The Gravida number denotes the number of pregnan-
judgmental attitude, conveying a commitment to the cies, and Para is the number of pregnancies resulting
C H A P T E R 11 Ne wbo rn Assessment • 201
TABLE 11-2
Obstetric History
CONDITION RISK TO THIS PREGNANCY OR INFANT
Modality of conception Increased risk with assisted reproductive technologies:
• Multiple gestations
• Preterm delivery
• Low birth weight
• Congenital anomalies
• Uterine infections
Recurrent abortion Etiology:

• Chromosomal abnormality
• Uterine anomalies
• Connective tissues disease
• Hormonal abnormality
• Thrombophilia
• Infectious disease of genital tract
Previous stillbirth or neonatal death Etiology:

• Random: low risk
• Chromosomal, maternal health, genetic disease, and thrombophilia
Previous preterm delivery Genital tract infection

Uterine or cervical abnormalities
Rh isoimmunization or ABO Positive antibody screen:

incompatibility • Anemia, hydrops fetalis, hyperbilirubinemia, kernicterus, birth asphyxia, and
hypoglycemia
Previous infant with genetic disorder Risk of recurrence dependent on anomaly and parental contribution
or chromosomal anomaly
Teratogen exposure Drugs (illegal or prescribed)

Alcohol and tobacco
Infectious agents (e.g., cytomegalovirus, rubella, toxoplasmosis, varicella, listeria)
in viable births (birth weight of 500 g or more, or assessment through ultrasound examination findings,
gestation of 20 completed weeks or more). The par- amniocentesis, chorionic villus sampling, and percu-
ity information may be expanded to four numbers to taneous umbilical blood sampling (Tables 11-3 and
denote term, preterm, abortions, and living children. 11-4). Complications of pregnancy, such as pregnan-
The notation of G5 P2-1-1-3 describes a mother who cy-induced hypertension, gestational diabetes, and
is presenting with her fifth pregnancy, with two term maternal illness during pregnancy, are important to
deliveries, one preterm delivery, one abortion (either assess because these conditions may impact neonatal
spontaneous or induced), and has three living chil- health. The results of any prenatal fetal testing should
dren. The presence of infertility treatments, such as also be noted (see Tables 11-3 to 11-5).
ovarian stimulation or in vitro fertilization; the mo- The labor and delivery histories include the tim-
dality of conception; and the status of previous preg- ing of membrane rupture, the length of labor, mater-
nancies, births, and living children should be noted. nal fever, and fetal monitoring findings. Prolonged
The adequacy of prenatal care and compliance with rupture of membranes and maternal fever predispose
follow-up must also be determined. Standard prenatal newborns to infection. The length of labor and fetal
testing varies but usually includes determination of monitoring findings are indicators of fetal health.
the mother’s blood type and Coombs status, hepati-
tis B status, rubella immunity, syphilis testing (RPR/
VDRL), gonorrhea, Chlamydia, group B Streptococcus BIRTH AND NEONATAL HISTORIES
and human immunodeficiency virus status, and a Pap The birth history includes the mode of delivery and
smear. Pregnancy history includes determination of delivery presentation. The need for assistive tech-
the estimated date of confinement (EDC) and fetal niques, such as forceps or vacuum extraction, must be
TABLE 11-3
Prenatal Testing
SCREENING TEST AGE AT SCREENING INFORMATION AND RESULTS
Increased size of nuchal fold: ultrasound 11–14 weeks Down syndrome
Cardiac abnormalities
Skeletal dysplasia
Maternal serum analyte “triple screen” or 15–22 weeks Open neural tube defects
“quad screen”: Some chromosomal abnormalities
• Alpha-fetoprotein (MSAFP) (trisomy 21 and others)
• Beta-hCG Multiple gestation
• Estriol
• Inhibin A (added test in “quad screen”)
Syndrome and disease testing Varies For populations at risk or a family

history
Diabetes: glucose challenge test 24–28 weeks Infant of diabetic mother:

Some recommend universal • Respiratory distress syndrome
screening; some screening based • Hypoglycemia
on risk factors • Macrosomia or growth retardation
• Congenital heart disease
• Neural tube defect
• Increased mortality
Vaginal culture for group B Streptococcus 35–37 weeks Septicemia, shock, and death
Fetal movement assessment: mother 20–40 weeks Assess fetal well-being:

counts movements 10 distinct movements in a period of up
to 2 hours is reassuring
Nonstress test (NST): fetal heart rate (FHR) Varies Reactive NST: two or more FHR
monitoring accelerations, at least 15 beats/minute
above baseline, lasting at least 15
seconds within a 20-minute period
Biophysical profile (BPP) with ultrasound: Varies Each normal component is worth
• Nonstress test 2 points.
• Fetal breathing movement Normal: 8–10
• Fetal movement Equivocal: 6
• Fetal tone Abnormal: 4 or less
• Amniotic fluid volume
• FHR
Modified BPP with ultrasound Varies Nonreactive NST, or AFI less than 50 mm
• NST Oligohydramnios requires further
• Amniotic fluid index (AFI) intervention.
• FHR
Contraction stress test (CST): Varies Positive (abnormal) test: late

• FHR monitoring during uterine decelerations occur with more than half
contractions; requires three of the contractions
contractions in 10 minutes Suspicious test: with any late
• Rarely used decelerations
Negative test: no late decelerations
Fetal growth with ultrasound Measurement every 3–4 weeks Normal growth is reassuring
in high-risk pregnancy
Doppler ultrasound of fetus, umbilical Can detect heartbeat as Assess for presence of heartbeat.
cord, and placenta: early as 6 weeks gestation Assess growth-restricted fetus.
• Evaluate umbilical artery outflow or (used throughout a high-risk Diagnostic tool, guides intervention
middle cerebral artery flow. pregnancy)
• Multivessel evaluation of fetal status
TABLE 11-4
Assessment of the Status of the Fetus
METHOD FETAL AGE PURPOSE AND RISKS
Ultrasound Initially at 6–20 weeks Standard: detects fetal number, presentation, fetal
viability, gestational age assessment, amniotic fluid
volume, placental location, fetal biometry, and
anatomic survey
Limited: directed search for suspected problem,
amniocentesis guidance, assessment of fetal well-being,
and presentation
Specialized: diagnose anomalies, fetal Doppler, BPP,
and fetal echocardiogram
Aneuploidy screening: for known markers of genetic
syndromes
Amniocentesis 15–20 weeks Alpha-fetoprotein for open neural tube defects

Cytogenetic analysis
After 20 weeks Fetal lung maturity assessment
Diagnose intra-amniotic inflammation and infection
Chorionic villus sampling (CVS) 10–12 weeks Cytogenetic analysis
Percutaneous umbilical blood Varies Assess Rh sensitization (hematocrit)

sampling (PUBS) Treat anemia with blood transfusion
Cytogenetic analysis
Alloimmune thrombocytopenia (platelet count)
Platelet transfusion
Metabolic analysis
noted. The appearance of the amniotic fluid should The neonatal history includes the birth history and
be recorded: green fluid indicates meconium passage the infant’s status before the health care provider’s
while yellow or cloudy fluid may indicate infection. examination. The provider should determine whether
APGAR scores and the need for resuscitation should be or not the infant has achieved temperature control (ther-
determined (Table 11-6). moregulation) and stable vital signs. Thermoregulation
TABLE 11-5
Fetal Lung Maturity Tests
TEST NORMAL NON-MATURE
Lecithin/sphingomyelin (L/S) ratio Ratio of 2.0 Less than 2.0
Amniotic fluid
Phosphatidylglycerol Present Not present

Amniotic fluid
Fluorescence polarization (TDx-FLM): Mature: 55 mg surfactant Immature: less than 55 mg

Uses polarized light to quantitate the competitive per gram of albumin surfactant per gram of albumin
binding of a probe to both albumin and surfactant
in amniotic fluid; directly measures surfactant
concentration.
Lamellar bodies ⬎30,000–50,000 ⬍10,000
Note: Fetal lung maturity tests are done before elective delivery at less than 39 weeks’ gestation unless there is firm confirmation of gesta-
tional age of 39 weeks or more.
TABLE 11-6
APGAR Scoring
SCORE OF 0 SCORE OF 1 SCORE OF 2 ACRONYM
Skin color Blue all over Blue at extremities Normal Appearance
Heart rate Absent ⬍100 ⬎100 Pulse
Reflex irritability No response to Grimace/feeble cry Sneeze/cough/pulls Grimace

stimulation when stimulated away when stimulated
Muscle tone None Some flexion Active movement Activity
Respiration Absent Weak or irregular Strong Respiration
is important in the newborn, as cold stress places the need for continued resuscitation and care (American
infant at risk for hypoglycemia, acidosis, and persistent Heart, 2006).
pulmonary hypertension. A lack of thermoregulation is The cursory physical examination of the infant accom-
common in preterm and ill infants. The provider should plished at delivery determines the infant’s gender and the
note whether the infant is breast- or bottle-fed and presence or absence of major birth defects. A complete
whether urine and stool have passed normally. physical examination of the infant is performed later,
usually in the first day of life after the infant is stable.
PHYSICAL EXAMINATION
AFTER STABILIZATION
IMMEDIATELY AFTER BIRTH Behavioral and physiologic changes (e.g., color, respira-
tory efforts, heart sounds, motor activity, mucus pro-
Physical examination of the neonate first occurs im-
duction, bowel sounds) in the normal newborn over
mediately following delivery when the transition to
the first 10 hours of extrauterine life were first described
extrauterine life is assessed. The APGAR score provides
40 years ago (Desmond, Rudolph, & Phitaksphraiwan,
a convenient shorthand method for reporting the
1966). Behavioral changes are described as periods of re-
status of the newborn infant and the infant’s response
activity.
to resuscitation (see Table 11-6). Each infant is assigned
an APGAR score at 1 and 5 minutes of life, continu- • The first period of reactivity is described as alertness
ing every 5 minutes until the score is greater than 7 following birth, lasting around 30 minutes. This
(Apgar, 1953; Apgar, 1966). However, the APGAR score is followed by a period of sleep, until the infant is
is not used in isolation to establish the diagnosis of around 3–4 hours of age.
birth asphyxia (American Academy of Pediatrics [AAP], • The second period of reactivity occurs between 3–
Committee on Fetus and Newborn; American College 6 hours after birth, when the infant is awake again.
of Obstetricians and Gynecologists [ACOG], & Com- The infant may be alert or have variable motor
mittee on Obstetric Practice, 2006). The 1-minute activity, such as gagging or arching.
APGAR score may be low because of prenatal or in- These periods of reactivity may impact the physical
trapartum events or medications and is not predictive examination of the infant; for example, it may be dif-
of outcomes. The 5-minute APGAR score reflects the ficult for the infant to attain and maintain a state of
success of the resuscitation or the severity of the neo- alertness in the sleep period shortly after birth.
natal depression. A 5-minute APGAR score of 0–3 is
associated with a slightly increased risk of cerebral pal- Initial Impression
sy compared with higher scores. The risk of poor neu- It is important that the parents are present at the ini-
rologic outcomes increases when the APGAR score is 3 tial examination to facilitate a dialogue between the
or less beyond 5 minutes (AAP, ACOG, & Committee health care provider and the parents. Parents can be
on Obstetric Practice, 2006). informed of the findings, and the infant’s strengths
Along with APGAR scoring, the principles of the can be emphasized. The provider can educate the par-
American Heart Association and the American Academy ents at this time about their infant and infant care.
of Pediatrics Neonatal Resuscitation Program are used to The health care provider’s initial impression of the
assess each newborn’s need for resuscitation. The infant’s infant is very important. The experienced provider
respirations, heart rate, and color are assessed, with sub- can quickly evaluate the infant’s overall status. Color,
sequent resuscitation efforts based on this assessment. transitional state, activity, cry, and respiratory effort
Repeated assessment of these parameters determines the are the main components of this initial impression. A
pink, active infant, breathing without distress “looks stressful to a compromised infant. Some portions of the
good,” while a pale or cyanotic, lethargic, or dyspneic examination must be deferred if the infant is critically
infant “looks bad” and requires physiologic stabiliza- ill. Manipulation of the infant on life support cannot
tion before physical examination. If the infant “looks be accomplished until the infant is stable and support
bad,” assessment for the cause and stabilization should measures are removed. Responses of the infant who is
take precedence. pharmacologically sedated are altered accordingly.
Many portions of the examination require that the
Maintenance of Physiologic Stability infant be quiet and cooperative; therefore, the provider
Neonatal assessment should occur in a setting that is should start with noninvasive maneuvers before the in-
conducive to a full examination. The neonate should vasive maneuvers; for example, auscultation before pal-
be kept warm during the assessment; this is difficult in pation. Auscultation of the heart, lungs, and abdomen
small infants as body heat is lost quickly when they are are completed if the infant is quiet, followed by a head-
exposed. Thermal stability is paramount and should to-toe examination.
not be compromised; a radiant heat source should
be used during the examination if needed to prevent GESTATIONAL AGE ASSESSMENT
cold stress. An infant without an external heat source
should not be exposed for long periods of time. A blan- Determination of gestational age is accomplished
ket can be used to cover the portions of the infant not through determination of the maternal EDC, prenatal
being examined. If possible, it is important to observe ultrasound, or physical examination. Determination
the undressed infant briefly. The room should be warm of the EDC, using the mother’s last menstrual period
and free of drafts, and the provider’s hands and stetho- (LMP), is imprecise if the mother’s menstrual cycles are
scope should be warmed prior to the assessment. The irregular or if there is early bleeding that is misinter-
infant should be handled gently and calmed as needed preted as menses. In addition, some women are poor
throughout the examination. The infant should be historians and do not recall their LMP. Lack of prenatal
warm and calm at the conclusion of the examination. care increases the uncertainty of gestational age.
The exact gestational ages of infants born as the
result of reproductive technologies, such as in vitro
Preparation for the Assessment fertilization, are easily determined, unless the mother
Before the infant’s first bath, the health care provider conceived outside of the implantation/fertilization
should wear gloves when handling the infant. Follow- process. Prenatal ultrasound early in gestation is accu-
ing the first bath, gloves are optional if the provider is rate in assessing gestational age (Neilson, 2000). Ultra-
not in contact with the infant’s body fluids. sound examinations later in gestation are less accurate
The health care providers’ tools—stethoscope, tape because of variations in fetal growth.
measure, and ophthalmoscope—should be ready for Infants born before 37 completed weeks’ gestation
the examination; the stethoscope bell and diaphragm are considered preterm. Infants born between the be-
should be cleaned with alcohol, an excellent disinfectant ginning of week 38 and the completion of week 41 are
(Parmar, Valvi, Sira, & Kamat, 2004). There should be a considered term. Infants born at 42 weeks’ gestation or
plan in place for the assessment so that it can be com- later are considered postterm.
pleted quickly. It is important to develop a system for the Neuromuscular and physical characteristics can be
comprehensive examination that varies as little as possi- used to estimate gestational age by observing and manip-
ble, allowing the provider to be efficient and thorough. ulating the infant in a systematic and standardized exam.
In the standardized exam, several indicators of physical
Assessment Sequence and neuromuscular maturity are scored and summed to
Assessment begins with observation, that is, always estimate the infant’s gestational age (Fig. 11-1).
observation before manipulation. Whether the infant
is clothed and wrapped in a blanket or undressed, the
health care provider should observe the infant prior to NEW BALLARD SCORE
touching. If the infant is sleeping, the provider should
observe the general color and body posture, as well as Physical examination of the infant’s maturity is
respiratory efforts and sleep activity. If the infant is in a routinely accomplished in the newborn nursery or
quiet alert state, the provider should observe color, pos- neonatal intensive care unit (NICU). Fetal physical
ture, movements, respiratory effort, and the ability to and neurologic developmental changes are assessed.
track visually. If the infant is crying, the provider should The Dubowitz examination (Dubowitz, Dubowitz, &
observe color, posture, movements, and respiratory ef- Goldberg, 1970) was created in 1970 but shortened
fort, and then calm the infant for further examination. If in 1979 by Dr. Jeanne L. Ballard (Ballard, Novak, &
the infant is compromised in any way, the examination Driver, 1979). The full Dubowitz examination in-
should be delayed or accomplished with extra care to cludes multiple items, many of which are difficult
maintain physiologic stability. An examination can be to accomplish with an infant who is ill, and it does
NEUROMUSCULAR MATURITY
SCORE RECORD SCORE
NEUROMUSCULAR
SCORE Neuromuscular
MATURITY SIGN –1 0 1 2 3 4 5 HERE Physical
Total
POSTURE
MATURITY
RATING
SQUARE WINDOW
(Wrist) Score Weeks
–10 20
ARM RECOIL –5 22
0 24
5 26
POPLITEAL ANGLE
10 28
15 30
SCARF SIGN 20 32
25 34
HEEL TO EAR 30 36
35 38
TOTAL NEUROMUSCULAR
40 40
MATURITY SCORE
45 42
50 44
PHYSICAL MATURITY
SCORE RECORD
PHYSICAL
SCORE
MATURITY SIGN –1 0 1 2 3 4 5 HERE
sticky, gelatinous, smooth, superficial cracking parchment, leathery,
SKIN friable, red, pink, peeling pale areas, deep cracked,
transparent translucent visible veins and/or rash, rare veins cracking, wrinkled
few veins no vessels
none sparse abundant thinning bald mostly

LANUGO areas bald
PLANTAR heel-toe anterior creases

>50 mm faint creases
SURFACE 40–50 mm: –1 transverse over
<40 mm: –2 no crease red marks crease only ant. 2/3 entire sole
stippled raised full areola
BREAST impercep- barely flat areola areola areola 5–10 mm
tible perceptible no bud 1–2 mm bud 3–4 mm bud bud
lids fused lids open sl. curved well-curved formed and thick
EYE-EAR loosely: –1 pinna flat pinna; soft; pinna; soft but firm cartilage,
tightly: –2 stays folded slow recoil ready recoil instant recoil ear stiff
scrotum testes in testes testes
GENITALS scrotum flat, empty, upper canal, descending, testes down, pendulous,
(Male) smooth faint rugae rare rugae few rugae good rugae deep rugae
clitoris prominent prominent majora and majora
GENITALS prominent clitoris and clitoris and minora majora large, cover
(Female) and labia flat small labia enlarging equally minora small clitoris and
minora minora prominent minora
TOTAL PHYSICAL
MATURITY SCORE
FIGURE 11-1. New Ballard Score. (Source: Ballard, J. L., Khoury, J. C., Wedig, K., Wang, L., Eilers-
Walsman, B. L., & Lipp, R. [1991]. New Ballard Score, expanded to include extremely premature
infants. Journal of Pediatrics, 119[3], 417–423.)
not include criteria for scoring the extremely pre- of gestation are determined by the Ballard maturity
term infant. The New Ballard Score (NBS) developed rating table (see Fig. 11-1).
by Dr. Ballard is a set of procedures to determine
gestational age through neuromuscular and physi-
cal assessment of a newborn infant (Ballard, Khoury, ASSESSMENT OF NEUROMUSCULAR
Wedig, Wang, Eilers-Walsman, & Lipp, 1991). The
MATURITY
NBS is accurate within 2 weeks in infants born at
26–42 weeks’ gestation if completed within 96 hours Posture
of birth; in infants born at less than 26 weeks’ gesta- (The following information is reproduced with
tion, the NBS is accurate within 2 weeks if done with- permission from www.ballardscore.com.)
in 12 hours of birth (see Fig. 11-1). The points ob- Total body muscle tone is reflected in the infant‘s
tained with the examination are summed; the weeks preferred posture at rest and resistance to stretch of
individual muscle groups. The preterm infant primar- appropriate square is selected on the score sheet
ily exhibits unopposed passive extensor tone, while (Table 11-7). The extremely preterm infant does not
the infant approaching term shows progressively exhibit any arm recoil (see Fig. 11-1, arm recoil score
less opposed passive flexor tone. To elicit the posture of 0). A score of 4 is selected only if there is contact
item, the infant is placed supine (if previously prone), between the infant‘s fist and face. This is seen in term
and the health care provider waits until the infant and postterm infants.
settles into a relaxed or preferred posture. If the in-
fant is found supine, gentle manipulation (i.e., flex if Popliteal Angle
extended; extend if flexed) of the extremities allows This maneuver assesses the maturation of passive
the infant to seek a baseline position of comfort. Hip flexor tone around the knee joint by testing for resis-
flexion without abduction results in the frog-leg po- tance to extension of the lower extremity. With the
sition as depicted in Figure 11-1, posture square #3. infant lying supine and with the diaper removed, the
Hip abduction accompanying flexion is depicted by thigh is placed gently on the infant‘s abdomen with
the acute angle at the hips in Figure 11-1, posture the knee fully flexed. After the infant has relaxed into
square #4. The figure that most closely depicts the in- this position, the provider gently grasps the foot at
fant‘s preferred posture is selected. the sides with one hand while supporting the side of
the thigh with the other. Care is taken not to exert
Angle of Wrist Flexion pressure on the hamstrings, as this may interfere
Wrist flexibility and resistance to extensor stretch- with their function. The leg is extended until a defi-
ing are responsible for the resulting angle of flexion nite resistance to extension is appreciated. Hamstring
at the wrist. The provider straightens the infant‘s fin- contraction may be visualized during this maneuver
gers and applies gentle pressure on the dorsum of the in some infants. At this point, the angle formed at
hand, close to the fingers. From extremely preterm to the knee by the upper and lower leg is measured. It
postterm, the resulting angle between the palm of the is important that the provider waits until the infant
infant‘s hand and forearm is estimated. stops kicking actively before extending the leg. The
prenatal frank breech position interferes with this
Arm Recoil maneuver for the first 24–48 hours of age as a result of
This maneuver focuses on passive flexor tone of the prolonged intrauterine flexor fatigue. The test should
biceps muscle by measuring the angle of recoil fol- be repeated once recovery has occurred; alternately, a
lowing very brief extension of the upper extremity. score similar to those obtained for other items in the
With the infant lying supine, the provider places one examination may be assigned.
hand beneath the infant‘s elbow for support. Taking
the infant’s hand, the provider briefly sets the elbow Scarf Sign
in flexion, then momentarily extends the arm before This maneuver tests the passive tone of the flexors
releasing the hand. The angle of recoil to which the around the shoulder girdle. With the infant lying su-
forearm springs back into flexion is noted, and the pine, the health care provider adjusts the infant‘s head
TABLE 11-7
Growth Assessment Terminology
TERM COMMON ETIOLOGIES COMMON RISKS
SGA ⫽ small for gestational age; less Placental insufficiency Hypoglycemia
than 10th percentile on curve Maternal hypertension Thrombocytopenia
Discordant twin Hearing loss
Maternal smoking Poor postnatal growth
Congenital viral infection
Infant factors (genetic syndrome)
AGA ⫽ average or appropriate for N/A N/A

gestational age; 10th–90th percentile
on curve
LGA ⫽ large for gestational age; Infant of diabetic mother Birth trauma
greater than 90th percentile on curve Hypoglycemia
Hypocalcemia
Respiratory distress syndrome
to the midline and supports the infant‘s hand across Lanugo begins to appear at approximately the 24th to
the upper chest with one hand. The thumb of the pro- 25th week and is usually abundant, especially across the
vider’s other hand is placed on the infant‘s elbow. The shoulders and upper back, by the 28th week of gesta-
provider nudges the elbow across the chest, feeling for tion. Thinning occurs first over the lower back, wearing
passive flexion or resistance to extension of the poste- away as the fetal body curves forward into its mature,
rior shoulder girdle flexor muscles, that is, the point flexed position. Bald areas appear and become larger
on the chest to which the elbow moves easily before over the lumbosacral area. At term, most of the fetal
significant resistance is noted. Landmarks noted in or- back is devoid of lanugo (i.e., the back is mostly bald).
der of increasing maturity are full scarf at the level of Variability in amount and location of lanugo at a given
the neck (⫺1); contralateral axillary line (0); contra- gestational age may be attributed in part to familial or
lateral nipple line (1); xyphoid process (2); ipsilateral racial differences and to certain hormonal, metabolic,
nipple line (3); and ipsilateral axillary line (4). and nutritional influences. For example, infants of
diabetic mothers characteristically have abundant lanu-
Heel to Ear go on their pinnae and upper back until close to or be-
This maneuver measures passive flexor tone around the yond full-term gestation. When scoring for lanugo, the
pelvic girdle by testing for passive flexion or resistance to provider selects the square that most closely describes
extension of posterior hip flexor muscles. The infant is the relative amounts of lanugo on the upper and lower
placed supine, and the flexed lower extremity is brought areas of the infant’s back (see Fig. 11-1).
to rest on the mattress alongside the infant‘s trunk. The
health care provider supports the infant‘s thigh laterally Plantar Surface
alongside the body with the palm of one hand. The other This item pertains to the major foot creases on the sole of
hand is used to grasp the infant‘s foot at the sides and to the foot. The first appearance of a crease is on the ante-
pull it toward the ipsilateral ear. The provider feels for rior sole at the ball of the foot. This may be related to foot
resistance to extension of the posterior pelvic girdle flex- flexion in utero, but dehydration of the skin may also be
ors and notes the location of the heel where significant a contributor. Very premature and extremely immature
resistance is appreciated. Landmarks noted in order of in- infants have no detectable foot creases. To help define
creasing maturity include resistance felt when the heel is the gestational age of these infants further, measuring the
at or near the ear (⫺1), nose (0), chin level (1), nipple line foot length or heel–toe distance is helpful. This is done
(2), umbilical area (3), and femoral crease (4). by placing the infant‘s foot on a metric tape measure and
noting the distance from the back of the heel to the tip
of the great toe. For heel-toe distances less than 40 mm, a
ASSESSMENT OF PHYSICAL MATURITY ⫺2 score is assigned; for those between 40 and 50 mm, a
Skin ⫺1 score is assigned (see Fig. 11-1).
Maturation of fetal skin involves the development of
its intrinsic structures concurrent with the gradual loss Breasts
of its protective coating, the vernix caseosa. Hence, The breast bud consists of breast tissue that is stimulated
it thickens, dries, and becomes wrinkled or peels to grow by maternal estrogens and fatty tissue, which is
and may develop a rash as the fetus matures. These dependent upon fetal nutritional status. The health care
phenomena may occur at varying paces in individual provider notes the size of the areola and the presence or
fetuses, depending in part upon the maternal condi- absence of stippling (created by the developing papillae
tion and the intrauterine environment. Before the de- of Montgomery). The provider then palpates the breast
velopment of the epidermis with its stratum corneum, tissue beneath the skin by holding it between thumb
the skin is transparent and adheres somewhat to the and forefinger, estimating its diameter in millimeters
provider‘s finger. Later it smoothes, thickens, and pro- and selects the appropriate square on the score sheet
duces a lubricant, the vernix, that dissipates toward (see Fig. 11-1). Under- and overnutrition of the fetus
the end of gestation. At term and postterm, the fetus may affect breast size at a given gestation. Maternal es-
may expel meconium into the amniotic fluid. This may trogen effects may produce neonatal gynecomastia, on
add an accelerating effect to the drying process, caus- the 2nd to 4th day of extrauterine life, potentially last-
ing peeling, cracking, dehydration, and imparting a ing until 2 weeks of age.
parchment, then leathery, appearance to the skin. For
scoring purposes, the square that describes the infant‘s Eyes and Ears
skin the most closely should be selected (see Fig. 11-1). The pinna of the fetal ear changes its configuration and
increases in cartilage content as maturation progress-
Lanugo es. Assessment includes palpation for cartilage thick-
Lanugo is the fine hair covering the body of the fetus. ness, then folding the pinna forward toward the face
In extreme immaturity, the skin lacks any lanugo. and releasing it. The provider notes the rapidity with
which the folded pinna snaps back away from the face the enlarging labia majora. The labia majora contain
when released, then selects the square that most closely fat, and their size is affected by intrauterine nutrition.
describes the degree of cartilaginous development Overnutrition may result in large labia majora early
(see Fig. 11-4). In very premature infants, the pinna in gestation, whereas undernutrition, like intrauter-
may remain folded when released. In such infants, the ine growth retardation or postmaturity, may result in
provider notes the state of eyelid development as an small labia majora with a relatively prominent clito-
additional indicator of maturation. The provider places ris and labia minora late in gestation. These findings
the thumb and forefinger on the upper and lower lids, should be reported as observed, since a lower score on
gently separating them. The extremely immature in- this item in the chronically stressed or growth-retarded
fant has tightly fused eyelids (i.e., the provider will not infant may be counterbalanced by a high score on cer-
be able to separate either palpebral fissure with gentle tain neuromuscular items.
traction). These findings allow the provider to select a
⫺2 score. The more mature infant has one or both eye-
lids fused, but one or both can be separated by the light GROWTH ASSESSMENT
traction of the provider‘s fingertips. For loosely or par- Growth parameters are important aspects of physical
tially fused eyelids, the provider selects a ⫺1 score. The assessment. Fetal growth is influenced by many genetic
provider should not be surprised by a wide variation and environmental factors. Normal fetal growth plots
in eyelid fusion status in individual infants at a given are available with the Ballard examination recording
gestational age, as the rate at which eyelids unfuse may sheet (Battaglia & Lubchenco, 1967). It is important to
be affected by stress-related intrauterine factors. determine if infant growth is normal, allowing close
monitoring for risk factors associated with abnormal
Male Genitalia growth (see Table 11-7).
The fetal testicles begin their descent from the peri- Measurements of the infant’s weight, length, and
toneal cavity into the scrotal sac at approximately head circumference (occipital frontal circumference
30 weeks’ gestation. The left testicle precedes the right [OFC]) are obtained following birth. Length is the
and usually enters the scrotum during the 32nd week. most difficult measurement to assess reliably; care
Both testicles are usually palpable in the upper to should be taken to extend the infant fully, using a
lower inguinal canals by the end of the 33rd to 34th length board if possible ( Johnson & Engstrom, 2002).
weeks’ gestation. Concurrently, the scrotal skin thick- Growth parameters are plotted on the growth curve
ens and develops deeper and more numerous rugae. according to the infant’s gestational age, determining
Testicles found inside the rugated zone are considered the appropriateness of growth. The infant’s gestational
descended. In extreme prematurity, the scrotum is flat, age must be determined as accurately as possible for
smooth, and appears sexually undifferentiated. At term accurate growth assessment. The infant’s weight deter-
to postterm, the scrotum may become pendulous and mines the appropriateness of growth at the determined
may actually touch the mattress when the infant lies gestational age.
supine. Note that in true cryptorchidism, the scrotum • Length: Normal crown-to-heel length at term is
on the affected side appears uninhabited and hypoplas- 44–55 cm.
tic with underdeveloped rugae compared to the normal • Weight: Normal weight at term is 2.5–3.9 kg.
side or, for a given gestation, when bilateral. In such • Head circumference/occipital frontal circumfer-
cases, the normal side should be scored, or if bilateral, ence (OFC): Normal head circumference at term is
a score similar to that obtained for the other matura- 33–36 cm.
tional criteria should be assigned (see Fig. 11-1). • Chest circumference: The chest circumference
should be 1–2 cm less than the head circumference,
thus giving a rough assessment of head size.
Female Genitalia
To examine the female genitalia, the provider should
only partially abduct the infant’s hips (i.e., to approx-
imately 45 degrees from the horizontal with the in- VITAL SIGN ASSESSMENT
fant lying supine). Exaggerated abduction may cause The infant’s axillary temperature is normally 36°–37° C.
the clitoris and labia minora to appear more promi- Some health care providers advocate one rectal tempera-
nent, whereas adduction may cause the labia majora ture after birth to rule out imperforate anus. The new-
to cover them. In extreme prematurity, the labia are born’s pulse is normally 100–140 beats/minute (bpm)
flat, and the clitoris is very prominent, resembling the at rest, but it increases with crying. Some normal new-
male phallus. As maturation progresses, the clitoris borns have a resting heart rate as low as 80–90 bpm at
becomes less prominent, and the labia minora become rest. The respiratory rate of a normal newborn is 30–60
more prominent. Nearing term, both the clitoris and breaths/minute, but this rate increases with crying. Uni-
labia minora recede and are eventually enveloped by versal blood pressure screening in the well newborn is
not warranted (AAP Committee on Fetus and Newborn, by 40 weeks’ gestation. Lanugo is more prominent
1993). Blood pressure should be monitored closely in ill or visible in darker-skinned infants.
infants. If congenital heart disease is suspected, blood • Vernix caseosa is a greasy white or yellow material
pressure measurements in all four extremities may be composed of sebaceous gland secretions and exfoliated
helpful in diagnosing coarctation of the aorta, where the skin cells. Vernix caseosa develops during the third
upper extremity (specifically, the right arm) pressure is trimester and covers the newborn skin, decreasing in
15 mm Hg or more higher than the lower extremity. amount as the fetus nears 40 weeks’ gestation.
• Meconium-stained skin is seen if meconium is
passed by the fetus and delivery is delayed; the skin
SKIN ASSESSMENT takes on a greenish color. This is most pronounced
Color Variants in the umbilical cord and the nails.
Skin color varies according to the racial background
of the infant (Thilo & Rosenberg, 2009), but it should
Skin Perfusion
be pink at birth. Pallor may indicate anemia or shock. Skin perfusion is assessed by inspection and palpation.
If the infant has dark skin tones, the provider should Poor skin perfusion may be seen with cold stress, hy-
observe for pink color in the lips, the palms of the pothermia, or shock. Mottling, a blotchy marbling ef-
hands, and the soles of the feet. Normal variants fect, is common with cold stress, although it is more
include the following (Harper, Orange, & Prose, 2005; common in infants with Down syndrome and may be
Morelli & Burch, 2009): present in infants with low cardiac output. Mottling is
less visible in dark-skinned infants.
• Acrocyanosis is a bluish-purple coloring of the
Capillary refill time is assessed by pressing on the
extremities that is worsened by cold stress.
skin, usually over the chest. Blanching of the skin is
• Mottling (cutis marmorata) is a normal variation
observed; refill time should be brisk. Abnormal or pro-
unless exaggerated and accompanied by other signs
longed capillary refill time is over 3 seconds. Capillary
of shock.
refill time in the extremities is normally more pro-
• Plethora is a deep red skin color that is normal,
longed than over the trunk.
especially with crying. If the infant also has a deep
red color with purplish extremities, a high hemato- Rashes
crit level (polycythemia) may be present. The hemato- Common newborn rashes are listed in Box 11-1. A few
crit level should be monitored in infants with pallor examples can be seen in Figure 11-2.
or plethora.
• Harlequin color change describes an infant who,
when lying on one side, is red on the inferior por-
HEAD AND NECK ASSESSMENT
tion and pale on the superior portion. The cause Shape and Size
is unknown, but it is thought to be a temporary Molding of the head is common with a vaginal de-
imbalance of the autonomic regulatory mechanism livery, as the head passes through the vaginal canal.
of the cutaneous vessels. Molding may also be seen with a cesarean section
• Jaundice is the yellow discoloration of skin be- delivery if the head descended into the pelvis before
cause of the subcutaneous accumulation of bilirubin the operative delivery. The parietal bones overlap the
(hyperbilirubinemia). Jaundice is pathologic in the first frontal bones, and the head appears elongated. This
24 hours and is initially most apparent in the face; resolves very quickly over the first few days of life.
however, as the hyperbilirubinemia worsens, jaun- The infant’s head has a different appearance fol-
dice is visible further down the body. Physiologic lowing breech delivery, as molding does not occur,
jaundice is not visible until after 24 hours, depending and the occiput appears prominent. Other variations
on the subcutaneous fat composition of the infant. in head shape may be seen temporarily, reflecting in
Preterm or thin infants with little subcutaneous fat utero positioning, usually resolving over the first few
do not appear jaundiced in proportion to the biliru- days of life (Fig. 11-3).
bin levels. Conversely, infants with generous subcu-
taneous fat appear jaundiced at lower levels. Jaundice Occipital-Frontal Circumference
is also less visible in dark-skinned infants. Jaundice The health care provider should plot the occipital-fron-
color estimation is not a reliable indicator of serum tal circumference (OFC) on the Ballard gestational age
bilirubin levels. assessment growth curve (see Fig. 11-1). Normal size is
33–36 cm at term (see Fig. 11-1). Head circumference
Other Skin Variants that is outside the normal range requires investigation
• Lanugo is a fine, soft, downy hair covering of the to determine the etiology, guide treatment, and aid in
fetus in utero and some term newborns. It ap- providing an accurate prognosis.
pears at about 20 weeks’ gestation, peaks at around • Microcephaly is defined by an OFC less than the
28 weeks’ gestation, and then thins; little is apparent 10th percentile. It is associated with congenital viral
BOX 11-1
Common Skin Variations in the Newborn Infant
• Erythema toxicum manifests as small white or yellow papules or vesicles with an erythematous base (see Fig. 11-2).
• Milia are yellow or white papules about 1 mm size. These are epidermal cysts caused by the accumulation of
sebaceous gland secretions (see Fig. 11-2).
• Miliaria are obstructed sweat ducts: (a) miliaria crystallina, 1–2 mm vesicles; (b) miliaria rubra: prickly heat, which
appears as small erythematous papules; and (3) miliaria pustulosa: pustular milia, which can lead to a secondary
infection of the deeper sweat glands (miliaria profunda).
• Sebaceous gland hyperplasia manifests as numerous tiny (less than 0.5 mm) white or yellow papules on the nose and
upper lip.
• Neonatal herpes manifests as vesicles that can appear anywhere. Crusting occurs after opening. This is ominous, as
infection can disseminate and be fatal.
• Petechiae are pinpoint-sized hemorrhagic spots on the skin. A few are normal over the face following vertex vaginal
delivery. Multiple petechiae may indicate thrombocytopenia.
• Mongolian spots are commonly seen, especially in dark-skinned infants, over the sacrum/buttocks, but they may be
anywhere on the body, indicating melanocytes infiltrating the dermis. Mongolian spots are benign and fade over the first
few years of life. These lesions may be mistaken for bruising by those unfamiliar with this common variant (see Fig. 11-4).
• Nevi are dark brown or black macules. These are generally benign, but malignant changes may occur in up to 10%
of larger (⬎2 cm diameter) nevi. A spilus is a nonhairy nevus, while a pilosus is a hairy nevus.
• Accessory nipples may be seen, usually over an imaginary line drawn from the main nipple to the umbilicus.
Breast tissue is usually not present, and the nipple is usually not well formed. Accessory nipples may be similar in
appearance to a dark nevus.
• Café au lait patches are tan or light brown macules or patches with well-defined borders. Larger spots or the presence
of more than six lesions may indicate cutaneous neurofibromatosis (von Recklinghausen disease).
• Cutis aplasia is the absence of some or all layers of the skin. These are most commonly found on the scalp.
• Traumatic skin lesions include forceps marks, which are most common on the cheeks, scalp, or face. The practitioner
must examine the child closely for facial palsy, fractured clavicles, and skull fractures (see Fig. 11-2).
• Subcutaneous fat necrosis is a subcutaneous nodule that is hard and sharply circumscribed; it may be red or purplish.
The cause is trauma, cold stress, or asphyxia. These may grow slowly, then resolve over several weeks.
• Facial bruising may be present, usually with face presentations or forceps marks at birth.
• Scalp lesions can result from scalp electrode placement. A scalp electrode provides monitoring of the fetal heart
rate during delivery. The skin is punctured as the spiral electrode is inserted. If the scalp is scratched with electrode
placement, the site should be monitored for infection.
• Edematous skin and subcutaneous tissues under a vacuum cup can result from vacuum extraction, which is used to
facilitate delivery as an alternative to forceps. Discoloration and skin abrasions may also be present.
• Scalp pH sampling leaves a puncture mark, which should be monitored for infection. Blood is often obtained during
labor for pH analysis, indicating the fetal acid-base status, a measure of fetal well-being.
• Sucking blisters are vesicles or bullae on the lips, fingers, or hands, resulting form the fetus sucking on the area.
• Hypoplasia or absence of the nails is associated with trisomies or Turner syndrome. Abnormal shape of the nails may be
a normal variant or associated with anomalies of the hair or skin.
VASCULAR SKIN LESIONS

• Telangiectatic nevi, or nevus simplex are commonly called stork bites. These are found at the nape of the neck and on
the upper eyelids, bridge of the nose, and upper lip. They blanch with pressure and fade over the first 1–2 years of
life (see Fig. 11-2).
• Port wine stain or nevus flammeus manifests as flat pink or reddish purple lesion consisting of dilated, congested capillaries
directly beneath the epidermis. The lesion has sharp borders, does not blanch with pressure, and does not fade over time.
• Strawberry marks (capillary hemangioma) are lesions that consist of dilated capillaries. These are usually not present at
birth but appear shortly after birth, often as small pinpoint lesions, which grow in size over the first 6–12 months of
life. They appear as bright red, raised, lobulated tumors. They feel soft when palpated and have sharply demarcated
margins. After a year of age, the lesions usually begin to resolve, appearing light color at the center. Surgical removal
is not recommended initially, since cosmetic outcomes are better if the lesion regresses without intervention.
Hemangiomas are more common in preterm infants; some have multiple lesions over their body. Intervention is
required if the hemangioma is over the eyelid, restricting vision, or if the lesion bleeds excessively.
• Cavernous hemangiomas are larger than capillary hemangiomas, purplish, and soft and compressible, with poorly
defined borders.
A B
C D
FIGURE 11-2. Erythema toxicum (A);

milia (B); mongolian spots (C); telangiac-
tatic nevi (D); and forceps marks (E). For
a full-color example, please refer to Figure
E 11-2 on page C1.
infections or results from unknown factors. If the mi- Skull

crocephaly persists, the developmental prognosis is The infant’s skull should be examined visually and by
poor. palpation. The infant’s skull shape, sutures, and bony
• Macrocephaly is defined by an OFC greater than the structure may provide information about congenital mal-
90th percentile. This may be present with congenital formations or birth trauma. The skull should be assessed
hydrocephalus, or it may be a normal variant that is when the infant is quiet, as the fontanelles become tense
familial. with crying (Fig. 11-4). The fontanelles should be soft and
flat and measured bone to bone, diagonally. The anterior
fontanelle is diamond-shaped. The size varies from less
than 1 cm by 1 cm to 4-5 cm; it closes by 12–18 months’
age. The posterior fontanelle is triangle-shaped. Size is usu-
ally less than 1 cm, closing by 2–3 months of age.
All sutures should be mobile and split less than 1 cm.
Sutures may be overlapping because of molding, resolv-
ing in the first weeks of life. Craniosynostosis describes
a condition in which one or more sutures close prema-
turely, leading to an abnormally shaped head.
Scalp and Hair

The infant’s head should be inspected and palpated to
detect congenital malformations or birth sequelae.
Caput Succedaneum. This is usually called simply

FIGURE 11-3. Molding in the infant’s head. caput and indicates edema of the fetal scalp as a result
Posterior Hair Whorls. One or two hair whorls, where the hair
fontanelle
grows in a circular pattern, are normal variants; however,
an increased number of hair whorls is associated with ab-
Lambdoidal normal brain development (Hudgins & Cassidy, 2006).
suture
Sagittal
suture Encephalocele. An encephalocele is a herniation of the
brain and meninges resulting from a defect in the skull,
most commonly in the occipital region. It may be small
Coronal Anterior or large and may or may not include brain matter.
suture fontanelle
Face
The provider must observe the infant’s face when the
Metopic infant is crying to assess for appropriate movement
suture
and for asymmetry. For example, facial palsy might
not be apparent unless the infant is crying.
Ears
The ears vary widely in appearance, and the provider
must observe the parents’ ears for comparison. It is im-
FIGURE 11-4. Skull, sutures, and fontanelles. portant to determine the position or placement of the
ears on the infant’s head. The provider must extend a
of labor and delivery. It is accentuated by a vacuum- line from the inner to the outer canthus of the eye to-
assisted delivery. Edema usually crosses suture lines, ward the ear. The insertion of the pinna should fall on
and the edges are poorly defined. Caput is noted im- this line. If the insertion falls below this line, the ears are
mediately after birth and resolves in a few days. low-set (see Chapter 14 for ear placement guidelines).
The provider should look for pits and skin tags
Cephalhematoma. A cephalhematoma is a collection around the ears; these are commonly found in front of
of blood between the periosteum and the skull. This is the ear (see Chapter 14). Otoscopic examination is not
usually not evident immediately after birth because of a part of the newborn examination, as the canals are
the slow bleeding process, and it may be masked by an very small and often filled with vernix.
overlying caput. Clearly demarcated edges are visible, Hearing screening is recommended for all infants
not crossing suture lines. A cephalhematoma may take before discharge from the newborn nursery (Nelson,
weeks or months to resolve (Fig. 11-5). Bougatsos, & Nygren, 2008; U.S. Preventive Services Task
Scalp
Periosteum
Skull
Caput
Scalp
Periosteum
Skull
Cephalhematoma
FIGURE 11-5. Differentiating between caput and cephalhematoma.

Force, 2008). Some state laws mandate neonatal hearing describes when the inner canthus is higher than outer
screening. Informal hearing assessment is accomplished canthus. An epicanthal fold is present in some races,
by shaking a rattle near the infant’s ear and observing and in infants with Down syndrome.
for a change in behavior or breathing patterns or by a Other notable abnormalities of the eyes include ptosis
startle reflex. Infants should turn to sound by 4 months. (drooping of the upper eyelid) and coloboma (defect in
Formal screening is accomplished in the nursery by an the closure of a portion of the lid or eye). Tear formation
audiologist or by another trained professional. Hearing does not begin until 2–3 months of age. Obstruction of
evaluation should continue for at least 3 years in infants the tear duct (nasolacrimal duct) is common, resulting
at risk for progressive or delayed-onset hearing loss, such in purulent or mucoid eye drainage. This is not usually
as preterm infants and children with Down syndrome. seen in the first few months. Redness or swelling of the
The preferred methods of screening infants for hearing area may indicate an infection.
loss are the evoked otoacoustic emissions (EOAE or OAE) The eye examination is most easily accomplished
or auditory brainstem response (ABR) tests. The ultimate when the infant is quiet and alert. The lights should be
goal of early audiologic diagnosis of hearing loss is to be- dimmed, and the ophthalmoscope adjusted to a small
gin treatment as soon as possible to minimize delay in round white beam. Assessment should be performed
speech, language, and academic development. from about 6 inches from the eye to assess pupil size and
constriction. The provider should look for a clear red
Evoked Otoacoustic Emissions. The EOAE test is a color (red reflex) over the lens. The absence of a red re-
rapid, noninvasive, computer-managed, and inexpen- flex could imply congenital cataracts, retinoblastoma, or
sive method of assessing cochlear function based on glaucoma. The red reflex is pale or pink in dark-skinned
the cochlea’s ability to transmit sound to the brain. infants. The corneal reflex describes blinking in response
This test also generates low-level sound that is trans- to blowing into the infant’s eye or gently touching the
mitted from the cochlea to the outer ear canal (Herer, cornea with a cotton swab to elicit a blink.
2002). The EOAE is fast and easy to perform but is af- The iris is dark gray, blue, or brown at birth, differ-
fected by debris or fluid in the external and middle ear ing among racial groups. The provider should examine
(Task Force on Newborn and Infant Hearing, 1999). the iris for Brushfield’s spots, which are white specks scat-
tered over the iris; these are associated with Down syn-
Auditory Brainstem Response. The ABR tests the drome. The sclera should be white, light blue, or bluish
cochlea’s response to sound and the auditory neural white. Blue sclera are associated with osteogenesis imper-
pathway (Task Force on Newborn and Infant Hearing, fecta (a collagen disorder characterized by brittle bones).
1999). A diagnostic ABR audiometry is a highly sensi- Sclera may become yellow with extreme jaundice. Areas
tive test for both hearing loss and neural disruption of of hemorrhage are common following birth. Sunset
the auditory pathway that explores threshold loss and eyes, where the eyes appear to look downward, may in-
activity in the auditory brainstem pathway. dicate hydrocephalus or other neurologic problems.
If an infant fails either the EOAE or the ABR screen-
ing test, the test should be repeated. If the infant fails Nose
the repeat examination, an otolaryngologist should The nose may initially be deviated because of the in
examine the ears for any abnormalities, and a diagnos- utero position and delivery. Patency of the nares must
tic ABR should be done as soon as possible. be assessed. Since infants are obligatory nose breath-
ers, it can be assumed that at least one nostril is patent
Eyes if the infant is quiet and breathing normally. Passing a
Esotropia (cross-eye) and exotropia (walleye) are normal feeding tube or suction catheter through each nostril
findings until the infant is 4 months of age. The term confirms patency but is not necessary unless nasal ob-
newborn is able to track visually when in a quiet, alert struction is suspected.
state. Palpebral fissures describe the elliptical spaces when Choanal atresia, the congenital blockage of nasal pas-
the eyelids are opened normally. The health care provid- sages by membrane or bone, may be an isolated defect
er should note an abnormal size or shape of the fissures. or part of a syndrome. The infant with choanal atresia
Edema or bruises of the eyelids are common, as are con- is pink when crying but becomes dyspneic and eventu-
junctival or subconjunctival hemorrhages. The provider ally cyanotic and bradycardic when quiet. An oral air-
should evaluate the placement and size of the eyes. Nor- way facilitates respirations. Infants with nasal passages
mal eye spacing is evaluated by measuring the eye width; that are partially obstructed by secretions or edema
the eyes are normally one eye width apart. Hypertelorism or that are congenitally narrow allow the infant to ei-
describes eyes that are wide-spaced, and hypotelorism de- ther inhale normally or inhale with varying amounts
scribes eyes that are closely spaced (see Chapter 15). of dyspnea, such as nasal flaring or retractions; with
The slant of the eyes should also be evaluated. A exhalation, air may escape through the mouth. Nasal
mongolian slant describes when the outer canthus is flaring is a sign of respiratory distress; the nostrils flare
higher than inner canthus; an anti-mongolian slant as the infant inhales. Sneezing and stuffiness are com-
mon in the newborn infant. Nasal drainage is an ab- the Pierre Robin sequence, mandibular hypoplasia, oc-
normal finding and should be evaluated. curs between the 7th and 11th week of gestation. This
A long, smooth philtrum may be present in an in- keeps the tongue high in the oral cavity, preventing
fant with fetal alcohol syndrome (FAS). Other features the closure of the palatal shelves and causing a cleft in
of FAS include short palpebral fissures, short nose, mi- the palate (Cole, Lynch, & Slator, 2008).
crocephaly, and mental retardation.
NECK
Mouth
Very little of an infant’s neck is visible as it is usually
The inside of the mouth is examined when the infant is
surrounded by skinfolds. Nevertheless, the neck should
crying, if possible, as opening the infant’s mouth is dif-
be palpated for masses. For example:
ficult. The infant’s cry should be assessed for normalcy;
term infants should have a vigorous cry. A tongue blade • Cystic hygromas involve lymph channel block-
can be used if necessary, and a bright light, usually the ages that dilate into cysts. These may be unilateral
otoscope, can be used to enhance visualization. or bilateral, occurring over the clavicle. Hygromas
A cleft lip is visible immediately. Cleft palate, if com- range in size from less than 1 cm to several centime-
plete, is easily visible when the infant cries. The palate ters in diameter.
is normally intact and highly arched, which can be as- • Thyroglossal duct cysts form from a persistent thyro-
sessed by placing a gloved finger in the mouth and pal- glossal duct, presenting as a mass high in the neck.
pating the palate. A cleft of the soft palate is not easily • Brachial cleft cysts are congenital epithelial cysts
seen. The health care provider should examine the infant resulting from a failure of the obliteration of the sec-
for the presence of the uvula, which should be midline. ond brachial cleft in embryonic development. Brachial
Absence or clefting of the uvula indicates a soft palate cysts are smooth, nontender, fluctuant masses on the
cleft (Merritt, 2005). latter part of the neck along the lower anteromediolat-
In addition, the tongue size should be assessed; a eral border of the sternocleidomastoid muscle.
large tongue (macroglossia) is associated with Beckwith Both thyroglossal duct cysts and brachial cysts may
syndrome. An infant with Down syndrome appears to present at birth or later in life and may require surgi-
have a large tongue, but the infant’s mouth is actually cal removal. A sinus tract from the brachial cyst to the
small, and the tongue is a normal size. The sublingual skin may be present (Telander & Deane, 1997).
frenulum should be observed when the infant cries. A A webbed neck may indicate Turner syndrome or Noon-
very short frenulum or true tongue-tie (ankyloglossia) is an syndrome. Redundant skin in the back of the neck is a
rare; providers must look for an indentation at the end common finding in infants with Down syndrome.
of the tongue. The frenulum historically was clipped The health care provider should palpate the clavicles,
with a scissors if judged to be short, but this is consid- feeling for crepitus (crackling feeling) over a fractured
ered unnecessary as most lengthen over time. clavicle. Callus at the fracture site may be palpated a
Gums must be inspected; neonatal teeth may be few days after the fracture. Arm movements bilaterally
present and should be removed if loose, to avoid as- must be assessed for brachial plexus injury.
piration. Sebaceous cysts on the gums (Epstein’s pearls) The infant’s head position must be observed in the
can resemble teeth; however, these are a normal variant supine position at rest and also in a supported sit posi-
and fade over time. The provider assesses the suck and tion. A tilt may indicate congenital muscular torticollis.
gag reflexes by placing a gloved finger in the mouth. The head is moved passively, tipping each ear to each
Excessive oral secretions may indicate the presence shoulder. A decreased ability to touch the ear to the shoul-
of esophageal atresia, a congenital malformation where der indicates torticollis. The sternocleidomastoid muscle
the esophagus ends in a blind pouch, prohibiting swal- must be palpated bilaterally for thickening or masses.
lowing of saliva or feedings. If the esophagus is patent,
excessive secretions may indicate a muscular or neu-
CHEST AND LUNG ASSESSMENT
rologic problem, resulting in an inability to swallow.
Swallowing problems are commonly associated with Inspection
a history of an abnormally large amount of amniot- Respirations. The normal respiratory rate is 30–60 breaths/
ic fluid (polyhydramnios) prenatally. Amniotic fluid is minute. Infants are abdominal breathers so chest move-
normally swallowed by the fetus; inability to swallow ment is low in the chest, with abdominal movement. The
results in excessive amniotic fluid. abdominal movement with breathing diminishes over the
A receding chin is common in newborns. A very first few months of life. Signs of respiratory distress include
small chin (micrognathia) may be an isolated finding. nasal flaring, grunting, and retractions. Symmetry in chest
Infants with the Pierre Robin sequence (a develop- movement should be observed (see Chapter 17).
mental defect)—consisting of micrognathia, glossop- Newborns normally have irregular breathing pat-
tosis (a large tongue), and a cleft palate—may present terns with short respiratory pauses between periods of
with severe respiratory distress. The initial event of breathing, termed periodic breathing. A pause of more
than 15–20 seconds, accompanied by bradycardia or Palpation

cyanosis, is termed apnea and is pathologic. The clavicles should be palpated for fractures or crepi-
Newborn infants have a round-shaped chest. The tus. The breast tissue should be palpated to evaluate
anterior-posterior (A-P) diameter should equal the trans- maturity and check for masses. The sternum and ribs
verse diameter. Chest circumference is normally 2 cm less should be palpated to evaluate for abnormalities.
than the OFC. Deviations of the chest include pectus cari-
natum, also called “pigeon chest,” with a protruding ster-
num, pectus excavatum, also called “funnel chest” with CARDIOVASCULAR ASSESSMENT
an indented sternum, and a barrel-shaped chest, with
an increased A-P diameter. A barrel chest is seen with air
Inspection
trapping, such as with meconium aspiration. Inspection of skin and mucous membranes is an im-
portant part of the cardiovascular assessment as skin
Nipples and Breasts. The nipples of a full-term infant perfusion is an important indicator of cardiac output
are raised and stippled with 0.75–1 cm of palpable breast and function (Keane, Fyler, & Lock, 2006). Acrocyanosis
tissue. The provider should note wide-spaced nipples, (cyanosis of the extremities) is a normal finding but
which accompany some syndromes. The space between is more apparent in pale-skinned infants and is com-
the nipples should be less than 1/4 of the chest circum- mon when the infant is cold stressed. Plethora is a
ference. Engorged breasts may be seen in male or female ruddy red color that may look like cyanosis and may
infants within the first few days of life as a result of ma- be secondary to polycythemia. The lips and tongue
ternal hormones. This resolves without intervention over are inspected for central cyanosis. If central cyanosis
several days. The breasts may secrete milk (i.e., physi- does not improve with oxygen administration, the
ologic galactorrhea). Supernumerary (accessory) nipples infant may have cyanotic heart disease. The provider
are raised or pigmented areas below the nipple in a line should note pallor, mottling, and poor perfusion, as
drawn from the nipple to the umbilicus. these may indicate anemia or shock. Edema is a rare
finding in the neonate. Generalized edema at birth is
Auscultation called hydrops fetalis.
Breath sounds of infants are loud and somewhat coarse. The health care provider should inspect the precor-
The stethoscope should be warm. The health care pro- dium for movement. A hyperactive precordium is pres-
vider must use the diaphragm and then the bell, begin- ent with cardiomegaly or cardiac lesions that increase
ning at the top of the chest and moving systematically ventricular work. The precordium, which is hyperac-
from side to side. The provider listens to the lower lobes tive in premature infants as a result of a thin chest
of the lung from the infant‘s back. Breath sounds are wall, should be palpated (using the palm of the hand)
normally vesicular (i.e., soft, short, low pitched during for heaves, taps, and thrills.
expiration, and loud, long, and high pitched during
inspiration). Breath sounds may be bronchovesicular Palpation
over the scapulas. These sounds are louder than vesicu- The peripheral pulses—including brachial, radial,
lar and demonstrate an inspiration and expiration that femoral, and posterior tibial at a minimum—are
are equal in quality, intensity, pitch, and duration. Ad- palpated, as pulses represent an approximate determi-
ventitious sounds include the following: nation of cardiac output and blood flow to the extrem-
• Crackles (rales) may be fine, medium, or coarse. ities. Pulse volume and character are graded on a scale
Crackles indicate that airways are popping open or of 0 to 4, with 0 indicating absent and 4⫹ indicating
that a liquid film is breaking. bounding. Normal pulses are designated as 2, or 2/4.
• Rhonchi are lower and more musical than crackles Weak pulses are designated as 1 or 1/4, and bounding
and are heard when secretions are loose. pulses are designated as 3/4 or 4/4. Bounding pulses
• Wheezes are unusual in the newborn. Wheezing in- are seen with some congenital heart defects such as
dicates narrowing of the airways or bronchospasm. patent ductus arteriosus, truncus arteriosus, and a sys-
• Rubs are unusual in neonates. temic arteriovenous fistula. Weak pulses indicate low
• Stridor is a high-pitched hoarse sound on inspira- cardiac output.
tion or expiration at the larynx or upper airways. The right femoral and right brachial pulses should
Stridor indicates partial airway obstruction or ma- be palpated simultaneously. A weak or absent femoral
lacia of the trachea or larynx and usually requires pulse indicates coarctation of the aorta until proven
further evaluation. otherwise. It could also indicate aortic stenosis or hy-
poplastic left heart syndrome.
Percussion The liver should be palpated, as it becomes en-
Percussion is difficult with large hands and a small gorged and enlarged with congestive heart failure. The
chest and, therefore, is often not included in the new- liver margin should be felt 2 cm or less below the right
born examination. costal margin (RCM).
Auscultation with a structurally and functionally normal heart. The

The provider should auscultate for cardiac position presence of a murmur does not indicate congenital
(point of maximal impulse, PMI). The PMI should be heart disease. For example, the most severe defects
at the 4th intercostal space (ICS) at the mid-clavicular often present without a murmur. Many heart defects
line (MCL). The PMI can be displaced with dextrocar- present with a murmur after the first 1–2 weeks of life,
dia, diaphragmatic hernia, and pneumothoraces. If the when pulmonary vascular resistance falls and shunt-
heart cannot be heard with a stethoscope or if the heart ing increases. The provider must distinguish between
sounds are muffled but the infant is pink with pulses systolic or diastolic murmurs. Continuous murmurs
present, air or gas may be present in the mediastinum are heard throughout systole and diastole.
( pneumomediastinum). Murmurs are graded according to how loudly they are
heard and whether or not there is a thrill present. The
Heart Rate. A normal heart rate in the term infant is murmur must be auscultated, and the hand of the pro-
80–160 beats/minute (bpm) and is higher with crying. vider must be placed over the precordium to feel a thrill,
A heart rate less than 80 is called sinus bradycardia. Sinus a rumbling feeling. Murmurs are graded as follows:
tachycardia describes a heart rate that is higher than • Grade I: barely audible
normal for age. This is usually greater than 160 bpm at • Grade II: soft but audible immediately
rest in a full-term infant. • Grade III: moderate intensity (no thrill)
Supraventricular tachycardia (SVT) is the most com- • Grade IV: loud (may have thrill)
mon arrhythmia in neonates. A heart rate over 200 bpm • Grade V: very loud; can be heard with the stetho-
is usually SVT. SVT is tolerated well for short periods but scope rim barely on chest, (may have thrill)
leads to heart failure if prolonged. • Grade VI: extremely loud; can be heard with the
Sinus arrhythmia is not uncommon. The heart rate stethoscope just slightly removed from the chest
increases on inspiration and decreases on expiration. (may have thrill)
Bradycardia, a very low heart rate in an infant who It is important to discern the location of the murmur
is breathing and appears well, is probably congenital and the PMI. By listening to other locations where the
heart block. The heart rate may be as low as 40 bpm. If murmur is heard, radiation or transmission of the murmur
the infant is pink and noncompromised, treatment is can be determined. The pitch of the murmur is described
not required emergently. as high, medium, or low. The quality of the murmur is de-
scribed as harsh, rumbling, musical, or machinery-like.
Heart Sounds. Auscultation of heart sounds in- Innocent murmurs are usually grade I or II, systolic,
cludes listening over the entire chest and over the and the infant is asymptomatic. Innocent murmurs
back. At minimum, the provider must listen over the are common, especially in the first 48 hours of life.
following: Common innocent murmurs include the following:
• Aortic area, second ICS, right sternal border (RSB) • Systolic ejection murmurs are usually grade I–II/VI
• Pulmonic area, second ICS, left sternal border (LSB) and heard over the mid- and upper LSB. These mur-
• Tricuspid area, fourth ICS, LSB murs are vibratory and heard between 1–7 days of
• Mitral area, fourth ICS, MCL age. The murmur is a result of increased flow across
Also, the provider must auscultate over the clavicles, the pulmonary valve with decreased pulmonary vas-
both sides of the back, the anterior fontanelle (for ce- cular resistance.
rebral arteriovenous fistulas), and the liver (for hepatic • Continuous systolic or crescendo systolic mur-
arteriovenous fistulas). Heart sounds likely to be heard murs are usually grade I–II/VI and heard over the
in the newborn include the following: upper LSB. These murmurs are heard in the infant’s
• S1 is the closure of the mitral and tricuspid valves, first 8 hours of life and are a result of the closure of
which is loudest at the apex; splitting is very hard to the ductus arteriosus.
hear and unusual. • Peripheral pulmonic stenosis (PPS) is an early soft
• S2 is the closure of the aortic and pulmonic valves, grade I–II/VI midsystolic ejection murmur heard at
which is loudest at the base; splitting occurs after the upper LSB with radiation to the clavicles and to
16 hours of age. Wide splitting is abnormal. the back. This murmur is heard at 1–2 weeks of age,
• S3 and S4 are difficult to hear in neonates as a result disappears by 6 months of age, and is the result of
of rapid heart rate. turbulence at the bifurcation of pulmonary artery.
• Ejection clicks, high and snappy sounds, are normal Pathologic murmurs may present after a few days
in the first 24 hours of life. or weeks of life or be present at birth. Soft murmurs in
asymptomatic infants can be observed for 48 hours.
Murmurs. Heart murmurs are caused by turbulent Further evaluation is required if the murmur persists
blood flow. Pathologic murmurs arise from cardiovas- beyond 48 hours, is louder than grade II, or the infant
cular defects or disease; innocent murmurs are heard is symptomatic.
Blood Pressure. Blood pressure evaluation is not

routine in normal newborn care. Four extremity blood
pressures are valuable if coarctation of the aorta is sus-
pected. Upper extremity blood pressure is more than
20 mm Hg higher than lower extremity blood pressure
if coarctation is present. A wide pulse pressure may be
a sign of a patent ductus arteriosus as a result of aortic
runoff. Low blood pressure is a late sign of shock. Early
signs of shock include poor perfusion, tachycardia,
weak pulses, and acidosis (Short, 2004).
ABDOMINAL ASSESSMENT
Inspection
Providers must inspect the abdomen before auscul-
tation or palpation (see Chapter 19). The abdomen
usually moves with the chest during respirations. The
shape of the abdomen is observed for symmetry, dis-
FIGURE 11-6. Umbilical hernia.
tention, fullness, or scaphoid appearance. Midline de-
fects are readily apparent and include the following:
postpartum and resolve without intervention in most
• Omphalocele is an anterior abdominal wall defect cases (Fig. 11-6).
at the base of the umbilical cord that results in her- Health care providers must inspect the anus for pa-
niation of the abdominal contents, covered by the tency. An imperforate anus is usually obvious; how-
parietal peritoneum, amnion, and Wharton’s jelly. ever, the anus may look normal in the presence of a
Occasionally, the omphalocele is open, indicating a blind pouch. Female infants commonly pass stool vag-
tear or opening in the encapsulating tissue. inally via a recto-vaginal fistula. Male infants may pass
• Gastroschisis is a herniation of the abdominal con- meconium from the penis via a rectal-urethral fistula.
tents through an abdominal fusion defect usually to Presence of meconium at an anal orifice determines
the right of the umbilical cord. patency. Meconium should be passed within 48 hours
• Bladder exstrophy is a malformation of the bladder of birth. Providers can determine the presence of an
and urethra in which the bladder is turned “inside anal wink by stroking the perianal area and observing
out” and exposed outside the body. Cloacal exstro- the reflexive contraction of the external anal sphincter.
phy involves bladder exstrophy; in addition, the ure- Digital rectal examination is not routine in neonates.
thra and genitalia are not formed completely, and
the anus and vagina appear anteriorly displaced. The Auscultation
pelvic bones are widely separated (diastasis). An om- Bowel sounds begin shortly after birth. The provider
phalocele and imperforate anus are usually also pres- must listen to all quadrants with the infant at rest.
ent (Heinrich, Huemmer, Reingruber, & Weber, 2008;
Islam, 2008; Mac Bird, Robbins, Druschel, Cleves, Palpation
Yang, & Hobbs, 2009; Mayhew & Mychaskiw, 2009; The health care provider must assess tone over the ab-
Stoll, Alembik, Dott, & Roth, 2008). domen. Tense, rigid tone suggests peritoneal irritation.
• Diastasis recti, a normal variant, is the gap between Flaccid tone is abnormal and may indicate an absence of
the rectus muscles. Visible bulging is apparent over musculature. The skin turgor over the abdomen must be
the midline when the infant cries. noted as well, as it is an indicator of hydration status.
The umbilicus is inspected next (Fraser, Daries, & The provider palpates the liver by moving the fin-
Cusack, 2006; Snyder, 2007). Three vessels—two arter- gers gently up from the groin to RCM to find the liver’s
ies and one vein—should be present. The cord may be edge. The liver should be palpated at or 1–2 cm below
thick or thin with Wharton’s jelly. The cord should the RCM. The spleen is palpated similarly but on the
dry quickly and fall off in 1–3 weeks. The cord clamp left side. The spleen tip may be palpable, but it is often
is usually left on for 12–24 hours or until the cord is difficult to palpate unless it is enlarged.
somewhat dry. A green-colored cord at birth results Normal kidneys are difficult to palpate in full-term
from meconium staining. Clear discharge from the infants. The provider’s fingers are placed under the area
stump suggests a patent urachus or duct, where urine adjacent to the umbilicus and pinched gently with the
passes from the bladder through the umbilicus. thumbs. Alternatively, the provider places the fingers of
Umbilical hernias are common in premature infants one hand under the flank and then presses gently with
and African-American male infants. They are not pres- the other hand. Kidneys are more easily palpated if they
ent at birth but appear after a few weeks or months are enlarged, if the infant is preterm, or if the infant has
decreased abdominal musculature or tone. The bladder hypospadias is present, the foreskin is often retracted
lies 1–4 cm above the symphysis pubis and is usually off the glans. Epispadias, an uncommon defect, presents
not palpable unless it is distended with urine. with the urethral opening on the dorsal shaft of penis.
A systematic approach should be used for palpation, The provider must inspect the scrotum, noting any
covering all four quadrants of the abdomen and feel- rugae, the color, size, and symmetry. Rugae can be
ing for masses. At first, palpation should be superficial, ridges, wrinkles, or folds appearing on the scrotum at
then deeper. The descending colon may be palpable in about 34–46 weeks’ gestation. The provider must pal-
the left lower quadrant. pate for testes bilaterally, noting that both testicles can
The groin area must also be inspected and palpated be felt and that one is not moving side to side or back
deeply. The inguinal and pubic areas should be flat. into the inguinal canal. Cryptorchidism, where one or
Swelling or bulging could indicate an inguinal hernia both testicles are undescended, should be noted. At
or undescended testicle. Bulging because of an inguinal least one testicle should be palpable below the ingui-
hernia may be apparent only with crying, as the intes- nal canal at term. Stimulation of the scrotum or in-
tine descends into the herniated sac. ner upper thigh activates the cremasteric reflex, which
Providers must palpate femoral pulses bilaterally for abruptly retracts the testes up the canal (retractile tes-
they should be equal in intensity. The presence of bilat- tes). Cold stimulation also causes the testes to retract.
eral femoral pulses virtually eliminates the possibility A hydrocele, a scrotal mass containing clear fluid,
of coarctation of the aorta unless the ductus arteriosus is commonly present. The scrotum can be transillumi-
remains patent. nated with the otoscope; light transmitted throughout
the mass indicates a hydrocele. A hematocele is similar
to the hydrocele except it is filled with blood instead
GENITOURINARY ASSESSMENT of clear fluid.
Female Genitalia Testicular torsion presents as a hard, painless, scro-
tal mass. Scrotal skin may be discolored and edema-
The clitoris is prominent in preterm female infants.
tous. This is a surgical emergency, although it may not
Hypertrophy of the labia minora is not significant, but
be possible to salvage the testicle. This may present at
hypertrophy of the clitoris requires investigation. The
birth or shortly thereafter.
genitalia may be bruised and edematous with breech
Congenital conditions in which development of
delivery. The urethral meatus lies just below the cli-
the chromosomal, gonadal, or anatomic sex is atypical
toris but is difficult to see. The infant should urinate
were previously termed ambiguous genitalia, intersex,
within 24 hours of birth.
hermaphroditism, pseudohermaphroditism, or sex
A fingertip space should be present between the vagina
reversal. Disorders of sex development (DSD) is pro-
and the anus in a term infant. Whitish mucoid discharge
posed as terminology that is sensitive to parents and
is normal. Bloody discharge (pseudomenses) may be pres-
patients, as well as encompassing molecular as well as
ent for a few days after birth and continues throughout
structural variations. Infants with DSD that are appar-
the first month. This indicates withdrawal of maternal
ent at birth should be treated as a genetic emergency.
estrogen. A hymenal tag, consisting of tissue from the hy-
Parents are understandably distressed when they are
men and labia minora, is frequently present and visible
unable to share the infant’s birth with others because
from the posterior opening of the vagina, usually disap-
the gender has not been determined.
pearing by the end of the first month (see Chapter 20).
Current recommendations of DSD include: (a) gender
assignment must be avoided before expert evaluation in
Male Genitalia newborns; (b) evaluation and long-term management
The provider should inspect and palpate the penis. In must be performed at a center with an experienced multi-
obese infants, the penis may be almost obscured by a disciplinary team; (c) all individuals should receive gender
fat pad over the pubic bone. The average penis length assignment; (d) open communication with patients and
from pubic bone to tip of glans is 3.5 cm. Average families is essential, and participation in decision-making
width is 0.9–1.3 cm. The prepuce (foreskin) normally is encouraged; and (e) patient and family concerns should
covers the entire glans. This cannot be retracted for a be respected and addressed in strict confidence (Lee, Houk,
few months. Phimosis, foreskin that is nonretractable, Ahmed, Hughes, & International Consensus Conference
cannot be diagnosed before the infant is 3 months of on Intersex organized by the Lawson Wilkins Pediatric
age. The prepuce can be gently stretched to reveal the Endocrine Society and the European Society for Pediatric
urethral opening, but the provider must be careful not Endocrinology, 2006).
to retract the foreskin until the infant is older. The me-
atus should be at the center of the penile glans. The
infant should urinate within 24 hours of birth.
MUSCULOSKELETAL SYSTEM
Ventral bowing of the penis is termed chordee. A ASSESSMENT
urethral opening on the ventral surface of the penis Common terms used to describe the musculoskeletal
is termed hypospadias, a common birth defect. When system are listed in Box 11-2 (see Chapter 21).
General Inspection nerve damage is probably present. Brachial plexus inju-

The neonate‘s posture reflects the intrauterine position. ries usually resolve spontaneously over the first few days
Legs are externally rotated and bowed with everted feet. of life. If not resolved within 1–2 weeks, further evalua-
The intrauterine breech position results in hips that are tion is required. Brachial plexus injuries for which the
flexed and abducted with extended knees. Abnormally provider must be alert include:
small amounts of amniotic fluid (oligohydramnios) can • Erb’s palsy describes a traction injury of the upper
cause skeletal problems as a result of compression, and brachial plexus. The arm is maintained in adduction
the face may have a “smashed” appearance. and internal rotation at the shoulder with the lower
The health care provider must observe for symmetry arm pronated.
of movement. Asymmetry could be secondary to nerve • Klumpke’s paralysis describes traction injury of the
damage, fractures, or muscular problems. In addition, the lower brachial plexus. The small muscles of the hand
provider must inspect the size, shape, general alignment, and wrist flexors are affected, causing a “claw hand.”
position, and symmetry of the extremities as well as soft The clavicles are inspected and palpated for size, con-
tissues and muscles for swelling, wasting, and symmetry. tour, and crepitus. Fractured clavicles are common and
Term newborns at rest lie in a symmetrical position heal in a few days. In addition, the provider must inspect
with the limbs flexed and the legs partially abducted at the hands, looking for a simian crease, a normal finding in
the hips. Spontaneous movement is random and unco- infants with short, broad hands but also associated with
ordinated, using both flexion and extension. Hands are Down syndrome. Overlapping of the second and third
fisted, often with the thumb under the fingers. A corti- fingers is common in trisomy 18. The provider must in-
cal thumb, where the thumb is always tightly under spect for syndactyly (webbed fingers) and polydactyly (extra
the fingers, is associated with neurologic irritability. digits) and assess the nail beds for color and perfusion.
Tremors with movement are common. To differ- The provider must inspect the spine with the infant
entiate between a tremor and a seizure, the provider prone or sidelying, looking for any skin disruption,
must attempt to stop the movement. Tremors can be tufts of hair, masses, hemangiomas, pilonidal cysts, or
stopped with restraint but seizures cannot. sinus tracts. The provider must palpate for the presence
The provider must evaluate the upper extremities by of normal dorsal spinal processes and for abnormal
performing passive range of motion (ROM) exercises. curvature such as scoliosis, which can be congenital.
However, observation of active ROM is more valuable in Variations of spina bifida, a congenital defect of the
evaluating for brachial nerve plexus injury. This injury is vertebral arch through which the meninges and the
rarely bilateral. If the arm does not move spontaneously, spinal cord protrude, are obvious. The defect can be
open (spina bifida cystica) or covered with skin (spina
BOX 11-2 bifida occulta). Lower extremity movement is usually
decreased, and anal tone may be absent or diminished.
Common Terms Used to
The lower extremities must be inspected as well. The
Describe the Musculoskeletal
hips are normally flexed and leg movements symmet-
System rical. The provider must inspect the hips for congenital
Flexion: bending a limb at a joint hip dislocation (Fig. 11-7) (Committee on Quality Im-
Extension: straightening a limb at a joint provement Subcommittee on Developmental Dyspla-
Abduction: moving a limb away from the midline of
sia of the Hip, 2000).
the body
Adduction: moving a limb toward or past the midline Maneuvers
of the body The hips and legs are systematically examined for
Pronation: turning face down congenital hip dislocation by inspection and specific
Supination: turning face up maneuvers. Treatment of congenital hip dislocation is
Dorsiflexion: flexion toward the back, as in flexion of facilitated by early detection.
the foot so that the forefoot is higher than the ankle
Plantarflexion: extension of the foot so that the
Ortolani Maneuver. The provider first flexes the
forefoot is lower than the ankle knee and hip, then grasps the thigh with the third or
fourth finger placed over the greater trochanter. Next,
Rotation: turning side to side
the provider abducts the leg with a lifting motion and
Valgus: bent outward or twisted away from the midline
then adducts the leg. A palpable or audible clunk is
of the body
noted as the femoral head passes over the acetabulum.
Varus: turned inward
High-pitched clicks and snaps can be heard or felt but
Everted: turning out and away from the midline of the
are usually not associated with hip pathology.
body
Inverted: turning inward toward the midline of the body Barlow Maneuver. One hip is stabilized by flexion
and held in neutral rotation and abduction. The hip
• Clubfoot (talipes equinovarus) is adduction of the

forefoot, varus of the heel, and a downward pointing
of the foot and toes. Treatment includes serial cast-
ing and possibly surgery.
• Talipes calcaneovalgus is excessive dorsiflexion of the
ankle and eversion of the foot. This resolves with growth
and passive stretching. Severe cases may need surgery.
• Tibial torsion is a twisting of the tibiofibular unit
around its long axis. This is a normal variant and is
the leading cause of in-toeing in toddlers. The cause
is probably intrauterine positioning, although prone
A sleep positioning with the knees and feet tucked un-
der the infant may also contribute; however, this is
now a less common cause as a result of recommen-
dations to avoid prone sleep positions.
• Streeter’s dysplasia, also called amniotic bands, is
rare. Fibrous bands from the amnion encircle one or
more extremity and occasionally the trunk. These
bands may amputate digits or extremities or cause a
circumferential narrowing at any point.
• Syndactly, a congenital webbing of fingers and or
toes, may be an isolated defect or associated with a
congenital syndrome (Fig. 11-8).
• Polydactly, a congenital anomaly with one or more
B extra digits on the hands or feet, is usually familial
or associated with a syndrome.
FIGURE 11-7. Congenital hip dislocation examination:
Ortolani’s maneuver (A) and Barlow’s maneuver (B).
NEUROLOGIC ASSESSMENT
to be tested is held with the provider’s thumb over the A general inspection provides important information
proximal medial thigh and with the long finger over on the neurologic status of the infant (see Chapter 22).
the greater trochanter. The hip is gently abducted with The health care provider must evaluate the cry and
a posteriorly directed gentle push with the provider‘s observe facial movements when the infant is crying;
thumb. If the hip is dislocated or subluxatable, a clunk a shrill or weak cry is abnormal. Stridor is more evi-
is felt. Gentle pressure anteriorly and medially with the dent when the infant is crying. The provider must also
finger over the greater trochanter reduces the femoral observe the resting posture as well as the quality of
head into the acetabulum, giving another clunk. movements, looking for tremors or jitteriness. Rest-
ing posture varies according to gestational age; term
Galeazzi Maneuver. The Galeazzi maneuver or Allis’ infants are flexed, and preterm infants are extended at
sign can be used to evaluate leg length. With the infant
rest. The term infant should be able to lift and turn the
lying supine, the provider places the feet flat on the
head in the prone position. The provider must observe
bed with the femurs aligned and the knees flexed. The
height of the knees is then inspected for symmetry.
Leg and Gluteal Folds Evaluation. The provider eval-

uates the leg and gluteal folds by comparing creases in
supine and prone positions. Unequal leg folds or creases
may indicate congenital hip dislocation, although mi-
nor differences in leg folds or creases may be a normal
variant. The health care provider must also inspect the
feet and ankles for mobility and abnormalities.
• Metatarsus adductus (forefoot varus, metatarsus
varus) is caused by intrauterine positioning. The
forefoot is abducted. If it is structural, the forefoot
does not abduct beyond neutral with manipulation.
If it is positional, the forefoot can be abducted be-
yond midline. Positional deformity corrects without
intervention. FIGURE 11-8. Syndactly.
for antigravity movements. The infant’s movement

and behavior are affected by gestational age, timing of
the last feeding, and prior handling and stimulation.
Motor Function
The provider must observe the infant, always looking for
symmetry. Resistance to movement can be tested with
passive ROM. Minimal resistance is felt at 28 weeks; this
increases with maturity, as muscle tone increases. Hypo-
tonia can be because of central nervous system, nerve, or
muscle pathology. Hypertonia is rarely seen in the neo-
nate; this develops over the first year of life and may in-
dicate cerebral palsy. Transient dystonia may be seen in
preterm infants in the first year of life; hypertonia or hy-
potonia develops but then tone normalizes (Sommerfelt,
Pederson, Ellertsen, & Markestad, 1996). Testing muscle
strength is difficult in the neonate because it is difficult
to distinguish tone from strength. Observation of anti-
FIGURE 11-9. Head lag.
gravity movement assists in evaluating muscle strength.
Deep Tendon Reflexes. Deep tendon reflexes, usu- infant. The provider holds the infant in the palm of
ally patellar and biceps, must be tested. The provider the hand prone. The term infant with normal tone can
should place the infant’s head in midline while testing maintain the head in line with the body and attempt
reflexes, since the asymmetric tonic neck reflex leads to keep the legs in line.
to differences between sides if the head is to one side. Axillary “slip through” maneuver evaluates shoulder
strength and tone. The provider supports the infant in
• Patellar reflex: To elicit the patellar reflex, the pro-
an upright position by placing his or her hands in the
vider taps the patellar tendon just below the patella
axillae. The term infant with normal tone and strength
while the provider’s hand supports the knee in a
will not “slip through” as the arms stay adducted.
flexed position. Normal response is extension at the
knee and visible contraction of quadriceps. Primitive Reflexes. The primitive reflexes are de-
• Biceps reflex: To elicit the biceps reflex, the provider scribed in detail in Table 11-8; some of these reflexes
holds the infant‘s arm with the elbow in flexion and are illustrated in Figure 11-10.
the thumb over the insertion of the biceps tendon at
the antecubital space. When the provider taps his or her Sensory Function
thumb with a hammer, flexion of the biceps occurs. Assessment of sensory function includes an assessment
Hyporeflexia, or weak reflexes, is normal in the pre- of touch and pain. Pain response is not usually assessed
term infant and is seen in asphyxiated infants, septic unless there is spina bifida or other suspected spinal cord
infants, and those with dysfunction of the motor unit. problems. Evaluation of the cranial nerves is difficult to
Hyperreflexia, or exaggerated reflexes, can be seen in accomplish formally and individually in the newborn
asphyxiated infants at a later stage, and in drug with- infant. Cranial nerves are assumed to be normal if the
drawal syndromes. Clonus is a rapid movement of a physical examination is normal (see Chapter 22 for a
particular joint brought about by sudden stretching of detailed discussion of the cranial nerves).
a tendon. This is tested in the ankle by sharply dor- The autonomic nervous system is not formally as-
siflexing the foot with the hip and knee in flexion. sessed. Trends in vital signs and general functioning
The clonus response consists of several repetitive jerks and response to stress are indicators of autonomic ner-
(beats) of the foot or no movement. Sustained clonus vous system function.
(greater than 6–8 beats) is abnormal.
Postural Tone. Postural tone is tested with the traction BEHAVIORAL ASSESSMENT
response (pull-to-sit maneuver). The provider grasps the Modifications in behavior are influenced by the envi-
infant’s hands and pulls the infant slowly from a supine ronment, transitional states, birth phenomenon (i.e.,
to a sitting position. Full-term infants have significant asphyxia, maternal medications), and gestational age.
head lag; complete head lag is abnormal (Fig. 11-9). • Sleep states: During a deep sleep, the eyes are closed,
Head lag should not be evident after 3–4 months of age there is no eye movement, breathing is regular, and
and cannot be tested in an ill infant. there is no spontaneous activity. During light sleep,
Ventral suspension, an indicator of overall muscle there is low activity, rapid eye movements, and the in-
tone, can be tested in a normal infant but not an ill fant startles easily.
TABLE 11-8
Primitive Reflexes
AGE OF AGE OF ACTION TO ELICIT NORMAL INFANT
REFLEX APPEARANCE DISAPPEARANCE RESPONSE RESPONSE
Sucking 26–28 weeks 3–4 months A gloved finger is placed Sucking is normally present,
gestation in the mouth to evaluate but weaker in preterm than
strength and coordination of term infants.
the suck.
Rooting 30–34 weeks 3–4 months The cheek and the corner of The head should turn
gestation the mouth are stroked. toward the stimulus, and
the mouth should open.
Palmar grasp 20–26 weeks 3–6 months The palmar surface of the The baby should grasp the
gestation hand is stimulated with a finger. Attempts to withdraw
finger. the finger lead to a tightened
grasp. When tested with
both hands, the term
neonate can be lifted off the
bed for a few seconds.
Plantar grasp 24–30 weeks 8–10 months The sole of the foot and the The toes curl around the
gestation toes are stimulated with a finger.
finger.
Asymmetric 28–30 weeks 3–4 months Also called “fencing position,” Extension of the arm on
tonic neck gestation the infant is placed in a the side toward which the
reflex supine position, and the head head is turned and flexion
is turned to one side. of the arm on the opposite
side occurs. The legs mimic
the arms: extension of the
leg toward which the head
is turned and flexion of the
leg on the opposite side.
Moro reflex 28–32 weeks 4–6 months Also called “startle reflex” as it The arms become extended
gestation is a response to the sensation and abducted with the
of loss of support. It can hands opened, followed
be elicited by a loud noise by inward movement and
or bumping the bed. This some flexion of the arms,
reflex can be elicited with the with closing of the fists.
neonate supine, grasping the There may also be a cry.
hands and pulling up until the Look for symmetry.
shoulders are slightly off
the bed, then letting go of
the hands, resulting in the
shoulders falling onto the bed.
Stepping 32–36 weeks 6–8 weeks The infant is held upright, Stepping movements can be
reflex gestation and the feet are allowed to observed.
touch a flat surface.
Placing reflex 32–36 weeks 6–8 weeks The infant is held upright, and The infant “steps” up onto
gestation the top of the foot is gently the table or counter.
scraped along the underside of
a table or counter. The infant
flexes the leg as if stepping up
onto the counter and then
extends the leg.
Truncal 28–32 weeks 2–4 months The infant is held in ventral A positive response is
incurvation gestation suspension. Firm pressure is flexion of the pelvis toward
(Galant) applied with thumb or cotton the side of the stimulus.
reflex swab to the trunk, parallel to
the spine in the thoracic area.
(continued)
TABLE 11-8
Primitive Reflexes (Continued)
AGE OF AGE OF ACTION TO ELICIT NORMAL INFANT
REFLEX APPEARANCE DISAPPEARANCE RESPONSE RESPONSE
Babinski Birth to 12–18 Should be negative The sole of the foot is The toes extend and fan
reflex months; positive after the child is stimulated from heel to toe out, termed a positive
response is walking with the practitioner’s finger. response.
normal
Corneal 32–36 weeks Never The practitioner blows into The infant blinks.
(blink) reflex gestation the infant’s face or gently
touches the cornea with a
cotton swab to elicit a blink.
Extrusion 32–36 weeks 4 months A tongue blade or spoon is The infant’s tongue thrusts
reflex gestation placed on the tongue. forward.
Landau 3 months 15 months–2 years The infant is placed in a The infant extends the
reflex/ horizontal, prone position to neck, head, and arms. Lower
reaction elicit this reaction. extremities are flexed.
A B
C D E
FIGURE 11-10. Primitive reflexes in the newborn: the suck reflex (A); palmar grasp (B); stepping
reflex (C); Moro (startle) reflex (D); and tonic neck reflex (fencer’s position) (E).
• Transitional states: During transitional states such avert metabolic crises and prevent irreversible neurologic
as drowsiness, there is a variable activity level, and developmental sequelae (Marsden, Larson, & Levy,
smooth movements, and occasionally mild startles. 2006; Seashore & Seashore, 2005). Early identification of
The eyes open and close and appear dull and heavy these conditions is crucial, as timely intervention can lead
lidded. There is a delayed response to stimuli. to a significant reduction of morbidity, mortality, and as-
• Awake states: If quietly alert, the infant interacts sociated disabilities in affected infants. State laws mandate
with the environment; the infant has a bright-eyed newborn screening for all newborn infants, but the num-
appearance. If actively alert, there is increased motor ber and types of diseases screened vary among states.
activity; however, the infant could also be fussy but The United States Department of Health and Human
consolable. A crying infant is obvious to all. Services and the March of Dimes recommend screen-
• Transitions from state to state: The provider should ing for 29 disorders for which effective treatment is
note signs of stress or fatigue, when an infant tran- available (see Table 11-9). These recommendations are
sitions from one state to another; in addition, the based on a report by the American College of Medical
provider should note acrocyanosis, mottling, grunt- Genetics (ACMG), commissioned by the United States
ing, tachypnea, apnea, vomiting, gaze aversion, jit- Health Resources and Services Administration. The
teriness, hiccups, finger splaying, sneezing, yawning, 29 disorders can be grouped into five categories:
arching, or stiffening.
1. Amino acid metabolism disorders
Evaluation of behavioral responses includes response 2. Organic acid metabolism disorders
to stimuli and habituation. The infant’s organizational 3. Fatty acid oxidation disorders
status is assessed by observing the ability to integrate 4. Hemoglobinopathies
physiologic and behavioral systems in response to the 5. Others
environment. The organized infant maintains stable vi-
The March of Dimes also urges states to provide test re-
tals, smooth state transitions, and smooth movements.
sults for an additional 25 “reportable” conditions named
Neonatal Behavioral Assessment Scale in the ACMG report. There are reliable tests for these con-
The Neonatal Behavioral Assessment Scale (NBAS), de- ditions but not yet documented treatments (Table 11-9).
veloped in 1973 by Brazelton and colleagues, represents
a guide that helps parents, health care providers, and
researchers understand the newborn‘s language. The ASSESSMENT OF THE PRETERM
NBAS looks at a wide range of behaviors and is suitable INFANT AFTER HOSPITAL
for examining newborns and infants up to 2 months
of age. By the end of the assessment, the provider has DISCHARGE
a behavioral “portrait” of the infant, describing the
baby‘s strengths, adaptive responses, and possible vul- Infants born prematurely may have different appear-
nerabilities. The provider shares this portrait with par- ance and behavior, especially during the first year of life
ents to develop appropriate caregiving strategies aimed (Kase, Pici, & Visintainer, 2009; Kelly, 2006; O'Shea, Nag-
at enhancing the earliest relationship between infants eswaran, Hiatt, Legault, Moore, Naughton, et al., 2007)
and parents (Brazelton & Nugent, 1995). (Table 11-10). In addition, these infants may not tolerate
examinations as tactile vulnerability and sensory inte-
Assessment of Preterm Infants’ Behavior gration problems are common (Weiss & Wilson, 2006).
The Assessment of Preterm Infants’ Behavior (APIB) is Preterm infants may be less tolerant of bright lights, loud
a neurobehavioral tool that assesses autonomic, motor, noises, and touch. Growth of the preterm infant over
state organization, attention, and self-regulation sub- the first 3 years of life should be reviewed, using growth
systems. It is appropriate for preterm, at-risk, and full- charts specific for preterm infants. Preterm infants of-
term newborns, from birth to 1 month after the EDC. ten require high-calorie feedings to increase growth and
The APIB is usually used for behavioral intervention normalize bone calcium accretion (Schanler, 2005).
and individualized care in the neonatal intensive care The infant’s head shape may be tall and narrow (dol-
unit (Als, Butler, Kosta, & McAnulty, 2005). ichocephalic) as a result of prolonged side-to-side posi-
The March of Dimes offers an excellent educational tioning in the NICU. This may change over time but
tool for assessing the behavior of term infants, and is can be apparent for life (Hummel & Fortado, 2005).
available online (March of Dimes, 2009). The palate may have an exaggerated arch, sometimes
with a palatal groove, as a result of head narrowing, or
use of an oral endotracheal tube for a prolonged peri-
NEWBORN SCREENING od. The primary teeth may be off-white or gray because
of poor enamel, leading to an increased incidence of
The goal of newborn screening is early identification of dental caries. The primary teeth may be a yellow or
children at increased risk for selected metabolic or genetic green color if the infant had cholestatic jaundice (usu-
diseases so that medical treatment can begin promptly to ally because of prolonged total parenteral nutrition) in
TABLE 11-9
Metabolic Screening Tests
AMINO ACID ORGANIC ACID FATTY ACID
METABOLISM METABOLISM OXIDATION
DISORDERS DISORDERS DISORDERS HEMOGLOBINOPATHIES OTHERS
Phenylketonuria Iisovaleric acidemia Medium-chain Hb SS, sickle cell anemia Congenital
acyl-CoA hypothyroidism
dehydrogenase
deficiency
Maple syrup Glutaric acidemia type I Very long- Hb S/Th, Hb S/beta-thalassemia Biotinidase
urine disease chain acyl-CoA deficiency
dehydrogenase
deficiency
Homocystinuria Hydroxymethylglutaric Long-chain Hb S/C, Hb S/C disease Congenital

aciduria or HMG-CoA lyase 3-OH acyl-CoA adrenal
deficiency or 3-OH 3-CH3 dehydrogenase hyperplasia
glutaric aciduria deficiency
Citrullinemia Multiple carboxylase Trifunctional Classical

deficiency protein galactosemia
deficiency
Argininosuccinic Methylmalonic acidemia Carnitine Hearing loss

acidemia because of mutase uptake defect
deficiency
Tyrosinemia Cbl A,B, methylmalonic Cystic fibrosis

type I acidemia cblA and cblB forms
3MCC, 3-methylcrotonyl-
CoA carboxylase deficiency
PRO Propionic acidemia
Beta-ketothiolase deficiency
Source: U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.
Newborn screening: Toward a uniform screening panel and system report for public comment. Retrieved November 11, 2009, from
http://www.marchofdimes.com/professionals/580.asp, http://mchb.hrsa.gov/screening/.
the NICU. However, secondary teeth are usually not Preterm infants, especially those with broncho-
affected (Ferrini, Marbo, & Gariao, 2008; Seow, Young, pulmonary dysplasia (BPD), a chronic lung disease,
Tsang, & Daley, 2005). have an increased incidence of reactive airway disease,
The preterm infant requires close ophthalmologic especially in the first year, and of asthma throughout
follow-up, particularly in the first few months after dis- their life (Dombkowski, Leung, & Gurney, 2008; Kase,
charge. Preterm infants are at risk for abnormal retinal Pici, & Visintainer, 2009; Kumar, Yu, Story, Pongrack,
vessel development, retinopathy of prematurity (ROP), Gupta, Pearson, et al., 2008). Breath sounds and respi-
which occasionally results in retinal detachment and sub- ratory efforts should be closely monitored. Viral infec-
sequent blindness. Myopia, amblyopia, and strabismus tions in the first year may result in severe illness in
are common sequelae of ROP (Azad & Chandra, 2005; the preterm infant. Respiratory syncytial virus (RSV) in
Tasman, Patz, McNamara, Kaiser, Trese, & Smith, 2006). particular can lead to pneumonia and can be fatal. Pro-
The provider must closely observe the corneal light reflex phylaxis during the first and possibly second winter
and visual tracking, as well as verifying that the infant is decreases morbidity and mortality associated with RSV
being followed by a pediatric ophthalmologist. infections (American Academy of Pediatrics, 2009).
Preterm infants should have hearing testing every Hernias, both umbilical and inguinal, are more com-
6–12 months for the first 3 years of life, as hearing mon in preterm than in term infants. The provider
deficits are more common in these infants. Ongoing should assess for inguinal hernias with each visit and
hearing evaluation is recommended even if the infant refer infants for surgical intervention. Incarceration is
passes the discharge screen, as some hearing deficits rare in preterm infants (Antonoff, Kreykes, Saltzman,
are progressive (Spivak & Sokol, 2005). & Acton, 2005; Lau, Lee, & Caty, 2007). Umbilical her-
TABLE 11-10
Preterm Infant Assessment
AREA OF ASSESSMENT ASSESSMENT PEARLS TYPICAL PROBLEMS
Growth Preterm infant growth charts are used for Slow growth
3 years.
Development Milestones are attained according to Delayed milestones

adjusted age. Abnormal muscle tone
Neurology Head growth is followed, and the infant is Hydrocephalus

observed for seizures. Seizures
Microcephaly
Ophthalmology The corneal light reflex and visual following Blindness: can be because of retinal or
are assessed. cortical damage
Myopia/hyperopia
Strabismus
Amblyopia
Audiology The response to sound is assessed. Hearing loss: conductive or cortical
Dentition The color of the teeth is assessed. Thin enamel: dental caries
Respiratory Breath sounds and the work of breathing Reactive airway disease
are assessed. Viral illness leading to severe illness
Hernia The infant is assessed for inguinal and Incarceration is rare in inguinal hernias and
umbilical hernias. virtually never seen with umbilical hernias.
Sensory integration Parents are asked about sensitivities to Sensory integration disorder
touch, light, and sound.
Skin Scars are inspected for changes, mobility, Scarring

and joint contractures.
nias nearly always resolve without intervention and tone and record developmental milestones. Milestones
rarely strangulate (Fall, Sanou, Ngom, Dieng, Sankale, & should be assessed according to the infant’s corrected or
Ndoye, 2006). Parents may need reassurance regarding adjusted gestational age, not chronologic age. Abnormal
hernia management, since most parents are ill-informed tone may normalize over the first year in infants born
concerning surgical treatment. Historic unnecessary prematurely (transient dystonia). Therefore, the diag-
measures to reduce umbilical hernias using tape, coins, nosis of cerebral palsy is usually not made before 1–2
binders, and other methods continue to be utilized. years of age. Low trunk tone and strength are common
The preterm infant’s skin is easily damaged by tape in preterm infants during the first year of life; these usu-
or pressure, which may lead to permanent scarring ally improve over the first years of life. Fine motor and
(Lund, Osborne, Kuller, Lane, Lott, & Raines, 2001). speech delays are also common. Attention difficulties
Thus, infants hospitalized in the NICU are more likely and intellectual deficits are more common in preterm
to have skin scarring. Surgical scars may also be pres- infants as compared to term infants but are usually not
ent and should be evaluated. Intravenous infiltration apparent in infancy. Fifty percent of infants with a birth
scars may cause joint contraction. Multiple heelstick weight under 1 kg at birth require special help in school;
blood draws may lead to scarring of the heels and it is interesting to note, however, that not all of these
sensitivity in the feet. Capillary hemangiomata are children show developmental delay in infancy (van
more common in preterm infants; some develop Baar, van Wassenaer, Briet, Dekker, & Kok, 2005).
multiple small lesions or large cavernous lesions. Preterm infants have an increased incidence of intra-
Developmental delay is more common in preterm in- cranial bleeding (usually intraventricular hemorrhage)
fants (Fily, Pierrat, Delport, Breart, Truffert, & E.N.P.D.C.S. or cystic brain damage (periventricular leukomalacia)
Group, 2006; Hack & Costello, 2008; Hoon, Stashinko, (Bassan, Benson, Limperopoulos, Feldman, Ringer, Vera-
Nagae, Lin, Keller, Bastian, et al., 2009; Krageloh-Mann cruz, et al., 2006). These are detected by screening head
& Cans, 2009; Moster, Lie, & Markestad, 2008; Nelson, ultrasounds. Posthemorrhagic hydrocephalus may be
2008; Paneth, 2008; Stephens & Vohr, 2009). In addition, present, usually requiring shunt placement (Brouwer,
preterm infants are more likely than full-term infants to Groenendaal, van Haastert, Rademaker, Hanlo, & de Vries,
develop cerebral palsy. It is important to note muscle 2008; Heep, Bartmann, Stoffel-Wagner, Bos, Hoving,
Brouwer, et al., 2006; Kazan, Gura, Ucar, Korkmaz, On- (cpr) and emergency cardiovascular care (ecc) of pediatric
and neonatal patients: Pediatric basic life support. [reprint
gun, & Akyuz, 2005; Willis, Javalkar, Vannemreddy,
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American academy of pediatrics section on surgery hernia sur-
lus or microcephaly may develop after discharge. Nor-
vey revisited. Journal of Pediatric Surgery, 40(6), 1009–1014.
mal head growth is 0.5–2 cm/week. Rapid head growth Apgar, V. (1953). A proposal for a new method of evaluation of
may indicate hydrocephalus, which requires referral to a the newborn infant. Current Research in Anesthesia & Analgesia,
32, 260–267.
neurosurgeon. Slow head growth, indicated by a falling
Apgar, V. (1966). The newborn (apgar) scoring system. Reflections
percentile on the growth curve, requires neurologic as- and advice. Pediatric Clinics of North America, 13(3), 645–650.
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SECTION 4
F O CU S E D A S S E S S M E NTS
CHAPTER
Assessment of the
12 Integumentary System
ELLEN M. CHIOCCA
Assessment of the integumentary system should be a The skin also helps excrete toxins through sweat glands
part of every pediatric health assessment, regardless of in a mixture of water, electrolytes, lactic acid, and urea.
the reason for the health care visit. The condition of Vitamin D synthesis occurs in the skin when exposed
the skin, hair, and nails provides important informa- to sunlight. The skin functions as a sensory organ when
tion about the child’s physical and emotional health. nerve impulses convey sensations of touch, pain, pres-
Many communicable infectious diseases or infesta- sure, heat, and cold. The skin also heals itself by replacing
tions common to childhood have characteristic skin cells to repair wounds and by controlling the coloniza-
rashes as a manifestation of the illness. Assessment tion of pathogens by continual shedding.
of the skin in children also yields crucial information The integumentary system also allows persons to
about a child’s nutritional, cardiovascular, and hydra- identify with a group through hair and skin color. In
tion status. Alteration in the integrity of the skin can addition, self-esteem can be affected, particularly in
result in dehydration, hypothermia, infection, and older school-aged children and adolescents, depend-
systemic illness. Child abuse or neglect may also have ing on the condition of the child’s hair or skin and
clinical manifestations of the skin, hair, or nails. Poor society’s standards of beauty.
personal hygiene (e.g., dirty hair or nails) may be an The skin begins to develop during the eleventh week
indication of depression or other mental health disor- of gestation. It consists of three layers; the epidermis,
ders. For these reasons, the health care provider should the dermis, and the subcutaneous tissue (Fig. 12-1).
be able to recognize dermatologic clues to injury, ill-
ness, or systemic disease and to assess and diagnose Epidermis
basic pediatric skin disorders.
The epidermis is the outermost, avascular layer of the
skin and is further divided into four or five cell layers,
depending on its location on the body (see Fig. 12-1).
ANATOMY AND PHYSIOLOGY In areas where the skin is exposed to chronic friction,
such as the palms and soles, the skin has five layers.
SKIN These layers, from outside inward, are the stratum cor-
The skin is the body’s largest organ, the major function of neum (the horny layer), stratum lucidum, stratum granu-
which is to keep the body in homeostasis. This is achieved losum, stratum spinosum, and stratum basale.
through several distinct functions. One function is to • The stratum corneum, the top layer, functions as a
provide a protective barrier against irritants, toxins, mi- barrier that protects the body’s underlying tissues
croorganisms, trauma, ultraviolet (UV) rays, and loss of and structures. The thickness of this layer depends
body fluids. The skin assists in body temperature regula- on the area of skin in question; skin is thinnest on
tion through vasoconstriction when the body is cold and the face and thickest on the feet. This layer of skin is
vasodilation and sweating when the body is too warm. continually shed and replaced.
230
C H A P T E R 12 A s s e s s m e n t o f th e I n te gum entar y S ystem • 231
Sweat pore
Hair
Stratum corneum
Epidermis
Arrector pili muscle
Sebaceous gland
Eccrine sweat gland

Dermis
Hair follicle Nerve
Papilla
Arteriole
Venule
Subcutaneous
tissue
FIGURE 12-1. The layers of the skin and related structures. (Source: Ball, J. W., & Bindler, R. C. [2006].
Child health nursing: Partnering with families. [p. 1456]. Upper Saddle River, NJ: Prentice Hall, with permission.)
• The stratum lucidum is a translucent layer of the epi- (a bright red pigment), and deoxyhemoglobin (a dark,
dermis that lies between the stratum corneum and blue pigment) contained in the skin.
stratum granulosum. This layer is mostly found in the
thick skin of the hands and feet. Dermis
• The stratum granulosum contains a layer of cells that The dermis underlies the epidermis and is richly vascular,
contain dark-staining granules that are involved in supplying the epidermis with nutrition (see Fig. 12-1). It
keratin formation. consists mostly of connective tissue, or collagen, which
• The stratum spinosum assists in the continual produc- provides elasticity to the skin, allowing it to stretch and
tion of a new epidermis. The stratum basale (basal resist tearing. The dermis also contains blood vessels, lym-
layer) and stratum spinosum are sometimes collec- phatic vessels, autonomic nerve fibers, muscles, and hair
tively referred to as the stratum germinativum because follicles. The autonomic nerves supply the arrector pili
this is where the new cells are germinated. muscles, blood vessels, and sweat glands. Cells in the der-
• The stratum basale houses keratinocytes, which mis include fibroblasts, mast cells, and macrophages. Each
produce waterproof keratin cells whose main func- of these cells has a specific function. Fibroblasts aid in the
tion is to protect the skin. This is done when ke- development of connective tissue, mast cells release his-
ratinocytes multiply and move upward through tamine during hypersensitivity reactions manifested by
the epidermis and form a hard layer of dead ke- the skin, and macrophages play a role in immunity. Skin
ratinocytes, which comprises the stratum corneum. appendages are embedded in the dermis and include the
The cells of the stratum corneum are continuously nails, hair follicles, sweat glands, and sebaceous glands.
desquamated and replaced with new keratino-
cytes from below, the process repeating itself every Subcutaneous Tissue
4 weeks. The subcutaneous tissue underlies the dermis and binds
The basal layer also contains melanocytes, which it to the underlying body tissue. This layer of skin is com-
synthesize melanin (brown pigment) to protect the posed of adipose and connective tissues and contains
skin from damage by UV rays from the sun. Each blood vessels, nerves, sebaceous glands, sweat glands,
person possesses a similar number of melanocytes in and deep hair follicles (see Fig. 12-1). The subcutaneous
their skin; the amount of melanin that is made var- layer cushions the body against trauma and insulates it
ies from person to person. Melanin production is also to maintain body temperature. Subcutaneous tissue is a
stimulated by exposure to sunlight. Skin color depends source of energy for the body and of hormone metabo-
not only on the amount of melanin, but also on the lism and contains the blood supply and nerves of the
amount of carotene (yellow pigment), oxyhemoglobin autonomic nervous system that support the dermis.
2 3 2 • S e c t i o n 4 F O C U S E D AS S ESSM ENTS
SKIN APPENDAGES Sweat Glands

Hair There are three types of sweat glands: eccrine, ceru-
Hair consists of a thread of keratinized cells. Hair fol- minous, and apocrine. The eccrine glands are widely
licles are found over most of the body except for the distributed throughout the body and open directly
lips, palms, knuckles, soles, nipples, labia minora, onto the skin’s surface. These glands help maintain
and penis. Hair consists of a shaft and root. The hair fluid and electrolyte balance, excrete waste (e.g., uric
shaft is visible above the skin; the root is surrounded acid and ammonia, both by-products of protein me-
by the hair follicle and a sebaceous gland (see Fig. 12-1). tabolism) and produce sweat in response to heat and
Hair on the scalp protects the skin there; nasal hair, emotional stimuli. These glands are controlled by the
ear hair, eyelashes, and eyebrows protect the nearby sympathetic nervous system. Ceruminous glands are
structures from dust and other airborne debris. Two located in the external auditory canal and produce
types of hair can be found on the body. Vellus hair cerumen. Apocrine glands are located primarily in the
is fine, short, pale, and covers much of the body. axillary, genital, and periumbilical regions. They open
Terminal hair is coarser, longer, and darker than vel- into hair follicles and require androgens to stimulate
lus hair and is found on the scalp, eyebrows, pubis, their secretions.
and axillae. Hair color and texture vary and are de-
termined by genetics and the type and amount of Sebaceous Glands
pigment produced.
Sebaceous glands are everywhere on the body except
the palms and soles (see Fig. 12-1). They are most abun-
Nails dant on the scalp and face. The sebaceous glands pro-
The purpose of nails is to protect the distal ends of the duce sebum, a lipid substance that is secreted through
fingers and toes against trauma. Nails are hard, trans- the hair follicles. Sebum keeps the hair from drying,
parent plates of epidermal cells that are converted to prevents water evaporation from the skin, moisturizes
keratin and grow from a root under the skin called the the skin, and is thought to have some fungicidal and
cuticle. Nails (i.e., the nail plate) appear pink because bactericidal effects.
of the highly vascular epithelial cells (i.e., the nail bed )
on which they rest. At the base of the nail is a crescent-
shaped, whitish area called the lunula, which lies over
the nail matrix where new keratin cells are formed. DEVELOPMENTAL
The cuticle works to cover and protect the nail matrix, CONSIDERATIONS
which is the growth region of the nail (Fig. 12-2).
SKIN
Skin development is a dynamic process from the em-
Nail bed Lunula
bryonic stage through adulthood. The skin of the neo-
Nail plate Cuticle Nail root nate continues to change during childhood through
late adolescence at which time the skin achieves adult
thickness and characteristics.
The stratum corneum does not develop until 23 to
25 weeks’ gestation (McLeod, 2006). Therefore, prema-
ture infants lack this top layer of skin, which greatly
increases the infant’s risk for infection, temperature in-
stability, and fluid loss. When an infant is born, the skin
is covered with a thick, white, cheesy substance called
Distal bone Growth region vernix caseosa (see Chapter 11), which consists of se-
A of finger (nail matrix) bum and shed epithelial cells. The earlier the gestation,
the more vernix will be covering the infant’s skin.
Lateral nail fold A neonate’s skin shares the same structure as mature
Lunula
Body of nail skin, but the functions are immature. At birth, the epi-
Cuticle dermis is very thin, with little underlying subcutane-
ous tissue (Saladin, 2006). These factors result in several
consequences for the neonate:
• They lack the ability to shiver to increase body tem-
perature.
B • They lose heat rapidly and have difficulty conserv-
FIGURE 12-2. The nail and related structures. ing body heat.
• They lose fluid readily, making them susceptible to hair is terminal hair, soft in texture, and often patchy.
dehydration. The amount of scalp hair varies, and scalp hair is shed
• Their skin has greater permeability to and increased within a few months of birth and replaced, often with
transcutaneous absorption of potentially harmful hair of a different color and texture (Ball & Bindler,
chemicals (Ball & Bindler, 2006). 2006). In children, hair grows approximately 1 cm a
• The thin epidermis allows superficial blood vessels month. At the onset of puberty, coarse hair appears in
to be visible, causing the newborn skin to appear red the pubic area and axilla and, in males, on the face.
to ruddy in color.
• They have a loose attachment between the epider- Nails
mis and dermis, making them more prone to blister Nails are formed in the fifth fetal month. The fetus’s
formation. Their skin contains more water than the fingernails should reach the end of the fingertips by
skin of an older child or adult, making it more sus- 36 weeks’ gestation and extend beyond the fingertips
ceptible to bacterial infection (Ball & Bindler, 2006). by 37 to 40 weeks’ gestation (McPherson, 2009). Nails
The pH of the skin in neonates is basic (as opposed are spoon-shaped and thin from birth until approxi-
to being acidic), which also makes infants prone to mately 2 to 3 years of age. In children, nails grow at a
skin infections, since an acidic pH creates a hostile en- rate of 1 mm or less a day.
vironment for bacteria. The epidermis and dermis be-
come more tightly bound by adolescence, increasing Sweat Glands
resistance to friction injuries and infection. Eccrine glands begin to function by 2 to 18 days of
There is less melanin in the skin at birth, so the skin age but do not fully function until middle childhood.
is lightly pigmented (Ball & Bindler, 2006). Because Therefore, infants and very young children sweat min-
UV light is required for melanin production, several imally and are unable to regulate body temperature as
weeks may pass before the neonate’s skin darkens. The efficiently as older children and adults. This partially
skin continues to darken as more pigmented cells rise explains the high fevers sometimes noted in children
through the epidermis. This is particularly noticeable in this age. Infants do, however, experience palmar sweat-
dark-skinned children. Throughout childhood, the hair ing in response to heat and emotional stimuli, and this
and skin color changes as the child matures. Melanin may be helpful when assessing pain in the neonate.
reaches adult levels by adolescence. Vascularization of Eccrine glands achieve full function at puberty; boys
the dermis is well developed by the second year of life. sweat more than girls.
At the onset of puberty, secondary sex characteristics Apocrine glands do not become active until puberty.
appear in the skin. In girls, subcutaneous fat deposits These glands secrete a fluid in response to heat or emo-
increase, especially in the pelvic region. The areola en- tional stress. Bacteria on the skin react with the fluid
larges in diameter and darkens in color, and breast tis- produced by apocrine glands to produce body odor.
sue develops. In boys, skin changes include thinning,
increased redness, and looseness of the scrotal skin. At Sebaceous Glands
puberty, a deceleration of fat mass accumulation occurs,
Sebum is present for the first few weeks of life, and its
resulting in a higher lean body mass than in girls.
presence produces milia (sebaceous cysts seen most of-
ten on the nose and chin of the newborn) (see Chapter
11) and seborrhea (e.g., cradle cap in infants and dan-
SKIN APPENDAGES druff in adolescents). Sebaceous glands decrease in size
Skin appendages are present at birth but, like all other and stop producing sebum between 6 and 12 months
body structures at this age, they are not fully devel- of age but become active again at puberty when stimu-
oped (Ball & Bindler, 2006). lated by testosterone. Decreased sebum production
provides less protection against evaporation and dry-
Hair ing, interfering with body temperature regulation and
Hair follicles develop in the fetus between the 3rd and skin integrity. Increased sebum production during pu-
4th months’ gestation (McPherson, 2009), and by ap- berty makes hair and skin oilier, often causing acne.
proximately 13 to 16 weeks’ gestation, the skin of the
fetus is covered with fine, downy hair called lanugo
(see Chapter 11). At approximately 36 weeks’ gesta- ASSESSMENT OF THE SKIN,
tion, lanugo begins to disappear and is completely
gone by 37 to 40 weeks’ gestation, except for the upper
HAIR, AND NAILS IN CHILDREN
arms and shoulders (McPherson, 2009). This lanugo is
usually shed by 2 to 3 weeks of age (Ball & Bindler, HISTORY
2006). In the first few months after birth, lanugo is Disorders of the skin, hair, and nails can be acute or
replaced by fine vellus hair. In a full-term infant, scalp chronic, localized, or caused by a systemic problem.
psoriasis). The PMH also includes the review of systems

(ROS) relative to the integumentary system. Included
in the PMH are questions about congenital nevi and
allergies.
Congenital Nevi. Nevi are a common finding in

children. The two most common types of nevi are
pigmented (e.g., café au lait spots, Mongolian spots)
and vascular (e.g., salmon patches, port-wine stains,
hemangiomas) (Vernon, Brady, & Barber Starr, 2009).
Some nevi should be noted because of their par-
ticular characteristics. Two examples of pigmented
nevi stand out. Café-au-lait spots are tan to brown
macules (Fig. 12-3). They are notable because if they
measure greater than 0.5 cm in diameter or number
five or more, the child should be evaluated for neuro-
FIGURE 12-3. Café-au-lait spot. Congenital nevus; round to fibromatosis (Kam & Helm, 2009). Mongolian spots
oval light brown macules; if there are six or more and over
5 mm in diameter, neurofibromatosis may be present. For a (Fig. 12-4) are noteworthy because they must be dis-
full-color example, please refer to Figure 12-3 on page C1. tinguished from bruises to rule out child abuse.
Vascular nevi are caused by a structural abnormal-
ity (vascular malformations) or an overgrowth of
The reason for the health care visit dictates the type blood vessels (hemangiomas). These nevi can be flat,
of history to be obtained. When a child is seen for his raised, or cavernous. Vascular malformations are pres-
or her first visit to the practice, the provider should ent at birth; hemangiomas (Fig. 12-5) are not present
obtain a very inclusive history and ask about nevi at birth but emerge by 1 month of age. Vascular mal-
(birthmarks), skin changes in the neonatal period, formations (e.g., salmon patches or “stork bites,” port-
past rashes, a history of injuries involving the skin, wine stains) grow along with the child (see Fig. 12-5);
past medical history (PMH), family history of skin hemangiomas may grow quite rapidly in some cases.
disorders or allergies, and habits such as nail-biting. Hemangiomas may be superficial, deep, or mixed. His-
Children presenting for a health maintenance visit tologically, hemangiomas are benign tumors of cap-
require an updated family and medical history, in- illary endothelial cells. Involution of hemangiomas
cluding recent illnesses, new allergies, and current begins at approximately 12 to 24 months of age, and
medications. A focused history is required for chil- most are flat by 5 to 7 years of age and the remain-
dren presenting with an integumentary complaint. der by puberty. Most hemangiomas appear as normal
Regardless of the type of history, the provider should skin after involution, but some leave residual skin
always ask about measures used to protect the child’s changes such as atrophy, telangiectasias, or scarring
skin from the sun.
When obtaining the history specific to the integ-
umentary system, it is important for the provider to
remember to ask questions in a matter-of-fact, non-
judgmental manner, especially when inquiring about
any dermatologic manifestations that may be the result
of poor hygiene or unhealthy behaviors. In addition,
some dermatologic conditions may be embarrassing to
a child or teen, for example, acne and tinea cruris (jock
itch), and a sensitive approach when asking questions
about these conditions is necessary.
Past Medical History

The purpose of the PMH is to establish a baseline der-
matologic assessment against which future assessments
can be measured. A history of allergies, illnesses, infec-
tions, injuries involving the skin, or sensitivity to UV
light may be directly related to rashes the child may FIGURE 12-4. Mongolian spot. These congenital blue-gray
have had in the past or may even explain a new rash. macular lesions are found primarily in the lumbosacral or glu-
teal area of dark-skinned newborns. These spots usually fade
A family history is important because certain dermato- by school age and should be differentiated from bruises. For a
logic disorders can be inherited (e.g., atopic dermatitis, full-color example, please refer to Figure 12-4 on page C1.
FIGURE 12-5. Types of vascular skin lesions. A. Port-wine stains are permanent dark red to purple
macules; they do not blanch with pressure or fade with time. They can be associated with congenital
syndromes. B. Salmon patches, also called stork bites, are flat, light pink macules that blanch with
pressure and fade with time. C. A capillary (“strawberry”) hemangioma is a soft, bright red, vascular
nodule that appears soon after birth and involutes spontaneously, usually by 7 years of age. D. A
cavernous hemangioma is a raised, soft, compressible lesion, light blue in color, that blanches with
pressure; it is variable in size. For a full-color example, please refer to Figure 12-5 on page C2.
(Antaya, 2009; Miller & Frieden, 2005). Hemangiomas allergies related to the following: medications, foods,
may interfere with body functions, depending on the chemicals, insect bites, animals, plants, and environ-
location of the lesion. Any hemangiomas that obstruct mental allergens. It is also important to determine if
the airway, the eye, or those that cause cardiac com- the parent has used any treatments for these allergies,
plications (e.g., high-output failure) require immediate and if so, to what effect.
treatment. The provider should always inquire about
any changes in the color, size, or shape of a nevus, or
if there is any new onset of tenderness, bleeding, or Family History
itching (Table 12-1). A family history is important to obtain, focusing on
hereditary skin disorders, such as atopic dermatitis
Allergies. The provider should ask the parents if their (eczema), seborrheic dermatitis, psoriasis, or any fam-
child has any allergies and should document the type ily history of sensitivities to topical creams or other
of reaction the child experiences after exposure to medications. It is also important to ask about any fam-
the allergen (e.g., itching, rashes, urticaria). The pro- ily history of asthma, allergic rhinitis, environmental
vider should inquire specifically about any history of or food allergies, persistent rashes, and diabetes. The
TABLE 12-1
Congenital Skin Lesions
TYPE OF LESION CHARACTERISTICS
Pigmented Skin Lesions
Café-au-lait spots Tan to light brown macules with discrete borders
Congenital pigmented nevi At birth, lesion may be pale pink to tan with soft vellus hairs; during childhood, nevus
darkens to light brown to black plaques often with dense hair growth.
Mongolian spots Dark blue, irregularly shaped macules seen in dark-skinned infants and children, most
often seen in the lumbosacral and gluteal areas; may occur on the upper back, shoulders,
and extremities. More uniform in color than bruises with well-defined borders; often fade
with time; their presence should be documented for medico-legal reasons (see Fig. 12-4).
Vascular Malformations
Port-wine stain or nevus Dark red to purple macules that occur unilaterally, usually on face, occiput, or neck.
flammeus Present at birth and do not enlarge or fade. Can be associated with Sturge-Weber disease
(see Fig. 12-5A).
Salmon patch (“stork bite”) Light pink macules found on forehead, back of neck, glabella, and upper eyelids; present at
or nevus flammeus birth; fade with time, usually by age 1 (see Fig. 12-5B).
Hemangiomas
Capillary hemangioma May not be present at birth. Begins as gray to white area and then becomes red, raised, and
(“strawberry mark”) well defined; grows rapidly. Lesions are soft, compressible, and elevated (see Fig. 12-5C).
Usually involute by age 5–7.
Cavernous hemangioma Lesions are beneath the skin and appear bluish; borders are indistinct; lesion fills with
blood if patient placed in a dependent position; with blanching, a soft, compressible
tumor is felt (see Fig. 12-5D).
provider should also ask if any family members have history; a history of immunosuppression; and nutri-
been ill recently, currently have a rash, or if all family tional disorders or deficiencies
members’ immunizations are up-to-date. A family his- • Skin, hair, and nails: Recent or long-term changes
tory of skin cancer should be noted. in the color, quality, or texture of skin, hair, or nails;
history of dry skin, skin disease, or rashes, including
acne, atopic dermatitis, contact dermatitis, seborrhe-
Review of Systems ic dermatitis, psoriasis; nevi; skin changes in the neo-
The pediatric ROS specific to the integumentary sys- natal period (e.g., jaundice, including day of onset;
tem includes asking the parent or caregiver about the cyanosis and its cause); diaper rash and what type;
child’s usual state of health and any recent illnesses. burns or bruises and circumstances surrounding in-
Many childhood illnesses have cutaneous manifesta- juries; habits such as nail-biting, hair-twisting, hair-
tions, most notably viral exanthems and bacterial ill- pulling (trichotillomania); pressure alopecia (because
nesses such as streptococcal infections. of persistent positioning on one side, which is mostly
The provider should also ask about a history of nu- seen in infants); traction alopecia (hair loss because
tritional deficiencies, many of which alter the condi- of tight hairstyles); hirsutism; history of sunburn or
tion of the hair, skin, and nails. For example, a lack of sensitivity to sunlight; fungal infections of the skin,
vitamins C and K may cause bruising, while a deficit hair, or nails; presence of acanthosis nigricans (Fig.
of vitamin A may cause dry hair. Food allergies may 12-6), which may indicate insulin resistance, diabe-
also have integumentary manifestations (e.g., rashes, tes, or polycystic ovary syndrome (PCOS); tattoos or
atopic dermatitis, pruritus, urticaria), and any history piercings; or urticaria
of these should be included in the ROS. Other areas to • Eyes, ears, nose, and throat: Swelling, itching,
assess include: drainage, circles around eyes; chronic nasal dis-
• General health: Usual state of health; recent illnesses, charge, mouth breathing, epistaxis; dry mouth, oral
especially viral or bacterial illnesses; immunization lesions, or pain
Current Medications
The provider should ask what medications the child
has taken over the past 3 to 5 days. This includes all
prescribed and over-the-counter drugs, topical med-
ications, and any herbal preparations. Side effects
or allergic reactions to medications often manifest
as skin rashes. The provider should ask the parent
what, if any, treatment was used for itching or dis-
comfort, noting the effectiveness of the treatment.
FIGURE 12-6. Acanthosis nigricans. Linear areas of velvety The provider should also inquire about the use of
thickening and hyperpigmentation of the skin, most often
seen in the skin folds of the neck and axilla; skin tags may also
anabolic steroids, which have several untoward side
be seen; most common in African American, Native American, effects, especially with chronic use. The most obvi-
and Hispanic children; they are related to obesity and may ous integumentary manifestation of steroid use is
indicate insulin resistance. For a full-color example, please
refer to Figure 12-6 on page C2.
the development of acne in adolescents who use
these drugs.
• Respiratory: Asthma, allergic rhinitis, chronic cough,

or wheezing History of Present Illness
• Endocrine: Diabetes; overweight or obesity; PCOS; Most pediatric integumentary complaints are re-
or current pregnancy (adolescent) lated to contagious skin infections, infestations,
or communicable diseases. Other complaints in-
Social History Specific to the clude skin dryness, oiliness, bruising, swelling,
Integumentary System increased pigmentation, lesions, rashes, changes in
Certain aspects of the child’s social situation and life- birthmarks, hair loss, and a change in the condi-
style can influence the condition of his or her skin, tion of the nails. When a child presents with an
hair, and nails. Below is a summary of what the pro- integumentary complaint, several key questions
vider should assess when gathering a social history are important to formulate a differential diagno-
relative to the integumentary system. sis (Table 12-2). The mnemonic OPPQRST is useful
ASSESSMENT RATIONALE
Sun exposure, frequency of sunbathing, and Recent or frequent sunburn can lead to dryness of skin or infection and
use of sunscreen over time increases the child’s lifetime risk for developing skin cancer.
Obesity Rashes in intertriginous areas (i.e., intertrigo) develop from chronic

heat, moisture, and friction; acanthosis nigricans may indicate insulin
resistance.
Personal hygiene Inadequate personal hygiene can lead to rashes and skin breakdown as
well as dirty hair and nails.
Hot or humid environment; extreme cold Chronic sweating can lead to skin rashes, especially in infants and young
temperature exposure children; frostbite or burns affect the blood supply and can damage the
skin.
Hobbies Some hobbies may increase exposure to paint, bleach, glue, chemicals, or
the sun, all of which can be drying and irritating to the skin.
Emotional disturbance Depression may interfere with daily hygiene routines such as bathing
and hair washing; depression may also lead to self-mutilation behaviors,
including self-inflicted scratching, punching, pinching, burning, and
cutting (Tumolo, 2005).
Use of tobacco (including exposure to Smoking tobacco interferes with the cell’s ability to repair damage (e.g.,
secondhand smoke), street drugs, or alcohol after intense UV exposure). Street drugs (e.g., amphetamines) can cause
dry, itchy skin, and profuse sweating may accompany alcohol use in
which case the skin feels cool to the touch but the drinker feels warm.
Habits Compulsive nail-biting, hair-pulling, or skin-picking may indicate

mental health disorders.
TABLE 12-2
Focused History Related to Skin Assessment
SUBJECTIVE OR
OBJECTIVE DATA KEY QUESTIONS
Date of onset of rash or Sudden or gradual?
lesions
Evolution of rash or lesions Intermittent or continuous? Has the rash or lesion changed since its onset (e.g., varicella
begins as erythematous macules then progresses to papules, then vesicles, then crusts)?
Location of rash or lesions Is the rash or lesion localized or has it spread? Where is the rash located?
Quality of rash or lesions Are there single or multiple lesions? Is it a primary or secondary lesion (see Tables 12-6
and 12-7)?
Associated symptoms Is there a history of a recent fever, malaise, systemic illness, or weight loss or gain? All of
these can indicate viral or bacterial illness.
Aggravating factors What makes the rash worse?
Alleviating factors Are any treatments (e.g., prescription or over-the-counter medications, heat, cold, creams,
lotions, home remedies) currently being used? If so, what are their effects?
Presence or absence of Is the itching because of dry skin, atopic or contact dermatitis, insect bites, allergies,
itching infection, infestations (e.g., scabies, lice), or systemic illness such as varicella, or is it a
prodrome to an asthma attack? Does it awaken child from sleep? Where does it itch?
Prior history of similar rash Could this be a chronic condition such as atopic dermatitis?
Change in skin or mucous Has the child had extensive sun exposure, which can cause skin color changes? Does
membrane pigmentation the child have atopic dermatitis, which can cause excessive itching and lead to skin
lichenification? Does the child have a cardiac condition, which can cause changes
in the color of the skin or mucous membranes? Is the child obese (increased brown
pigmentation, especially in the folds of the neck and axillae, can indicate insulin resistance
[i.e., acanthosis nigricans; see Fig. 12-6]) (Olson, 2004)?
History of eating large Is it possible that diet caused yellow skin pigment change (carotenemia)?
amounts of yellow fruits or
vegetables
Hair loss Does the child have any known nutritional deficiencies? Is there a history of recent weight
loss? Does the child pull out his or her own hair? Does the child have a history of rubbing
his or her head against the mattress? Is the child on chemotherapy?
Change in nails Does the child have any change in nail color or contour?
Immunization status Is it possible that immunizations for communicable diseases have caused integumentary
manifestations?
Current medications Is it possible that the rash or urticaria is caused by an allergic reaction to medication?
Allergies Is it possible that the child is having an allergic reaction with cutaneous manifestations?
Has a new formula or food been recently introduced to the child?
Family history Is the rash a hereditary or contagious problem? Other family members may need to be
assessed for the same symptoms (e.g., tinea or pediculosis infections).
Recent travel Is it possible that recent travel resulted in a communicable disease with cutaneous
manifestations?
Recent sun exposure Is there a recent history of excessive sun exposure, which can cause erythema, vesicles, and
burns? Does the child wear sunscreen, a hat, and a long-sleeved shirt?
SUBJECTIVE OR
OBJECTIVE DATA KEY QUESTIONS
Recent exposures:
• Communicable illnesses • Infectious (viral, bacterial, fungal) illnesses common to children have cutaneous
(e.g., roseola, varicella, manifestations.
scarlet fever)
• Contagious skin
conditions (e.g., tinea,
scabies, impetigo)
• Infestations (e.g.,
pediculosis, scabies)
Known infectious contacts Child should be assessed for same manifestations as sick contact.
Infestations may be common in group babysitting situations (e.g., day care).
New soaps, lotions, Can cause irritant or allergic contact dermatitis

shampoos, detergents,
fabric softeners, dryer
sheets, or powders
Use of jewelry Can cause contact dermatitis
Plants Plants such as poison ivy, oak, or sumac cause allergic contact dermatitis.
Animals Some animals may be vectors in the transmission of certain contagious skin conditions
(e.g., kittens and puppies often carry the fungus known as ringworm [i.e., tinea corporis]).
as a guideline when collecting subjective data (see acrocyanosis or mottling does not occur as a result
Chapter 6). Table 12-3 lists some common pediatric of a cool room temperature or flushing or sweating
skin conditions. does not occur as a result of a hot room tempera-
ture. This may confuse the clinical picture as these
color changes and the diaphoresis can result from
PHYSICAL EXAMINATION cardiac etiologies.
The skin is the most easily examined organ because Helpful tools that assist the provider during in-
of its size and accessibility. Assessment of the integu- spection of the skin include a penlight, a magni-
mentary system involves inspection and palpation fying glass to enlarge small areas of the skin for
of the skin, hair, scalp, and nails. The integumentary closer inspection, and a centimeter ruler to mea-
system is unique in that thorough, systematic inspec- sure any lesions. It is also helpful to have a glass
tion alone most often provides the most useful data. slide to aid in assessment; the provider could use
Palpation is also useful as it enables the examiner to this to press onto the child’s skin gently to assess
assess the temperature, texture, and turgor of the skin. skin color (e.g., jaundice) and capillary refill time. A
Palpation also aids in assessing elevated skin lesions. Wood’s lamp, which provides UV light, is useful to
For example, when examining dark-skinned children examine fluorescent-positive skin fungal infections.
and adolescents, inspection alone is often inadequate A microscope, potassium hydroxide (KOH), a glass
and palpation is an important part of assessment, es- slide, and a cover slip are necessary to diagnose skin
pecially when keloids form or lichenification occurs. fungal infections.
The provider should always wear gloves when palpat- To assess and diagnose any dermatologic condi-
ing the skin, especially over areas of lesions and skin tions accurately in children, the provider must be
breakdown. familiar with the correct terminology used to de-
Inspection of the skin should take place in a room scribe dermatologic lesions (Table 12-4). Before the
with good light with neutral colored walls. Natu- physical assessment, the provider should prepare
ral daylight is the best, but if this is not possible, the child for the exam. For children toddler age or
the best alternative is the direct light provided by younger, an explanation to the parent alone will suf-
a gooseneck lamp. The lamp should have at least fice. However, the provider should alert older chil-
a 60-watt bulb; fluorescent lighting should not be dren and adolescents about the skin areas that will
used as this light is not natural. The examination be examined and touched. To assess the skin accu-
room temperature should be comfortable so that rately, the child should remove all clothes and wear
TABLE 12-3
Common Skin Conditions in the Pediatric Patient
TYPICAL
ARRANGEMENT
DIAGNOSIS PHYSICAL FINDINGS PATTERN LOCATION OF LESIONS
Allergic and
Inflammatory
Reactions
Acne Closed and open comedones Localized Face, neck, shoulders, chest, and back
(noninflamed acne); pustules,
papules, nodules, and cysts
(inflamed acne)
Allergic dermatitis Erythema, vesicles, and pruritus Localized or diffuse Area in which antigen contacted
skin
Atopic dermatitis Erythematous, intensely Confluent, localized, or Infantile eczema: cheeks, forehead,
(eczema) pruritic papules, plaques, and diffuse; symmetrical scalp, trunk, and extensor surfaces of
vesicles that ooze and crust. extremities. Diaper area spared.
Chronic form has pruritic, dry, Childhood eczema: wrists, ankles, and
scaly rash with lichenification. antecubital and popliteal fossae
Secondary lesions often develop
because of scratching (e.g.,
infection, lichenification).
Contact dermatitis Pruritic rash that has sharply Confluent, localized, or Localized to the affected area
demarcated borders and often diffuse; may be linear
mimics the shape of the contact
irritant. Papules and bullae may
be present.
Diaper dermatitis Depends on cause: chemical Localized or confluent Diaper area

dermatitis causes shiny, peeling,
erythematous maculopapular
rash, sparing skinfolds; bacterial
dermatitis causes erythematous,
peeling blisters and pustules.
Drug eruptions Macular or papular, Confluent or diffuse; Begins on trunk; extends to palms,
erythematous; intensely pruritic symmetric or soles, and face
morbilliform
Insect bites Erythematous, edematous, Localized to diffuse; Anywhere on body

and urticarial papules; pruritic. grouped
Secondary lesions often emerge
as a result of scratching.
Urticaria (“hives”) Erythematous, pruritic raised Confluent, annular, Face, trunk, and extremities
wheals with pale, edematous localized, or diffuse
centers that blanch with
pressure; accompanied by
edema of lips, tongue, eyelids,
hands, and feet
Infections:
Bacterial
Cellulitis Erythema, tenderness, and Localized Dermis and subcutaneous tissue of

swelling; area warm to touch affected area
Folliculitis Erythematous papule or pustule Localized Hair follicle

at hair follicle; pruritic
Impetigo Honey-crusted thin-roofed Confluent, localized, or Superficial layers of skin over

vesicles on an erythematous grouped affected area
base; pruritic
TYPICAL
ARRANGEMENT
Scarlet fever Flushed face, perioral pallor, Confluent; symmetrical Involves all body surfaces except the
diffuse blanching; sandpapery, face; may be more noticeable in the
pruritic, nontender erythematous joint areas (“Pastia’s lines”)
papular rash, strawberry tongue;
postacute phase desquamation
Infections:
Fungal
Candidiasis Erythematous papules and Localized Intertriginous regions, especially

pustules with sharply demarcated diaper area; can be associated with
borders and surrounding satellite oral candida
lesions; some loose scales
Tinea corporis Flat, scaly, erythematous circular Confluent, annular, or Anywhere on body
patches with central clearing; localized
border of lesions are raised.
Tinea cruris Erythematous to slightly brown, Arciform; symmetrical Groin, thighs, and inguinal folds
scaly, sharply demarcated lesions
with raised border
Tinea pedis Erythematous, scaly, cracked Confluent or localized Feet

rash on soles of feet and
interdigital spaces; pruritic
Tinea versicolor Hypopigmented to Confluent or discrete; an- Mostly on trunk; can be on neck,
hyperpigmented scaly macules nular, localized, or diffuse shoulders, upper arms, back, and face
Infections:
Viral
Coxsackie virus Mildly painful, shallow ulcers Diffuse Face, extremities, and mucous
(hand, foot, and surrounded by red halos; membranes
mouth disease) vesicles seen on palate
Erythema Patchy facial erythema for Confluent or localized; Face, scalp, trunk, and extremities
infectiosum 1–4 days, then maculopapular symmetrical or reticular
(Fifth disease) reticular rash appears on
extensor surfaces of extremities
Molluscum Sharply circumscribed Confluent or localized Face, scalp, trunk, and extremities
contagiosum umbilicated papules that are
pearly white in color
Herpes simplex Vesicles on an erythematous Confluent, grouped, or Lips, nose, tongue, genitalia, and
(canker sores) base; vesicles dry, leaving a crust, localized buttocks
then shallow, painful ulcers
Herpes zoster Painful, pruritic vesicles Confluent or localized; Face, scalp, and trunk; lesions cluster
(shingles) zosteriform along dermatome
Roseola Erythematous to rose-pink Confluent or diffuse Begins on trunk; spreads to

maculopapular rash extremities
Rubella (German Discrete pinkish red Diffuse Begins on face; spreads

measles) maculopapular rash cephalocaudally
Rubeola (measles) Pathognomonic exanthema on Confluent or diffuse; Begins on forehead and behind the
buccal mucosa (Koplik’s spots) evi- discrete distally ears, then spreads to face, neck, and
dent during prodrome; progresses arms, and then back, abdomen, and
to erythematous, blanching thighs
maculopapular rash; papules
enlarge, become confluent, and
progress cephalocaudally
(continued)
TABLE 12-3
Common Skin Conditions in the Pediatric Patient (Continued)
TYPICAL
ARRANGEMENT
Varicella Erythematous papules evolve Diffuse; symmetrical Face, palms, soles, trunk, extremities,
into thin-walled vesicles on and mucous membranes
an erythematous base (“dew
drops on a rose petal”); vesicle
ruptures, causing crusting;
intensely pruritic. Lesions
appear in crops.
Warts (common Elevated, flesh-colored papules Confluent, contiguous, Can be found anywhere on the
warts) with scaly surfaces or localized body; most commonly found on
fingers, nails, legs, hands, and feet
West Nile virus Erythematous, maculopapular Morbilliform Trunk

rash; painful but not pruritic;
blanches with pressure
Infestations
Scabies Linear, brownish-gray burrows; Burrows; linear or Trunk; intertriginous areas; webs
intensely pruritic; numerous diffuse of fingers and toes; sides of hands,
vesicular lesions in infants. palms, and soles; axillae; belt line;
Secondary lesions (e.g., buttocks and extremities
crusting, excoriation, infection)
often because of scratching
Pediculosis Small white nits seen on hair Linear Head, body, or pubic area
shaft (head lice); excoriated
macules or papules (body lice);
excoriation over pubic area
with small bluish macules and
papules (pubic lice). Secondary
infection commonly because of
scratching
Lyme disease Distinctive exanthem: erythema Annular; localized to Groin, axilla, and thigh proximal to
migrans. Appears 4–20 days after diffuse tick bite
tick bite; red macule or papule at
bite site; lesion enlarges to form
plaque, which clears centrally,
becoming annular; lesions warm
to touch; mildly pruritic
Miscellaneous
Seborrhea Oily, white to yellow to salmon- Confluent, localized, or Scalp, eyebrows, eyelashes, and
colored scaly patches (infants); diffuse postauricular areas, along hairline;
manifested as dandruff in intertriginous areas, neck, axillae,
adolescents. and groin
Sunburn Erythema, edema, blisters, and Localized or diffuse Sun-exposed areas

desquamation
Psoriasis Thick, dry, well-demarcated, Guttate Scalp, ears, forehead, eyebrows, trunk,
erythematous plaques covered extensor surfaces of extremities,
with silvery scales elbows, knees, and buttocks
TABLE 12-4
Dermatologic Arrangement Patterns and Descriptive Terms
ARRANGEMENT PATTERN DESCRIPTION EXAMPLE
Acral Involving extremities Infantile acropustulosis
Annular Ring-shaped Tinea corporis, erythema migrans, pityriasis

rosea
Arciform Arch-shaped Tinea cruris
Burrows Narrow, elevated channel in the skin Scabies

caused by a parasite
Circinate Circular Impetigo, tinea capitis
Confluent Lesions that run together Smallpox, urticaria
Contiguous Touching or adjacent Tuberous sclerosis
Discrete Lesions that are individual and Nevus

distinct
Diffuse or generalized Scattered and widely distributed over Drug eruptions

the body
Eczematous Vesicles with oozing, crusted lesions Atopic dermatitis
Grouped Arranged close together Impetigo, insect bites, contact dermatitis
Guttate Small, drop-like lesions Psoriasis
Herpetiform Grouped lesions that resemble those Aphthous ulcers

of herpes
Iris Arranged in circles resembling a target Erythema multiforme
Linear Arranged in a line Scratches, poison ivy
Localized Confined to a local area Irritant dermatitis
Morbilliform Looks like measles or other viral Drug eruptions

exanthems
Nummular Coin-shaped Nummular eczema
Pedunculated Having a stalk Genital warts
Polycyclic Oval lesions that tend to run together Psoriasis, contact dermatitis
Punctate Having tiny spots, points, or Petechiae

depressions
Reticular Net-like Erythema infectiosum (Fifth disease)
Scarlatiniform Small red papules; resembling scarlet Kawasaki disease

fever
Serpiginous Follows a snake-like, creeping track Erythema marginatum, tinea corporis
Symmetric Balanced on both sides Gianotti-Crosti syndrome (papular

acrodermatitis)
Umbilicated Lesions with depressed centers Molluscum contagiosum
Verrucous Wart-like Inflammatory verrucous epidermal nevus
Zosteriform Linear lesions clustered along a nerve Herpes simplex virus

root dermatome
an age-appropriate patient gown. Privacy must be en- This is a transient, normal variation and reflects the
sured. Infants can remain in a diaper, which can be transition to extrauterine life. Acrocyanosis that per-
removed easily when the diaper area is inspected. For sists despite warming of the infant may be indicative
the exam, infants can lie on the exam table or be held of congenital heart disease (see Chapter 11 for fur-
on the parent’s lap. Older children and adolescents ther discussion of neonatal skin assessment).
should sit on the exam table for the integumentary Inspection of skin color should be correlated with in-
exam; children of preschool age and younger will spection of the color of the nailbeds, earlobes, sclerae,
likely want their parent nearby. conjunctivae, lips, and mucous membranes. Any varia-
tions should be noted. When describing skin color,
Skin concrete, specific descriptions are important. Table 12-5
Inspection. When examining a child’s skin, it is im- lists the abnormal findings providers may find when in-
portant to examine the child’s entire body, not just specting skin color in children.
the exposed areas of skin. The provider should begin The provider should also inspect the skin for
by inspecting the scalp, progressing in a head-to-toe lesions or rashes. A systematic approach is necessary
fashion to the neck, upper extremities, trunk, and then when assessing and describing these findings. After
the lower extremities. The provider should evaluate reviewing the history, this involves assessing and de-
the skin’s color, texture, turgor, and look for edema, scribing the distribution (i.e., location) and pattern
rashes, and lesions. (i.e., anatomic arrangement) of the skin findings
Assessment of the skin should begin by inspecting (Fig. 12-7). Then the provider should identify the
the child’s skin color. Normal skin color varies from morphology of the lesions. Primary lesions (Table
pink, yellow, olive green, brown to dark brown or 12-6) develop from previously normal skin; second-
black, depending on the child’s race. It is essential to ary lesions (Table 12-7) evolve from primary lesions
know the child’s normal skin color to assess for color and are usually because of the child scratching or
or pigment changes accurately. picking the primary lesions. Next, the color and ele-
Acrocyanosis, a bluish color of the hands and feet vation of the lesion should be assessed. The provider
in newborns, may persist for 8 to 24 hours after birth. should measure the lesion with a centimeter ruler. If
TABLE 12-5
Abnormal Skin Color Findings in Children
COLOR POSSIBLE CAUSES BEST PLACE TO OBSERVE
Yellow-orange (jaundice) Hepatitis, hemolytic disease, biliary Sclerae, skin, mucous membranes,
obstruction, infectious mononucleosis, fingernails, soles, palms, abdomen; in dark-
carotenemia, neonatal sepsis, and skinned children, inspect palate, palmar
chronic renal disease surfaces, sclerae; if renal cause, assess
exposed skin only (not sclerae or mucous
membranes).
Blue (cyanosis) Anxiety, cold temperatures (peripheral Peripheral cyanosis can be observed in the
cyanosis), and cardiac and respiratory nails, soles, and palms.
(central cyanosis) problems Central cyanosis is observed in the lips,
tongue, and oral mucosa and indicates
hypoxemia. Dark-skinned children may not
appear blue when cyanotic but gray or pale.
The best places to assess are conjunctivae,
oral mucosa, and nail beds.
White (pallor) Anemia, shock, syncope, and edema Face, mouth, conjunctivae, and nail beds
(Dark-skinned children
appear yellow-brown to gray.)
Red (erythema, flushing) Fever, blushing, hyperthermia, Face, localized affected area; inspection may
(Dark-skinned children may polycythemia, burns, inflammation, need to be augmented by palpation in dark-
appear purplish.) infection, increased vascularity, allergies, skinned children and assessment of skin and
and alcohol consumption body temperature.
Absence of color Vitiligo and albinism Symmetric white patches (vitiligo); a

generalized absence of pigment involving
skin, hair, and eyes (albinism)
(Tumolo, 2005). Providers should also assess and

document whether or not the teen is wearing long-
sleeved shirts and pants during warm weather in an
attempt to cover injuries, which is also a warning sign
of self-mutilation.
The provider should inspect the skin for needle or
“track” marks, which may indicate use of street drugs.
Adolescents are the primary age group for which to
target this assessment. Areas to inspect include the an-
tecubital fossae, forearms, or any other area of the skin
where large veins are noted.
For adolescents who present with weight loss or
weight fluctuations; nutritional deficiencies; erosion
FIGURE 12-7. Petechiae and purpuric lesions. Both lesions of dental enamel; dry skin and mucous membranes;
indicate bleeding into the skin. Petechiae are small, non- dry, dull, and brittle hair and nails, and in some
blanching red to purple macules; purpuric lesions are larger cases lanugo, the provider should inspect the index
macules that are dark red to purple.
or middle finger on the dominant hand, noting any
abrasion or scarring on these fingers (Russell’s sign).
This, coupled with the above assessments, may indi-
the lesions are extremely small, the provider should cate chronic, self-induced vomiting, an indicator of
use a magnifying glass to inspect the lesion’s char- bulimia nervosa.
acteristics. During this time, the provider could also Any skin odor or taste should also be noted. For
teach skin self-examination to a school-aged child example, a salty taste to the skin may indicate cys-
and older. tic fibrosis. Other skin odors may indicate infection,
The provider should inspect for vascular lesions as well poor hygiene, or neglect. If a child presents with an
(Table 12-8). There should be no increased vascularity illness complaint related to the skin, the provider
or any evidence of bleeding of the skin. Petechiae or should start by assessing the child’s general appear-
purpuric lesions (see Fig. 12-7) on the skin may indicate ance. One of the first things that should be deter-
systemic disease such as idiopathic thrombocytopenic mined is whether the child appears ill or is in any
purpura (ITP), leukemia, or meningococcemia. Bruises, type of distress to differentiate a systemic illness
lacerations, abrasions, and other marks on the skin from a simple rash. Even when a skin problem is
may indicate intentional or unintentional injuries the chief complaint, other body systems should be
in children, depending on their color, pattern, and examined because of the cutaneous manifestations
location (see Chapter 23) (Hornor, 2005). Any congenital of many childhood diseases. If a systemic illness
nevi (birthmarks) should be noted; they can be benign is suspected, the provider should note the child’s
or indicate an underlying disorder (see Assessment of age and also assess the child’s eyes, nose, mouth,
the Skin, Hair, and Nails in Children and Table 12-1). lymph nodes, and lungs to make an accurate diag-
Changes in the birthmark should be documented in the nosis. Any fever or nuchal rigidity should be noted.
child’s medical record. The child’s nutritional and hydration status should
The provider should also inspect the skin for pierc- also be assessed. Endocrine, allergic, infectious, and
ings and tattoos. These forms of body art may be cul- nutritional problems all have possible cutaneous
tural or a form of self-expression in adolescents (Larzo manifestations.
& Poe, 2006). Areas to assess for body piercing include
the ears, eyebrows, nose, tongue, lips, nipples, navel, Palpation. The skin should be palpated to assess
and genitals (Larzo & Poe, 2006). Tattooed skin can temperature, texture, turgor, moisture, perfusion, and
be highly sensitive as a result of pigment additives; in edema. Any lesions should be palpated as well.
addition, the tattooed area can be itchy and painful The skin should feel warm when palpated. Skin
several weeks after the tattoo has been placed (Larzo & temperature that is cool to the touch may indicate
Poe, 2006). Dermatologic complications for which to hypothermia or poor localized circulation. This is
look when inspecting pierced or tattooed skin include a common finding in the neonate who needs to be
infection, signs of delayed healing, keloid formation, treated by warming the infant. Hypothyroidism can
and allergic and contact dermatitis, among others (Lar- also cause cool skin temperatures. Skin that feels
zo & Poe, 2006). hot when palpated may be the result of fever, hy-
Inspection of the skin in adolescents should also perthermia, hyperthyroidism, infection, or recent
include looking for unexplained cuts, burns, bruises, sunburn.
and pinch marks on the body, especially on the arms Normal skin texture in a child is smooth, firm, and
and legs, which can indicate self-mutilation in teens even. Skin that feels rough when palpated may be
TABLE 12-6
Primary Skin Lesions
TYPE DESCRIPTION EXAMPLES ILLUSTRATION
Macule ⬍1 cm in diameter, flat, Brown: freckle, junctional nevus,
nonpalpable, circumscribed, lentigo, melasma
discolored Blue: Mongolian spot, ochronosis
Red: drug eruption, viral
exanthema, secondary syphilis
Hypopigmented: vitiligo,
idiopathic guttate hyopmelanosis
Patch ⬎1 cm in diameter, flat, Brown: larger freckle, junctional

nonpalpable, irregular nevus, lentigo, melasma
shape, discolored Blue: Mongolian spot, ochronosis
Red: drug-eruption viral
exanthema, secondary syphilis
Hypopigmented: vitiligo,
idiopathic guttate hyopmelanosis
Papule ⬍1 cm in diameter, raised, Flesh, white, or yellow: flat wart,

palpable, firm milium, sebaceous hyperplasia,
skin tag
Blue or violaceous: venous lake,
lichen planus, melanoma
Brown: seborrheic keratosis,
melanoma, dermatofibroma, nevi
Red: acne, cherry angioma, early
folliculitis, psoriasis, urticaria,
eczema
Nodule ⬎1 cm, raised, solid Wart, xanthoma, prurigo

nodularis, neurofibromatosis
Plaque ⬎1 cm, raised, superficial, Psoriasis, discoid lupus, tinea

flat-topped, rough corporis, eczema, seborrheic
dermatitis
TYPE DESCRIPTION EXAMPLES ILLUSTRATION

Tumor Large nodule Metastatic carcinoma,
sporotrichosis
Vesicle ⬍1 cm, superficially raised, Herpes simplex, herpes zoster,

filled with serous fluid erythema, multiforme, impetigo
Bulla ⬎1 cm vesicle Pemphigus, herpes gestationis,

fixed drug eruption
Pustule Rasied; superficial; filled Acne, candidiasis, rosacea,

with cloudy, purulent fluid impetigo, folliculitis
Wheal Raised, irregular area of Hives, cholinergic urticaria,

edema, solid, transient, angioedema, dermatographism
variable size
Cyst Rasied, circumscribed, Digital mucous, epidermal

encapsulated with a wall inclusion, pilar
and lumen, filled with
liquid of semisolid
Source: Rhoads, J. (2006.) Advanced health assessment and diagnostic reasoning. (Table 5-2). Philadelphia, PA: Lippincott Williams & Wilkins,
with permission.
TABLE 12-7
Secondary Skin Lesions
TYPE DESCRIPTION EXAMPLES/CAUSES
Atrophy Loss of epidermis/dermis; may cause Striae; consequence of atopic dermatitis or
thinning or depression of skin chronic topical steroid use
Crusts Dried serum, blood, or exudates; Impetigo, tinea capitis, atopic dermatitis,
slightly elevated; varied color varicella, or herpes
Desquamation Skin peeling in sheets of scales Poststreptococcal scarlet fever or seborrheic

dermatitis
Erosion Localized loss of epidermis; area often Herpes simplex, eczema herpeticum,
depressed, oozing, and moist; heals epidermolysis bullosa or aphthous ulcers
without scarring; does not extend into
dermis
Excoriation Abrasion or hollowed-out area of Scratching, atopic dermatitis, intertrigo, or

epidermis, frequently caused by tinea cruris
chronic itching
Fissure Linear break in the skin extending Dry skin, intertrigo, or contact dermatitis
into the epidermis and dermis
Lichenification Thickened epidermis with visible Chronic itching or irritation; dry skin,
furrows caused by chronic rubbing atopic dermatis, or psoriasis
Scales Thin, exfoliated layers of epidermis Psoriasis, poststreptococcal scarlet fever,

tinea versicolor, pityriasis rosea, or
seborrheic dermatitis
Scar Healed fibrous tissue after a Keloid, burns, or acne

dermal injury; some areas may be
hypertrophied
Striae Pink or silver bands, stripes, or lines Obesity, pregnancy, or chronic topical
on skin where skin has been stretched steroid use
Ulcer Deeper than erosion; loss of epidermis Decubitus or stasis ulcer

and dermis; varies in size
because of overbathing, poor nutrition, or chronic in infants and children who have hyperthyroidism
exposure to cold weather or chemicals. The texture or cardiac conditions or who are in shock. Exces-
of the skin should also be uniform. Older children sively oily skin is associated with acne in adolescents.
and adolescents may have rough skin on the palms Mucous membranes should be moist; dry mucous
and soles because of chronic friction. Rough skin may membranes indicate dehydration.
also be the result of prolonged scratching of a specific
area. Scratching that is prolonged and intense may
lead to lichenification of that area of skin (Fig. 12-8).
Flaking or scaling of an area of the skin can also be
palpated. Scaling or flaking may be because of nutri-
tional deficiencies, fungal infections, contact derma-
titis, or atopic dermatitis.
The provider should also assess skin moisture by
palpation. The skin is normally slightly dry. Excessive
skin dryness may be because of overbathing, poor
nutrition, sunburn, chronic exposure to cold tem-
peratures, or hypothyroidism. Skin that feels moist FIGURE 12-8. Lichenification (thickening and roughening
of the skin) is caused by prolonged pressure, rubbing, or
in a child could simply be the result of perspiration scratching. For a full-color example, please refer to Figure 12-8
after physical activity or diaphoreses, which occur on page C2.
TABLE 12-8
Vascular Skin Lesions
TYPE DESCRIPTION EXAMPLES/CAUSES
Ecchymosis (bruise, contusion) Purple to yellow to green to brown Injury or trauma
in color, depending on age of injury;
irregularly shaped macular or papular
lesion ⬎10 mm in diameter; because
of extravasation of blood into skin or
mucous membrane; does not blanch
with pressure.
Hematoma Accumulation of blood from ruptured Subdural or epidural hematoma from

blood vessel; ⬎1 cm; bluish-red. traumatic injury
Petechiae Pinpoint hemorrhages, ⬍2 mm in Injury, thrombocytopenia, infection,

diameter, round and discrete, dark red immune suppression, sepsis,
to purple meningococcemia, hemophilia, nutritional
deficiency, violent vomiting or coughing;
anticoagulants, aspirin, and steroids
Purpura Purple flat, macular lesions 2–10 mm Vitamin C deficiency, Henoch-Schönlein

in diameter; dark red to purple purpura, infection, sepsis, meningococcemia,
thrombocytopenia, hemophilia;
anticoagulants, aspirin, and steroids
Telangiectasia Dilated terminal vessels under the Chronic topical steroid use, liver disease
skin
Vascular malformations Abnormal clusters of blood vessels Port-wine stain, salmon patch, pyogenic
that occur during fetal development granuloma
When evaluating perfusion, the provider should pal- the ease and quickness with which the skin moves (mo-
pate the skin for blanching and capillary refill. Pressing bility) and returns to place (turgor). Skin that remains
a finger against the skin to produce blanching also en- folded (i.e., “tenting”) indicates dehydration (Fig. 12-9).
ables a more accurate assessment of jaundice. Capillary Skin that has decreased mobility indicates edema.
refill greater than 2 to 3 seconds indicates dehydration Edema is a sign of fluid retention (Fig. 12-10). Edema
or hypoperfusion. in children can be generalized, dependent, or perior-
Assessment of skin turgor evaluates the elasticity of bital. Generalized edema is most serious, likely reflecting
the skin. With the infant or child lying down, the pro- a cardiac, hepatic, or renal disorder. Dependent edema
vider should assess skin turgor by grasping a skinfold is seen in the lower extremities or buttocks and is also
on the child’s abdomen and quickly releasing it, noting likely to have a renal or cardiac etiology. Periorbital
FIGURE 12-9. Assessment of skin turgor to assess dehydration.

The provider should also assess the distribution

of the child’s scalp hair, eyelashes, eyebrows, and
body hair. Fine vellus hair should appear on the
body. Lanugo is seen in preterm infants and in chil-
dren or adolescents with extreme weight loss (e.g.,
anorexia nervosa). Following acute febrile illness or
stress, many hairs convert from anagen (growth)
to telogen (rest) stage, resulting in noticeably thin-
ner scalp hair that could persist for months. Hair
that appears thin may also be the result of the
following:
• Poor nutrition
• Abuse or neglect
• Infection of the scalp (e.g., tinea capitis [ringworm],
impetigo)
• Hypothyroidism
FIGURE 12-10. Periorbital edema. • Liver disease
• Drug toxicity
• Autoimmune disorders (e.g., alopecia areata)
• Chemotherapy or radiation
edema in children could be the result of recent sleep,
• Pressure or traction alopecia
crying, allergies, alteration in renal function, or hy-
• Trictillomania (i.e., chronic hair pulling in a child or
pothyroidism. Edema can be easily assessed by simple
adolescent may be a clue to anxiety or compulsive
inspection. It should be noted that edema can mask
disorders)
the child’s normal skin color, producing a false pallor,
because the fluid that causes the edema is between the Hair distribution is also important to note when
surface of the skin and the pigmented and vascular ar- estimating sexual maturity in a child. Precocious or
eas. The provider should also palpate for edema. This delayed appearance of body hair may be indicative
is done by pressing firmly against the skin. If indenta- of hormonal disturbances (see Chapter 20). Increased
tions are left after palpation, the edema is positive for body hair (hirsutism) could be the result of polycys-
pitting, which is associated with cardiac or renal disor- tic ovary syndrome (PCOS) (Olson, 2004), Cushing’s
ders. Pitting is graded on a four-point scale to quantify
the extent of the edema (Table 12-9).
With a gloved hand, the provider should gen-
tly palpate any rashes, lesions, or nevi . Lesions with TABLE 12-9
scales should also be gently scraped to assess for Grading of Pitting Edema
bleeding (e.g., Auspitz sign in psoriasis) or to note SCALE DESCRIPTION INDENTATION
whether the scales are easily removed. The pro-
vider can use information gleaned after palpation, 1⫹ Slight pitting; slight 2 mm
coupled with inspection findings, to formulate a indentation of skin; no
perceptible swelling;
diagnosis. pitting disappears
quickly after being
Hair compressed.
Inspection. Assessment of the hair begins by inspect- 2⫹ Slightly deeper pitting; 4 mm
ing the hair color, quality, cleanliness, and amount. indentation subsides
Scalp hair should be shiny, strong, and elastic. Hair rapidly (~10–15 sec).
that is lusterless, matted, or has an odor may indicate
3⫹ Deep pitting; noticeable 6 mm
neglect or depression. Hair that is dry and dull can be
swelling; indentation
the result of poor nutrition, hypothyroidism, frequent remains for a short
swimming or shampooing, application of chemicals time; may last for more
(i.e., permanents, hair dyes, bleaches), sun damage, than 1 min.
heat from curling irons or blow dryers, and genetics.
4⫹ Very deep pitting; 8 mm
African-American hair is naturally drier (see Cultural marked swelling;
and Ethical Considerations in Pediatric Dermatologic indentation lasts
Assessments). Hair that is oily or dirty may be a sign of approximately 2–5 min.
poor hygiene or neglect.
Nails
Inspection. The provider should inspect the child’s
nails for color, contour, thickness, texture, cleanli-
ness, and general condition. Nail beds should be pink,
smooth, flat, or slightly convex in shape with uniform
thickness. Nails that appear white or yellow and thick-
ened can indicate a fungal infection of the nail plate
(onychomycosis), which is often associated with the ap-
plication of artificial fingernails.
Nail changes can also be a sign of systemic illness;
for example, cyanotic nail beds can indicate hypoxia.
Pale nail beds may indicate anemia. In older children,
nail polish and artificial nails interfere with an accu-
rate assessment of nail bed color. Artificial nails can
FIGURE 12-11. Tinea capitis with kerion, a raised, boggy, also affect the assessment of nail bed contour. Convex
pustular mass that can result in localized scarring. For a full-
color example, please refer to Figure 12-11 on page C2. or concave nail beds may be hereditary or related to
trauma, iron deficiency, or infection. Hypoxia that is
chronic affects the shape of the nail bed, causing club-
bing (Fig. 12-12). A transverse nail furrow may indicate
syndrome, endocrine abnormalities, adrenal hyperpla- acute infection, anemia, or malnutrition. The provider
sia, testicular or ovarian tumors, hyperinsulinism, and should note any splinter hemorrhages under the nails,
anabolic steroid use. Hair tufts noted over the spine, as this may indicate trauma or cardiac conditions such
especially in the sacral area, can indicate spina bifida as subacute bacterial endocarditis or mitral stenosis.
occulta. Pubic hair in a child younger than 8 indicates Nails should also be inspected for signs of biting or
precocious puberty. picking, which may indicate chronic stress in a child
The provider should also inspect the scalp thor- and can also lead to infection.
oughly. Gray, scaly, well-defined areas with broken The provider should also inspect the tissue sur-
hairs may indicate tinea capitis. The provider should rounding the nail. Inflammation in this area is a sign
separate and lift the hair to inspect it and the scalp of paronychia, an acute or chronic infection of the epi-
for lesions. Seborrhea (oily scales) may be present in thelium lateral to the nail plate. Thumb-sucking, nail-
an infant or adolescent. Any presence of nits (eggs of biting, and the use of artificial nails predispose a child
head lice) on the hair shaft should be noted. Nits can to this condition. Skin that is macerated at the thumb
be differentiated from dandruff by noting whether the tip signifies chronic thumb-sucking.
nits stick to the hair shaft; dandruff does not. The scalp
should also be inspected for ticks, which appear as gray Palpation. The provider should palpate the nail beds
or brown oval bodies. and assess time of capillary refill, which should be 2
Palpation. While wearing gloves, the provider should to 3 seconds or less. Prolonged nail bed capillary refill
palpate the hair and scalp noting the texture of the hair may indicate poor peripheral circulation. The provider
and assessing for the presence of lesions. Hair should should also palpate the texture of the nail bed, focus-
feel soft or silky. Dry, brittle hair can indicate a nutri- ing on whether the nail bed is firm, smooth, uniformly
tional deficiency, hypothyroidism, or overuse of chem- thick, and adherent to the nail bed, all of which are
ical hair products. Hair that is very fine can indicate normal findings. Dry, brittle nails can be the result of
hyperthyroidism. Tinea capitis infection can progress hypothyroidism or poor nutrition (e.g., calcium, vita-
to the development of a kerion, an intense inflamma- min A, protein deficiency). The provider should also
tory response that, when palpated, is a tender, raised, palpate the nail beds for tenderness, which indicates
boggy mass (Fig. 12-11). inflammation or infection.
Normal Early clubbing Advanced clubbing
FIGURE 12-12. Nail clubbing is a sign of chronic hypoxia.

dark-skinned people have pigmentary demarcation

CULTURAL AND ETHNIC lines (PDLs), known as Futcher’s or Voight’s lines, on
CONSIDERATIONS IN PEDIATRIC their upper arms, chest, and abdomen (Galbraith &
DERMATOLOGIC ASSESSMENT Esterly, 2006). PDLs are physiologic, sharply demar-
cated, vertical lines from areas of deeper pigmenta-
tion to areas that are more lightly pigmented. This
ASSESSING CHILDREN WITH trait is thought to be dominantly inherited (Laude
DARK SKIN & Russo, 1983).
It is important for the pediatric provider to be knowl-
edgeable about normal variations in the hair and skin
Cutaneous Reaction Patterns
in children from varying ethnic backgrounds. This
Children with dark skin from many different cultur-
includes being knowledgeable about basic skin care,
al backgrounds may have an exaggerated cutaneous
variations that are considered within normal limits,
response to common disorders of the skin (Burrall,
and the natural tendency to show certain cutaneous
2006). These groups include Africans, African Ameri-
reaction patterns in the skin. Skin and hair vary in
cans, Hispanics, and Asians, and Asian Americans.
amount, color, texture, and distribution, according to
Three identified cutaneous reaction patterns are pig-
the child’s genetic background. The provider should
ment changes, follicular response changes, and mesenchy-
be able to recognize normal variations as well as der-
mal reactions.
matologic lesions in children with more darkly pig-
mented skin.
Pigment Changes. Inflammatory skin conditions
Normal Variations can cause pigmentation lability in dark-skinned
The skin cells that are shed as part of the normal phys- children because of alterations in melanin produc-
iologic process are dark if the cell nuclei have more tion (Burrall, 2006). If the condition is superficial
melanin, as with dark-skinned children (Burrall, 2006). and involves the epidermis only, normal pigmen-
The normal skin exfoliation process in dark-skinned tation often returns in approximately 6 months
persons leaves a fine layer of dry, gray scales. African ( Vernon, Brady, & Barber Starr, 2009). Hypopig-
Americans may refer to their skin as “ashy” when dry mentation can occur in dark-skinned children after
and flaky. Also, when the skin of an African American pityriasis alba, seborrhea, tinea versicolor, or atopic
child is cleaned with an alcohol wipe, the wipe looks dermatitis (Goodheart, 2009). Hyperpigmentation
brownish-gray but not because the skin is dirty but be- as a postinflammatory response is more persistent
cause melanin-rich skin cells have been wiped off the in dark skin. These changes often signify that the
child’s skin. changes have gone beyond the epidermis and that
Any alterations in skin color (e.g., pallor, jaundice, the dermis is involved. This can cause permanent
cyanosis) in dark-skinned children may be difficult skin color changes or changes that last for years
to assess because of increased pigmentation. Mild de- (Burrall, 2006). Impetigo, varicella, lupus, infect-
grees of erythema may be missed completely, because ed atopic dermatitis, contact dermatitis, and scars
of the skin’s dark color. Some lesions that appear red from burns or acne, lacerations, and abrasions
or brown on a light-skinned child may appear purple can all cause long-lasting or permanent hyperpig-
or black in darkly pigmented skin. Because of this, as- mentation (Vernon, Brady, & Barber Starr, 2009;
sessment of the palms and soles may yield the most Goodheart, 2009).
useful data.
In children with dark skin, it is normal for the Follicular Response Changes. Follicular response
skin to vary in color from one part of the body to changes in dark-skinned children are manifested as
another (Burrall, 2006). This is because of the varia- prominent papules and hair follicles. These changes
tions of skin thickness over the body; the thicker the typically follow injury or inflammation. A papular or
skin, the more layers of melanin-rich cells. This is follicular response in dark-skinned children often fol-
why the elbows and knees of dark-skinned people are lows atopic dermatitis, nummular eczema, pityriasis
darker in color. In persons of all races, the palms and rosea, seborrheic dermatitis, tinea versicolor, or pseu-
soles produce no melanin, so these areas of the skin dofolliculitis barbae (Burrall, 2006; Vernon, Brady, &
are lighter than skin in other areas. This contrast is Barber Starr, 2009).
more noticeable in those with dark skin. Pigmenta-
tion of gingival tissue, the hard palate, mucous mem- Mesenchymal Reactions. Exaggerated mesenchy-
branes, tongue, sclerae, and nails correlates with the mal reactions result in hypertrophic scars and ke-
degree of cutaneous pigmentation (Vernon, Brady, loid formation, primarily in dark-skinned children
& Barber Starr, 2009). Approximately 20% to 30% of (Burrall, 2006; Vernon, Brady, & Barber Starr, 2009).
and why oiling the hair and washing it less often

are common practices among this group. African
American adolescents may apply chemicals to
their hair to change the texture. These chemicals
may cause changes in the natural appearance of
the hair. The provider needs to keep this in mind
when inspecting the hair in this group of children.
Also, pediculosis capitis (head lice) is less common
in African American children (Govere, Speare, &
FIGURE 12-13. Keloid. Hypertrophic scar formation beyond origi- Durrheim, 2003). This is because of the spiral na-
nal wound area; it is more common in African American children.
ture of the hair shaft; in addition, the use of oils
or pomades on the hair shaft makes it difficult or
impossible for the lice to move or for nits to cling
Keloids are benign overgrowths of skin of variable to the hair shaft (Rubeiz & Kibbi, 2006; Govere,
size that occur after injury (Fig. 12-13). Keloid for- Speare, & Durrheim, 2003).
mation often follows infection, ear piercing, sur-
gery, burns, and other skin trauma. Infants are much
less likely to form keloids. Although medically be- CULTURAL AND ETHNIC
nign, keloids may cause the child psychologic dis- PRACTICES IMPACTING PEDIATRIC
tress. Other exaggerated mesenchymal reactions
INTEGUMENTARY ASSESSMENT
likely to be experienced by dark-skinned children
are skin lichenification with chronic pruritus and The grooming, cosmetic, or healing practices of some
vesicular or bullous eruptions after bites or staphy- ethnic groups bear mentioning, as these practices
lococcal infections. may lead to variations in the hair or skin with which
the provider must be familiar. Some of these practices
and their possible results include (Vernon, Brady, &
Common Problems Barber Starr, 2009):
Children with dark skin are more prone to certain der-
• The use of hair oils or pomade on African Ameri-
matologic conditions. These conditions occur in dark-
can hair or skin oils for lubrication of black skin may
skinned children for a variety of reasons, including
cause acne.
variations in skin pigment and in grooming practices.
• Tightly braiding African American hair may cause
The provider should be familiar with these dermato-
traction or traumatic alopecia.
logic conditions to identify them correctly and plan
• Curling irons or hot combs used to style African
appropriate management. Table 12-10 summarizes
American hair may cause burns on the scalp.
these common dermatologic problems in dark-skinned
• Application of chemical hair straighteners may
children.
cause alopecia; broken, dry hair; or scalp contact
dermatitis.
• Bleaching creams used on African American skin
ASSESSING THE HAIR OF CHILDREN may cause hypopigmentation and erythematous
FROM DIVERSE CULTURAL GROUPS nodules.
Children from various ethnic groups have different • Tattoos or piercings may leave scars or keloids.
hair shaft patterns with which the provider should • Henna application to the hair or skin (usually
be familiar. The hair shaft is described as straight, hands and feet) may cause skin discoloration or al-
wavy, spiral, or helical. Children of Asian descent lergic reactions.
tend to have straight hair, and the hair shaft itself • Coin rubbing (nonabusive, vigorous stroking
is round. Children of European origin have a wide of the trunk and back with the edge of a coin)
range of hair shaft shapes, from straight to helical. as practiced by Southeast Asian people to treat
Children who can trace their ancestry to Africa gen- fever in children leaves linear bruising (see
erally have spiral or helical hair shaft shapes. These Chapter 23).
children also have hair that is described as kinky • Cupping (a nonabusive Southeast Asian healing
or wooly and is tightly curled with a closely knit practice that involves placing a glass cup of steam
distribution pattern on the scalp; thus, the hair can against the child’s chest, which creates suction) is
get matted or tangled more easily. Also, when the used to treat pain, gastrointestinal disorders, cough,
hair shaft is straight, the sebaceous glands are bet- and wheezing; however, it leaves a circular ecchy-
ter able to lubricate the hair. This explains why the mosis on the chest where the cup was placed (see
hair of African American children tends to be drier Chapter 23).
TABLE 12-10
Common Dermatologic Problems and Cutaneous Reaction Patterns in
Children With Dark Skin
CUTANEOUS REACTION
DISORDER/LESION PATTERN CHARACTERISTICS
Acanthosis nigricans Hyperpigmentation Symmetrical brown to black hyperpigmentation with
velvety texture in skinfolds and creases in flexural
surfaces, most often the neck, knees, elbows, underarms,
and groin; considered a cutaneous marker for insulin
resistance (Olson, 2004)
Atopic dermatitis Follicular response Papules more prominent with follicular accentuation in
changes; postinflammatory African Americans; distribution more on extensor surfaces
hypopigmentation (Burrall, 2006)
Infantile acropustulosis Hyperpigmentation Affects mainly African-American boys ⬍2–3 years of age;
lesions begin as pinpoint pruritic erythematous macules
and papules that evolve into vesicles then pustules;
mostly affects hands and feet; lesions heal with macular
hyperpigmentation; etiology unknown (Pride, 2009)
Keloids Mesenchymal reaction Hypertrophic scarring thought to be related to

inflammatory triggers (Burrall, 2006)
Lichenification Mesynchymal reaction See Table 12-7
Papulosa nigra Hyperpigmentation Most commonly seen among African Americans; multiple
firm, dark brown to black flattened papules, most often seen
on face; usually begins in adolescence and is rare under 7
years (Nowfar-Rad & Fish, 2005)
Pityriasis alba Hypopigmentation Scattered patches of poorly defined postinflammatory

hypopigmentation, often with a superficial scale,
commonly because of atopic dermatitis; takes months or
years to resolve
Pityriasis rosea Exaggerated follicular response Larger papules occur with the eruption; nodules may even
occur (Burrall, 2006)
Pomade acne Hyperpigmentation Multiple comedones on forehead and along the hairline;
(postinflammatory) seen primarily in African American patients and caused
by use of hair oils and pomades
Pseudofolliculitis barbae Hyperpigmentation; follicular Papules and pustules that form as a result of coarse,
response change curly hair that is shaved and the distal end curves,
growing back into the skin (“ingrown hair”); occurs
predominantly in blacks; can leave hypertrophic scars
Seborrheic dermatitis Postinflammatory pigmentary May appear more annular in African Americans (Burrall,
changes; may resolve within 6 2006)
months
Tinea versicolor Hyperpigmentation, Postinfection inflammation causes changes in

hypopigmentation, or pigmentation and exaggerated follicular response.
exaggerated follicular response Hypopigmentation needs to be differentiated from vitiligo.
Transient neonatal Hyperpigmentation Occurs more commonly in black infants, rash presents
pustular melanosis at birth with vesicles and pustules that rupture, leaving
pigmented macules and scale; a benign disorder.
Hyperpigmentation fades within 3 weeks to 3 months;
etiology unknown (Durham & Laumann, 2005); must
be differentiated from herpes simplex, staphylococcal
infections, and Candida
Vitiligo Hypopigmentation Hypopigmentation because of loss of melanocytes; cause

unknown; can occur after trauma
• Very long hair in girls in some American Indian tribes

is common, as the hair is not cut until the coming- DIAGNOSTIC STUDIES
of-age ceremony.
• Moxibustion, a traditional Chinese healing practice Once the history and physical examination are complete
often done in conjunction with acupuncture, in- on a child who presents with a dermatologic complaint,
volves burning the skin, which may produce scars the provider can begin to formulate a list of differential
after the burn is healed. diagnoses. A few in-office diagnostic studies can aid in
• Head-shaving in the first year of life in many Asian identifying or excluding specific dermatologic disorders
cultures, based on the belief that the hair will grow during this process. Care must be taken to procure the tis-
back thicker and longer, may be confused with sue sample properly; the provider should also wear gloves
alopecia. when doing so. Box 12-1 summarizes these studies.
BOX 12-1
Selected Laboratory and Diagnostic Studies Used to Diagnose
Dermatologic Conditions
Microscopic Examination of Dermatologic Scrapings
• Identifies presence of bacterial, viral, or fugal infections in skin, hair, or nails.
• Obtain scrapings from edges of skin lesions, hair and its roots, the nail plate, and subungal debris.
• Obtain scrapings of lesions with no. 15 scalpel blade or sterile toothbrush.
• Place scrapings on microscope slide then apply cover slip.
• Tzanck’s smear identifies herpes or varicella; needs application of Giemsa or Wright’s stain on scrapings. False-
negatives can occur; send viral culture as well.
• Giemsa or Wright’s stain also identifies bacterial infections; use ⫻ 40 magnification to examine.
• Potassium hydroxide (KOH) 20% is used to identify hyphae and spores with suspected fungal infections; gently
heat (not boil) slide, use ⫻ 10 magnification to view.
Wood’s Light (UV) Examination
• Used to examine fluorescent-positive skin infections (e.g., fungi) and depigmenting conditions.
• Apply the light in a dark room; color changes occur according to the type of infection or pigmentary disorder.
• Selected findings related to Wood’s lamp examination
• Tinea versicolor fluoresces a dull golden yellow.
• Pseudomonas aeruginosa fluoresces a yellowish green.
• Vitiligo (depigmentation disorder) shows no visible pigment; fluoresces white.
Cultures
• Need to culture infected areas of the skin, hair, or nails to identify the organism and prescribe appropriate treatment.
• Can obtain bacterial, viral, and fungal cultures and grow them in appropriate media.
Skin Testing
• Should be done by dermatologist or allergist.
• Used to diagnose allergic or contact dermatitis.
• For patch testing, apply patches containing common allergens to the skin, then removing after 2 days; a
papulovesicular eruption at the site indicates a positive reaction.
• For skin prick or intradermal testing, inject the allergen into the skin, either by scratching (skin prick testing) or
intradermally; development of a wheal at the site of injection indicates a positive reaction.
Skin Biopsy
• Should be done by a dermatologist.
• Done to identify accurately the pathology of a skin lesion that has not been definitively diagnosed.
• Done by punch, shave, or excisional method, depending on type of lesion.
• Requires local anesthesia.
Complete Blood Count
• Alterations in white blood cell count indicate infection.
Erythrocyte Sedimentation Rate
• Elevation in erythrocyte sedimentation rate indicates the presence of inflammation.
SAMPLE WRITE-UP OF A Heart S1, S2, RRR; no murmurs or extra sounds.

HEALTHY CHILD Lungs Breath sounds clear bilaterally.
Review of Systems
Assessment
Skin Denies previous skin lesions, masses, petechiae,
bruising, and pruritus; denies temperature or color Impetigo
changes. No birthmarks. Reports dry skin (“eczema”)
with intense itching, especially in winter. Applies Plan*
Eucerin cream after bathing for treatment. Parent *Please note that this text focuses on health assess-
applies sunscreen when outdoors. ment only and does not address management of client
Hair Denies recent hair loss, unusual hair growth; problems.
no changes in hair texture. No history of scalp
infections.
Nails No history of nail infections; has history of REFERENCES
chronic nail-biting. Antaya, R. J. (2009). Infantile hemangioma. Retrieved November 14,
2009, from http://www.emedicine.com/derm/topic201.htm.
Ball, J. W., & Bindler, R. C. (2006). Child health nursing: Partnering
Family History with families. Saddle River, NJ: Prentice Hall.
Burrall, B. (2006). Ethnic skin: a spectrum of issues. Retrieved
Positive for atopic dermatitis, asthma, and allergic November 14, 2009, from http://www.medscape.com/view
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Durham, B. A., & Laumann, A. (2005). Transient neonatal pus-
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disorders: Diagnosis and management. Philadelphia: Lippincott
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Hair clean and shiny; no nits or scalp lesions seen. Govere, J. M., Speare, R., & Durrheim, D. N. (2003). The preva-
Nails Nails present on all 10 digits, nail beds pink, lence of pediculosis in rural South African schoolchildren.
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and evaluation. Advance for Nurse Practitioners, 12(12), 24–26.
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ous scattered honey-colored crusted lesions on 14, 2009, from http://www.emedicine.com/derm/topic8.htm.
erythematous areas of skin on face and neck; no Rubeiz, N., & Kibbi, A. (2006). Pediculosis. Retrieved November 14,
2009, from http://www.emedicine.com/emerg/topic409.htm.
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Skin elsewhere warm and dry with elastic turgor. and function. New York: McGraw-Hill.
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themselves to dull inner pain. Advance for Nurse Practitioners,
visible landmarks, no nasal discharge, turbinates 13(12), 54–56.
pink and nonedematous; pharynx pink; no exu- Vernon, P., Brady, M. A., & Barber Starr, N. (2009). Dermatologic
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& Blosser, C. G. (Eds.). Pediatric primary care: A handbook for
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CHAPTER
Assessment of the
13 Head, Neck, and

Regional Lymphatics
ELLEN M. CHIOCCA
Assessment of the head and neck is very important in are soft areas of the skull that are formed when two or
the pediatric population. Common minor childhood three cranial bones merge. The fontanelles are named
infections often cause symptoms in the head and neck for their anatomic location: anterior, posterior, sagit-
area. For example, upper respiratory infections and tal (parietal), sphenoidal, and mastoid. The fontanelles
acute otitis media often cause ear pain, headaches, and that are routinely assessed are the anterior and poste-
lymphadenopathy. Acute infections or injuries to the rior fontanelles (see Fig. 13-2). The anterior fontanelle
head and neck can lead to long-term developmental is diamond-shaped and measures approximately 4 to
delays, disabilities, and even death in infants and chil- 5 cm (2 in) in diameter at its widest part. The posterior
dren. When obtaining the history and physical exami- fontanelle is triangular and measures approximately 0.5
nation of the head and neck, the health care provider to 1 cm (0.5 in) at its widest part.
can also identify parent and child teaching opportuni-
ties, such as encouraging repositioning in young in-
fants with positional plagiocephaly or the consistent NECK
use of bicycle helmets. The neck is composed of muscles, ligaments, and the
cervical vertebrae (Fig. 13-3). Nerves, major blood ves-
sels, lymph nodes, the larynx, hyoid bone, trachea,
and thyroid gland are also contained within the neck.
ANATOMY AND PHYSIOLOGY The cervical vertebrae (C1 though C7) function to sup-
port and assist with movement of the head. The major
HEAD neck muscles are the sternocleidomastoid (sternomas-
The skull is a hard, bony structure that houses and toid) muscle and the trapezius muscle (Fig. 13-4). These
protects the brain and other structures in the central muscles work together to allow rotation and flexion
nervous system; it consists of 22 bones that include of the head. The sternocleidomastoid muscle, the larg-
the cranium and face. Eight bones comprise the cra- est muscle in the neck, arises from the sternum and
nium: frontal bone, two parietal bones, two temporal clavicle and passes diagonally across the neck. The
bones, occipital bone, ethmoid bone, and sphenoid sternocleidomastoid muscle rotates and flexes the
bone (Fig. 13-1). The face consists of 14 bones; assess- head, as well as acts like an accessory muscle of inspi-
ment of the face is discussed in Chapter 16. ration by raising the sternum during respiration. The
In neonates, the cranial bones are moveable to ac- trapezius muscle forms a triangle on the upper back,
commodate the fetus’s head during delivery. These arising from the occipital bone and twelfth thoracic
bones are joined together by soft, fibrous tissue spaces vertebrae, extending and attaching to the scapula and
called sutures that separate the cranial bones. The sagit- clavicle. This muscle supports, extends, and turns the
tal suture line runs from the anterior to the posterior head and moves the shoulders. The trapezius muscle
portion of the skull in the midline position; the coronal also rotates the scapula. The sternocleidomastoid and
suture line runs laterally from side to side, beginning at trapezius muscles are innervated by the spinal accessory
the anterior fontanelle, and the lamboidal suture runs nerve (cranial nerve XI).
along both sides of the head, beginning at the poste- The sternocleidomastoid muscle divides the neck
rior fontanelle (Fig. 13-2). The sutures intersect at the into the anterior and posterior triangles (see Fig. 13-4).
areas of the skull known as fontanelles. The fontanelles The boundaries of the anterior triangle are the mandible
258
C HAP T E R 13 A s s e s s m e n t o f th e He ad, Ne ck, an d Re gio n al Lymphatic s • 259
Anterior fontanal
Su
Coronal Thyroid
bo
suture Parietal cartilage
cc
Frontal Hyoid bone
ipi
tob
Occipitofrontal
reg
Cricoid Sternomastoid
Sphenoid
ma
cartilage muscle
Temporal
tic
Thyroid:
Ethmiod Isthmus
Lobe
Posterior
fontanel
Lambdoidal
suture Clavicle
FIGURE 13-1. The cranial bones. Sternal

notch Trachea
Manubrium
above, the sternocleidomastoid muscle laterally, the
midline of the trachea medially, and the suprasternal FIGURE 13-3. Structures of the neck.
notch inferiorly. The sternocleidomastoid muscle to the
anterior, the trapezius muscle to the posterior, and the
clavicle below demarcate the posterior triangle. These is the passage through which air enters the lungs and
triangles serve as important landmarks for physical as- respiratory secretions are expelled.
sessment. Important structures contained within the The thyroid gland also lies within the neck; it is the
anterior triangle include the larynx and thyroid gland; largest endocrine gland in the body. Butterfly shaped,
both triangles contain lymph nodes. it consists of two lateral lobes connected by the thyroid
The trachea is located in the middle of the neck (see isthmus, which lies directly across the fifth or sixth
Fig. 13-3). It is a cylinder-shaped structure, composed tracheal ring and below the cricoid cartilage (see Fig.
of smooth muscle and encircled by C-shaped cartilagi- 13-3). Below the cricoid cartilage lies the thyroid car-
nous rings. The uppermost ring is termed the cricoid tilage (“Adam’s apple”). Attached to the tongue and
cartilage. The trachea extends from the larynx to the at the floor of the mouth is the U-shaped hyoid bone,
bronchi in the upper thorax to below the sternum. It which lies between the mandible and larynx.
The superior portion of each lateral lobe of the
thyroid gland extends upward, toward the thyroid
cartilage; the inferior portion of each lobe lies at the
Frontal suture
Anterior
fontanel
Frontal bone
Coronal
suture
Sternomastoid
muscle
Parietal
Sagittal bone Trapezius Anterior
muscle triangle
suture
Posterior
triangle
Posterior
fontanel
Lambdoid
suture
Occipital bone
FIGURE 13-2. The cranial sutures and fontanelles in the
infant. FIGURE 13-4. The major neck muscles.
portion of the trachea that is partially covered by LYMPH NODES OF THE HEAD
the sternocleidomastoid muscle. The thyroid gland AND NECK
is highly vascular; it synthesizes and secretes thy-
Lymph nodes in the head and neck are numerous. These
roxine (T4) and triiodothyronine (T3), hormones
lymph nodes are part of the immune system and play
that play a large role in normal growth and cellular
a role in phagocytosis and the production of lympho-
metabolism. The thyroid gland also produces calci-
cytes and antibodies. Lymph nodes consist of an ac-
tonin, which regulates calcium ion concentration in
cumulation of lymphatic tissue; they are round and
the blood by facilitating calcium deposition in the
oval structures typically found in chains or clusters.
bones. Behind the lateral lobes of the thyroid gland
The size and shape of each lymph node varies but
lie four parathyroid glands. These glands are very small
should be 1 cm or less in length or diameter. Only the
and cannot be palpated. The parathyroid glands pro-
superficial lymph nodes are amenable to physical as-
duce and secrete parathyroid hormone, the function
sessment. Lymph nodes in the head and neck include
of which is to regulate calcium ion concentration in
the following:
the blood by increasing calcium absorption by the
intestines and kidneys and releasing calcium from • Preauricular: anterior to the tragus; not usually pal-
the bones. pable unless localized infection exists
Blood vessels in the neck include the common, • Postauricular: behind the ear, over the mastoid pro-
external, and internal carotid arteries and the internal cess; drain the ear and posterior portion of the scalp
and external jugular veins (Fig. 13-5). The carotid arter- • Occipital: found along the occipital ridge of the
ies and internal jugular veins are located on either cranium bilaterally; drain the scalp
side of the neck, parallel and anterior to the sterno- • Tonsillar: in the angle of the mandible; drain the
cleidomastoid muscle. The external jugular veins lie tongue, floor of mouth, and oropharynx
diagonally over the sternocleidomastoid muscle. The • Submaxillary (submandibular): on the mandible
common carotid begins in the thorax and neck and between the angle and the tip; drain the tongue,
then bifurcates, becoming the external and internal teeth, floor of mouth, and pharynx
carotid arteries. The external carotid artery circulates • Submental: on the mandible under the chin; drain
blood to the head, face, and neck; the internal carotid the same areas as the submandibular nodes
artery carries blood to the brain. Deoxygenated blood • Superficial cervical: anterior and superficial to the
is drained from the head through the subclavian and sternocleidomastoid muscle; include the anterior and
jugular veins. posterior groups, which lie along the jugular vein;
drain the anterior third of the scalp, face, and thyroid
gland
• Posterior cervical: in the posterior triangle, along
the anterior margin of the trapezius muscle; drain the
thyroid gland and posterior two thirds of the scalp
• Deep cervical: includes superior and inferior groups;
are rarely palpable. The superior deep cervical nodes
drain the palatine tonsils and submental nodes;
the inferior deep cervical nodes drain the larynx,
trachea, thyroid, and esophagus.
Temporal
vessels
Facial vein
External Postauricular
jugular vein
Occipital
Preauricular
Superficial cervical Submental
Submaxillary
Posterior cervical Tonsillar
Supraclavicular Anterior
cervical
FIGURE 13-5. The major blood vessels in the neck. FIGURE 13-6. The lymph nodes of the head and neck.
• Supraclavicular: found deep in the area formed by until age 2. By age 6, the head is approximately 90% of
the clavicle and sternocleidomastoid muscle. Enlarge- the adult size (Fig. 13-7).
ment of a left supraclavicular node often indicates a The anterior fontanelle closes by 12 to 18 months;
malignancy in the abdomen or thorax. the posterior fontanelle normally closes by 2 months.
The locations of these lymph nodes are illustrated The smaller fontanelles (i.e., sagittal, sphenoidal, mas-
in Fig. 13-6. toid) remain open in the first year of life to allow for
rapid brain growth. Ossification of the skull begins in
infancy and continues into adulthood.
DEVELOPMENTAL The cranial sutures are not fully fused at birth to al-
low for cranial molding during the birthing process
CONSIDERATIONS and to accommodate brain growth, which is very rapid
until school age (see Chapter 1). Cranial sutures begin
HEAD to fuse by age 6 months, and gradually ossify during
During fetal development, the head grows rapidly, early childhood. The cranial sutures can be separated
accounting for most of the fetus’s size. By the eighth by increased intracranial pressure until approximately
week of fetal life, the embryo takes on a human shape, age 12. Infants begin to develop head control cepha-
with the head disproportionately large in comparison locaudally, first by turning the head from side to side
to the body. At this time in fetal development, the head while prone by 1 month, then by lifting the head while
accounts for approximately one half of the embryo’s prone by 2 months. By 4 months, the infant should be
body size. By the time an infant is born, head size ac- able to hold the head erect at midline when placed in
counts for approximately one fourth of overall body a vertical position; by 6 months, no head lag should be
size and one third of the infant’s body weight. Normal noted when the infant is pulled to sit.
growth of the cranial bones depends on optimal pla-
cental function, adequate nutrition during pregnancy
and childhood, and hereditary factors. Any altera- NECK
tions in placental function or nutrition can affect skull Until age 3 to 4, infants and children have a pro-
growth and impede development of the brain. Head portionately shorter neck. After age 3 to 4, the neck
circumference averages 32 to 38 cm (12.6 to 14.9 in) in lengthens, becoming more proportionate to body size.
the full-term newborn, exceeding the infant’s chest cir- In infants and young children, the trachea is short, has
cumference; these measurements do not become equal a narrow diameter, and is more moveable than that of
Newborn 6 years 25 years
FIGURE 13-7. Proportion of head to body size in an infant, child, and young adult.
an adult. In the prepubertal child, the cricoid ring is asphyxia can lead to cerebral palsy, which, in turn, af-
between C3 and C4. If tracheal edema occurs, there is fects head control.
no room for expansion, causing further narrowing of The labor and delivery record should be reviewed for
the internal diameter of the trachea and consequent any history of prolonged labor, precipitous delivery, or
airway compromise. respiratory distress at birth; these conditions can lead
The thyroid gland is small but fully functional at to asphyxia, which can cause abnormalities of the head
birth and is often not palpable in infants and young and neck, including hydrocephaly, cerebral palsy, and
children because of its small size. The thyroid gland poor head control. Some neonatal conditions involving
increases slowly in size (by approximately 1 gram a severe asphyxia may necessitate extracorporeal mem-
year), until age 15, when it reaches adult size. brane oxygenation, which involves cannulation of the
jugular vein and carotid artery.
Any history of maternal thyroid disease should
LYMPH NODES be explored, as should any gestational diabetes.
The lymphatic system begins to develop during the Gestational diabetes leads to hypoglycemia and
third week of embryonic life. This system continues to large-for-gestational age neonates, as does congenital
change and develop throughout infancy, childhood, hypothyroidism. Feeding difficulties, poor weight gain,
and early adolescence. The lymph nodes in infants are constipation, prolonged jaundice, hypothermia, hypo-
difficult to palpate; this lymph tissue gradually increas- tonia, wide anterior and posterior fontanelles, a hoarse
es in size during childhood. Beginning in infancy, the cry, an enlarged tongue, and noisy respirations sug-
amount of lymphoid tissue increases, and both cervi- gest congenital hypothyroidism (Fig. 13-8) (Postellon,
cal and occipital lymph nodes enlarge with each respi- Bourgeois, & Varma, 2007). Congenital hypothyroid-
ratory infection. By age 10, lymph tissue size is at its ism, if untreated, leads to delayed growth and mental
largest, approximately two times adult size. Beginning retardation in children (Postellon, Bourgeois, & Varma,
in early adolescence, lymph tissue begins to shrink, be- 2007). The provider should always note any history of
coming adult size by the end of adolescence. congenital hypothyroidism; this condition is detected
on newborn screening, which is required in all 50 states
(see Chapter 9). Any maternal or neonatal infections
should also be noted. Maternal group B streptococcal
ASSESSMENT infection can lead to sepsis; neonatal meningitis and
resultant respiratory compromise, and asphyxia can
HISTORY cause intracranial complications that can affect head
When gathering historical data, providers should fo- size and head control (see Chapter 22).
cus on inquiring about genetic or metabolic disorders, Any history of craniosynostosis (premature closure
head trauma, or central nervous system infections that at birth of one or more cranial sutures) should be noted;
can impact the growth and development of the young this can cause microcephaly and abnormal head shape.
child. When assessing the neck, providers should ob- Congenital torticollis should also be noted; this condi-
tain historical information regarding the trachea and tion manifests as a persistent head tilt (Fig. 13-9).
thyroid gland. When encountering masses in the head
and neck, providers should obtain the history with Review of Systems. In addition to the prenatal and
certain differential diagnoses in mind (Table 13-1). perinatal histories, the pediatric review of systems
(ROS), involving the head and neck, includes asking
Past Medical History the parent about specific conditions accompanied by
In addition to the standard information gathered in the signs and symptoms that manifest in the head or neck
pediatric past medical history (PMH) (see Chapter 6), the region. In children school-aged and older, the provider
information described below is important to obtain. should inquire about any history of headaches, which
can have multiple etiologies. A history of fatigue or
Prenatal, Perinatal, and Neonatal Histories. In insomnia may be because of hypothyroidism or hyper-
children 3 and younger, the provider should review thyroidism, respectively. Any dizziness, neck pain, or
the child’s prenatal, perinatal, and neonatal histories. masses should be investigated. Infections of the head
Prenatal exposure to alcohol, drugs, or tobacco smoke or neck should also be noted, including orbital or peri-
can lead to abnormalities involving the head or neck. orbital cellulitis or scalp infections, such as impetigo
For example, fetal alcohol syndrome (FAS) can cause or tinea capitis (see Chapter 12). Other areas of assess-
microcephaly, and cocaine use can lead to preterm de- ment include the following:
livery and the complications of prematurity, including • General: Usual state of health, recent and recurrent
asphyxia, intraventricular hemorrhage, hydrocephaly, febrile illnesses, immunization history, sleep posi-
and cranial molding (dolichocephaly). Maternal ciga- tion in infants (may lead to plagiocephaly), and his-
rette smoking can cause pre- or perinatal asphyxia, and tory of congenital syndromes (e.g., Turner syndrome
TABLE 13-1
Differential Diagnosis of Head and Neck Mass in Infants and Children
TYPE OF MASS PHYSICAL FINDINGS
Congenital
1. Hemangioma 1. Congenital vascular anomaly; red, blue, or purple in color; warm to touch,
compressible, then refills with blood; bruit and thrill present
2. Thyroglossal duct cyst 2. Midline neck mass
3. Dermoid cyst 3. Midline neck mass
4. Cystic hygroma 4. Posterior to sternocleidomastoid muscle

(lymphangioma)
5. Brachial cleft abnormalities 5. Anterior to sternocleidomastoid muscle

(e.g., cysts, fistulas)
6. Cervical rib 6. Bilateral, hard, immoveable orthopedic anomalies found in the neck
7. Laryngocele 7. Soft, cystic, compressible neck mass; may cause stridor, dyspnea, and cough;
characterized by varying degrees of upper airway obstruction
8. Sternomastoid tumor 8. Firm, painless mass in neonate; fusiform in shape; approximately 1–3 cm in length;
because of perinatal injury; mass usually grows for roughly 8 weeks, then involutes
by age 6 months; usually accompanied by torticollis
Inflammatory/Infectious
1. Abscesses: 1. Localized infection with inflammation and exudate:

• Retropharyngeal • Retropharyngeal abscess: sore throat, fever, neck mass, neck stiffness, torticollis,
• Peritonsillar neck swelling in infants; cervical lymphadenopathy
• Peritonsillar abscess: infection of head and neck region; causes headache and neck
pain, also fever, dysphagia, sore throat, malaise, and otalgia. Cervical lymphadenitis
also seen.
2. Lymphadenitis 2. Inflamed/enlarged lymph node, most often in response to infection; a single node
or group of nodes may be affected; lymph nodes are tender, inflamed, soft, fluctuant,
and increase rapidly in size with infection
3. Lymphadenopathy 3. See section on lymphadenopathy
4. Parotitis (mumps) 4. Inflammation of the salivary glands; causes swelling along the angle of the jaw
Neoplastic
Benign Benign
1. Thyroid nodule 1. Midline neck mass
2. Goiter 2. Located near thyroid
Malignant Malignant
1. Non-Hodgkin’s lymphoma 1. Lymphadenopathy; mediastinal mass; hepatosplenomegaly
2. Hodgkin’s disease 2. Asymptomatic lymphadenopathy, unexplained weight loss, fever, and night sweats
can cause neck webbing and extra neck skin folds; • Integument: Dry skin (hypothyroidism); thinning
Down syndrome can cause extra neck skin folds and of hair (hyperthyroidism); and coarse, sparse hair
enlarged anterior fontanelle) (hypothyroidism)
• Growth: Weight gain, short stature (hypothyroidism), • Head: Microcephaly, macrocephaly, craniosynostosis,
and weight loss (hyperthyroidism) and craniostenosis
Lethargy
Protruding tongue
Hypotonic
abdominal
muscles
Abdominal
protrusion
Umbilical hernia
FIGURE 13-8. An infant with signs of congenital hypothyroidism.
• Neck: Pain, injury, stiffness, impaired movement,

lumps, masses, torticollis, cystic hygroma, cellulitis,
lymphangioma, laryngocele, and opisthotonos FIGURE 13-9. Torticollis in the infant.
• Eyes: Exophthamia (hyperthyroidism), lid lag, lid
retraction, periorbital edema (hyperthyroidism), and
vision problems (hypothyroidism) conditions that cause increased intracranial pressure,
• Ears: Recurrent acute otitis media (causes lymphade- paresthesias, vertigo, syncope, hypotonia (congenital
nopathy) and vertigo hypothyroidism), tremors (hyperthyroidism), a his-
• Cardiac: Jugular venous distention (may be present tory of falls, and clumsiness
with some cardiac conditions), Kawasaki disease, • Musculoskeletal: Osteogenesis imperfecta, facial tics,
congenital heart disease (may affect carotid pulses), muscle weakness, fatigue (hyperthyroidism), and
palpitations, tachycardia, edema, flushing (hyper- character of gait
thyroidism), and bradycardia (hypothyroidism) • Developmental: Achievement of developmental
• Respiratory: Upper respiratory infections (cause milestones (e.g., delayed gross motor control such as
lymphadenopathy in neck) head lag may indicate cerebral palsy), developmen-
• Endocrine: Hypothyroidism, Hashimoto’s thyroid- tal delay (congenital hypothyroidism), hyperactiv-
itis, hyperthyroidism, Graves’ disease, goiter, thy- ity, and hyperthyroidism
roglossal duct cyst, amenorrhea (hyperthyroidism),
precocious puberty (hypothyroidism [young chil- Immunizations. A child’s immunization status is
dren]), and delayed puberty (hypothyroidism) particularly relevant to assessment of the head and
• Metabolic: Rickets (may cause craniotabes), dehy- neck. Several diseases for which children are im-
dration (may cause depressed fontanelle), and lead munized can cause abnormalities in the head and
poisoning neck, including infection with Haemophilus influen-
• Immunity: Cervical lymphadenitis; lymph node zae type B (Hib) and Neisseria meningiditis; Strepto-
swelling, pain, or erythema; night sweats (suggests coccus pneumoniae meningitis (bulging fontanelle in
lymphoma); infectious mononucleosis; tonsilli- infants, headache, neck pain, stiffness in older chil-
tis; pharyngitis; mumps, rubella, or roseola; hu- dren); measles (encephalitis, lymphadenopathy),
man immunodeficiency virus (HIV); malignancies mumps (parotid gland swelling), rubella, rubeola,
(cause lymphadenopathy); cat-scratch fever; Ep- and varicella; polio; diphtheria (lymphadenopa-
stein-Barr virus, tuberculosis; coxsackievirus; and thy); tetanus (neck muscle rigidity); and pertussis
juvenile rheumatoid arthritis (sunken fontanelle secondary to dehydration). Cer-
• Neurologic: Meningitis, meningeal irritation (can vical and occipital lymphadenopathy can also oc-
cause opisthotonos), hydrocephalus, brain tumor, cur as a postimmunization response following the
headaches, migraines, neurofibromatosis, intracranial diphtheria-pertussis-tetanus or poliomyelitis vaccine
hemorrhage, craniosynostosis, craniostenosis, any (Leung & Robson, 2004).
BOX 13-1 Family History

Causes of Cervical Masses It is important for providers to determine the child’s
in Children family history, focusing on genetic disorders, any reports
of recurrent headaches, migraines, or thyroid disease.
• Brachial cleft cyst
• Cervical ribs Social History
• Cystic hygroma It is important for providers to determine if there are
• Dermoid cyst any environmental risks that may cause head or neck
• Hemangioma complaints. One risk to children is living in an old
• Laryngocele dwelling with peeling, lead-based paint; this can lead
to lead poisoning. Lead poisoning can cause headache,
• Mumps
intracranial pressure, and possible encephalopathy.
• Sternomastoid tumor
Exposure to secondhand smoke can cause headaches.
• Thyroglossal cyst
Contact with hazardous chemicals or waste or expo-
sure to radiation can result in head and neck cancers.
Source: Leung, A. K. C., & Robson, W. L. M. (2004). Childhood cervical
Children who have declining school performance or
lymphadenopathy. Journal of Pediatric Health Care, 18(1), 3–7.
headaches may be suffering from hyperthyroidism,
which can result in a decreased ability to focus, con-
centrate, or sit still; hyperactivity; impulsivity; and
Hospitalizations. Provider inquiries about past hospi- consequently, poor academic performance (Kaplowitz,
talizations for infections or injuries involving the head 2007). The provider must also inquire about the child’s
or neck, as well as chronic illnesses that cause lymph- participation in contact sports that increase the risk for
adenopathy such as Hodgkin’s and non-Hodgkin’s head or neck injuries. It is also important for providers
lymphoma, tuberculosis, or leukemia, are included to inquire routinely about the presence of firearms in
as a relevant part of the history. Cervical masses are the home (see Chapter 7). Young children may unin-
common in children and can be mistaken for cervical tentionally cause head or neck injuries when playing
lymphadenopathy; some of these conditions may re- with a gun; older children and adolescents who are de-
quire hospitalization or surgery. These conditions are pressed may harm themselves intentionally.
listed in Box 13-1.
Developmental History
Injuries. It is important for the provider to obtain When assessing the head and neck in children, it is im-
any history of falls or other type of head trauma such portant to include an assessment of growth and develop-
as blows to the head, gunshot wounds, or shaking ment (see Chapters 2 and 8). Measurement of head size
injuries. Any of these injuries can cause skull frac- as well as length or height helps to identify abnormali-
tures and intracranial bleeding that can lead to per- ties in growth as well as systemic problems. Assessment
manent damage to the growing brain, resulting in of the child’s muscle tone and strength, head control,
developmental delays. The provider must also deter- and the achievement of age-appropriate developmental
mine past head and neck injuries and ask about the milestones in both fine and gross motor domains can
use of car seats, booster seats, seat belts, and bicycle give providers clues to other abnormalities such as ce-
helmets to evaluate risk for head or neck injuries. rebral palsy and developmental delays. Early identifica-
Trampolines are particularly dangerous and can lead tion of any developmental delays is critical to maximize
to head and neck injuries (see Chapter 7); providers the child’s potential. Prompt referrals are necessary for
should inquire if the child plays on a trampoline and children who have difficulty achieving developmental
specifically if the trampoline is used to jump into a milestones.
swimming pool.
Medications
Surgical History It is important for providers to inquire about any pre-
Providers should ask the parent if the child has had scribed or over-the-counter medications the child is
any surgery involving the head or neck, including cra- taking. The indication for the drug may explain an
niotomy or placement of a ventriculoperitoneal shunt abnormality in the head, neck, or lymph nodes. For
(see Chapter 22), incision and drainage of a lymph example, a child may be taking antibiotics to treat a
node in the head or neck, thyroid surgery, or trache- bacterial infection that has caused neck swelling or
otomy. The date of the surgery and the condition for cervical lymphadenopathy. Steroids prescribed for a
which the surgical procedure was done should be as- brain neoplasm can cause neck and facial swelling.
certained. Providers must also determine whether the Also, certain drugs such as isoniazid may cause gener-
condition was resolved with surgery. alized lymphadenopathy (Karch, 2007).
TABLE 13-2
History of Present Illness: Abnormalities and Complaints
Related to the Head and Neck
CONDITION ASSESSMENT EXPLICATION
Alopecia, dry skin Onset? Texture of hair? Is skin Thinning of hair occurs with hyperthyroidism.
dry as well? Coarse, sparse hair and dry skin occur with
hypothyroidism.
Cough Recent exposure to respiratory illness? It may be a viral (e.g., respiratory syncytial virus)
What type? What is the child’s or a bacterial (GABHS pharyngitis) respiratory
immunization status? Recent immigrant illness that causes cough; lymphadenopathy may
from a country where tuberculosis be associated with these infections.
infection is widespread?
Dizziness Recent head injury? History of cardiac Neurologic complaints (see Chapter 22), cardiac
problems? Any associated loss of problems (see Chapter 18), or inner ear abnormalities
consciousness? Vertigo? (see Chapter 14) may cause dizziness.
Exposure Recent exposure to infection? What type? Lymphadenopathy of the head and neck can occur
to infection What is the child’s immunization status? with scalp, oral, or respiratory infections.
Fatigue Onset? Any associated symptoms New-onset fatigue can indicate hypothyroidism;
(e.g., cold intolerance, emotional lability, fatigue associated with weight loss can indicate
constipation) or weight loss? a malignancy.
Fever Recent exposure to infection? What type? Lymphadenopathy of the head and neck can occur
Is the child tugging at his or her ears? with scalp, oral, or respiratory infections (e.g., tinea
Cough or other respiratory complaints? capitis, pediculosis capitis, scalp impetigo, acute otitis
Any infections of the scalp? Any media, otitis externa, tonsillitis, pharyngitis (viral
oral infections? What is the child’s or bacterial), or dental abscess.
immunization status?
Headache Type of pain, location, intensity, Detailed description of headaches aids in formulating
duration? diagnosis (see Chapter 22).
Head Injury When did injury occur? Mechanism of Head injuries in children can have profound,
injury? Did child fall or was the child long-lasting effects on the child’s growth and
struck? Did the child lose consciousness? development. The extent to which the child is
Was child riding a bicycle or skateboard? injured must be determined to ensure appropriate
Was the child wearing a helmet? Was the assessment and follow up (see Chapter 22).
child involved in a motor vehicle collision?
Was the child properly restrained?
Lymphadenopathy Characteristics of lymph tissue: Swelling, It may be because of respiratory infection,

of head or neck pain, mobility, or enlargement of lymph malignancy, Kawasaki disease, collagen vascular
nodes? Fever? Tooth pain? Recent travel? diseases, serum sickness, and drug or vaccine side
effects (Leung & Robson, 2004). It may also be
because of dental infection or tuberculosis.
Macrocephaly Occipital-frontal head circumference It may be because of hydrocephalus, space-

more than two SD above the mean for occupying lesions (e.g., hematomas, brain tumors),
age and sex or one that is growing too neurofibromatosis, autism, or tuberous sclerosis;
rapidly it may also be familial.
Microcephaly Occipital-frontal head circumference It may be because of craniosynostosis, craniostenosis,

more than two SD below the mean for Down syndrome, fetal alcohol syndrome, or
age and sex or one that is not growing hypopituitarism; it may also be familial.
at the normal rate
Neck masses, Intolerant to cold? Heat? When was A neck mass could be an enlarged thyroid,
lumps, or swelling the onset? Palpitations? Recent fever? lymphadenopathy, malignancy, or cervical masses.
Weight loss or gain? Immunization Cold intolerance is likely because of acquired
status? IV drug use? hypothyroidism, and heat intolerance
is because of hyperthyroidism. Palpitations
could be because of hyperthyroidism.
CONDITION ASSESSMENT EXPLICATION

Fever is a sign of infection (e.g., lymphadenitis, cellulitis).
Unexplained weight loss may be because of malignancy
or hyperthyroidism; weight gain may be because of
hypothyroidism. Neck swelling may be caused by
parotitis (mumps) or other neck masses (see Box 13-1).
IV drug use can lead to lymphadenopathy.
Neck pain Sleep position? Recent injury? Neck pain can be positional after sleep; it can accompany
Involved in sports? What type? Recent head or neck injury associated with rough play or
respiratory or flu-like illness? contact sports; neck pain and stiffness with a history of
recent febrile respiratory or flu-like illness may indicate
meningeal inflammation.
Neck stiffness Age of child? Onset of neck stiffness? Neck stiffness can be because of congenital torticollis; it can
Recent infection of head or neck? also be a sign of meningeal irritation, which occurs with
Fever? meningitis. Fever with stiff neck can be retropharyngeal
or peritonsillar abscess, or bacterial meningitis.
Night sweats Onset? Fever? Lymphadenopathy? Malignancy or tuberculosis are possibilities that should
Weight loss? be investigated.
Plagiocephaly Sleep position? Was infant premature? Occipital plagiocephaly is because of prolonged supine
Where on skull is the plagiocephaly? positioning, and parietal plagiocephaly is because of
Occipital region? Parietal region? prolonged side-lying positioning. Asymmetrical head
shape can be caused by craniostenosis or craniosynostosis.
Sore throat Onset? Fever? Accompanying It may be streptococcal pharyngitis or retropharyngeal or

nasopharyngitis? Tonsillar exudate? peritonsillar abscess.
Weight loss Fever? Lymphadenopathy? Associated It may be because of malignancy, hyperthyroidism,

symptoms such as tremors, or tuberculosis.
nervousness, anxiety?
GABHS, group A beta-hemolytic Streptococcus; IV, intravenous; SD, standard deviation.
History of Present Illness examination. In infants and toddlers, assessment of

When a pediatric client presents with a complaint re- the head and neck is done near the end of the physi-
lated to the head or neck, the provider must keep in cal examination, as palpation of the head and neck
mind the child’s age and developmental level, concur- may cause the infant or young child to become agi-
rent illness, associated findings, and past health when tated and cry. Purposeful visual inspection of the head
considering diagnostic possibilities. For example, once and neck is best done when the infant or toddler is
children begin to walk, they are more prone to falls. quiet and not agitated to yield the most detailed, accu-
Similarly, older children who use skateboards or ride rate results. Assessment of the head and neck in older
bicycles without a helmet are predisposed to more se- children and adolescents can be done in a head-to-toe
vere head injuries after a fall. Children with a febrile sequence. Examination of the head and neck is usually
illness who have headache and lymphadenopathy performed with the infant or child sitting upright in
may have a streptococcal infection. When children front of the examiner, either in the parent’s arms or on
are school-aged or older, lymphadenopathy is less pro- the examination table.
nounced during acute infections. Table 13-2 summa- No specialized equipment is necessary to examine
rizes the data providers need to obtain for the history the head or neck. Gloves must be worn during the
of present illness (HPI) concerning common pediatric examination if any lesions are noted. The examin-
complaints related to the head and neck. ers must have short fingernails when palpating the
neck. Good illumination is essential. When assessing
the head of a child 3 years or younger, or if providers
PHYSICAL EXAMINATION are concerned about head size, a paper or metal tape
Examination of the head and neck in young children measure is necessary to measure head circumference
is challenging. Some of the areas to be examined are (see Chapter 8). This tape measure can also be used to
not easily visualized, and children toddler-aged and measure lymph node size in the case of lymph node
younger are often resistant to this portion of the enlargement.
Assessment of the Head The head should be symmetrical when inspected,

Because of cephalocaudal development, a develop- without depressions or bulging. Asymmetry of the
mental approach is necessary when examining the head such as flattening in one particular area of the
head in the pediatric client. Inspection findings have skull (i.e., plagiocephaly or brachycephaly) may indicate
the potential to vary greatly, depending on the child’s that the infant or child spends an inordinate amount of
age (i.e., head size, open or closed fontanelles, head time lying in one position. For example, occipital flat-
control). Assessment of the head is critically impor- tening (i.e., brachycephaly) can indicate prolonged su-
tant in newborns and infants but should not be mini- pine positioning and is more commonly seen since the
mized in older children. Examination of the head and inception of the “Back to Sleep” initiative (Fig. 13-10).
scalp in infants and children can reveal integumentary Plagiocephaly or brachycephaly can also be because of
disorders or infections that should be treated prompt- neglect, especially if alopecia is noted over the same
ly to prevent complications (see Chapter 12). area. Asymmetry of the head can also be caused by cra-
niosynostosis, which is caused by premature closure of
Inspection. Assessment of the head begins with inspec- the coronal sutures; it can have multiple etiologies and
tion and can be done informally during initial contact must be treated surgically (Table 13-3).
with the child. The provider begins by inspecting the Cranial molding refers to an abnormal shape of the
head for size, symmetry, and shape. In infants, head control head that is seen in neonates in the immediate post-
should be assessed. In infants and toddlers 18 months partum period. This is caused by pressure exerted on
and younger, the anterior and posterior fontanelles the skull during delivery and is considered normal dur-
should be assessed; the posterior fontanelle should be ing the first 7 days of life. The skull shape of infants
assessed in infants age 2 months and younger. born prematurely is often dolichocephalic (long and
Brain growth is essential for normal growth and narrow), because of positioning of these infants on
development of the infant and young child. Head size their side for prolonged periods of time. In most cases,
reflects brain growth. Head size is determined by mea- the skull shape normalizes by age 1 to 2. Prominence
suring head circumference; this is done at birth (see of the frontal area of the cranium (“bossing”) is seen
Chapter 11) and in children 3 years and younger. The with hydrocephalus (see Chapter 22).
head circumference is measured at all health mainte- Inspection of the head in infants should include as-
nance visits and when the provider has a concern about sessment of head control. Head control is assessed by
the child’s head size or shape. These measurements determining the infant’s ability to hold the head erect
should be plotted on age and gender-appropriate growth when it is unsupported. Infants develop some head
charts (see Chapter 8). The head circumference reflects control when in the prone position by approximately
estimated brain size. A head that is larger than normal 2 months. The provider should place infants at this age
(macrocephaly) is defined as a head circumference more on the examination table in the prone position and
than two standard deviations (SD) above the mean for
age and sex or one that increases too rapidly. Macro-
cephaly often indicates an enlarged brain, which may
be because of hydrocephalus, space-occupying lesions
(e.g., hematomas, brain tumors), neurofibromatosis, or
tuberous sclerosis (Moe, Benke, & Bernard, 2007). Small
head size (microcephaly) is defined as a head circumfer-
ence two SD below the mean for age and sex or one that
is growing more slowly than normal. Microcephaly may
be because of premature closure of the cranial sutures
(craniosynostosis), craniostenosis, or Down syndrome
(Elias, Tsai, & Manchester, 2009). Microcephaly is also
a clinical finding in FAS (Chambers & Vaux, 2009) and
in newborns who have been exposed to cocaine in
utero (Martinez, Partridge, & Taeusch, 2004). The pro-
vider must keep in mind that head size may be familial
and should compare the child’s head size to that of the
parents (see Chapter 11). Premature infants also may
appear to have large heads because of continuing cepha-
locaudal development; these infants should have their
head circumference measurements plotted, according to
conceptual versus chronologic age (Sherman & Aylward,
2009). Abnormal findings in head circumference mea- FIGURE 13-10. Occipital flattening because of prolonged
surement necessitate referral to pediatric neurology. supine positioning.
up and down and assessing whether they are able to

TABLE 13-3
follow these simple commands. Head lag is most com-
Causes of Craniosynostosis monly caused by prematurity, hydrocephalus, and as-
in Children phyxic injuries, causing alterations in neuromuscular
TYPE OF control. Lack of head control after 6 months is abnor-
CRANIOSYNOSTOSIS CAUSES mal and can be the result of asphyxic brain injury and
may indicate cerebral palsy.
Primary craniosynostosis • Defect in ossification of The fontanelles are best inspected with infants or tod-
cranial bones
dlers in the sitting position. The anterior fontanelle should
Secondary • Endocrine: be flat and open until 12–18 months. With vomiting or
craniosynostosis hyperthyroidism; vigorous crying, the anterior fontanelle may be tense or
vitamin D deficiency; bulge very slightly; this is a normal finding. Abnormal
hypercalcemia; and rickets findings include a sunken or depressed anterior fonta-
• Hematologic: sickle cell
disease and thalassemia nelle; this is a sign of moderate-to-severe dehydration or
• Inadequate brain growth: malnutrition. A noticeably bulging anterior fontanelle
microcephaly and indicates overhydration or increased intracranial pres-
shunted hydrocephalus sure; Box 13-2 lists some causes of increased intracra-
Syndromic • Genetic mutations
nial pressure in infants and children. In some instances,
craniosynostosis the anterior fontanelle is visibly pulsatile. Pulsations
of the anterior fontanelle reflect the peripheral pulse.
Source: Sheth, R. D., Aldana, P. R., & Iskandar, B. J. (2009). Marked pulsations can be because of increased intracra-
Craniosynostosis. Retrieved September 7, 2007, from nial pressure, decreased venous return from the head, or
http://www.emedicine.com/neuro/topic80.htm. increased pulse pressure.
The provider should also inspect the fontanelles
for size. This is done by measuring the width and
observe whether or not they can lift their head while length of the open anterior fontanelle. It may be
prone. Older infants can be placed on the examination small at birth because of cranial compression during
table in the supine position and then be pulled to a sit- vaginal delivery and then increase in size in the first
ting position while the provider assesses head control. weeks of life. The open anterior fontanelle should
Infants 4 months or younger will display some head measure approximately 1 to 5 cm (0.4 to 2 in) in
lag; most infants this age are able to hold their head length and width until 9 to 12 months. An anterior
erect at midline when being held in a vertical posi- fontanelle that measures greater than 4 to 5 cm (2 in)
tion. By age 6 months, no head lag should be noted in diameter may be within normal limits in some
(Fig. 13-11). To assess head control in older infants, the
provider can show the infant a colorful object or toy,
move it in different directions, and assess whether the
child turns his or her head to follow the movement. BOX 13-2
Head control can be determined in older children by Causes of Increased
asking them to turn their head from side to side and Intracranial Pressure
in Children
• Abscess
• Brain tumor
• Encephalitis
• Head trauma
• Hematomas
• Hepatic failure
• Hydrocephalus
• Hypoxic-ischemic injury
• Intracranial hemorrhage
• Lead poisoning encephalopathy
• Meningitis
• Reye syndrome
• Stroke
• Vitamin A toxicity
FIGURE 13-11. This infant demonstrates no head lag when
pulled to sit.
children but also may indicate congenital hypothy- a ridged cranial suture, called metopic ridge. This occurs
roidism, rickets, osteogenesis imperfecta, or increased when the two halves of the frontal bone fuse prema-
intracranial pressure (Kiesler & Ricer, 2003). The pos- turely. This finding is normal if the infant’s head shape
terior fontanelle may or may not be palpable at birth. and circumference are within normal limits. A metopic
If palpable, it should measure 0.5 to 1.5 cm at birth, suture (or sagittal suture) occurs when the two halves
gradually closing by approximately 2 months. The of the frontal bone remain separated; this is commonly
presence of a sagittal fontanelle (between the anteri- seen in children with Down syndrome (Kiesler & Ricer,
or and posterior fontanelles) can indicate Down syn- 2003). These children should be monitored for increas-
drome (see Palpation of the Fontanelles). ing head size, particularly in the first year of life. When
When examining young infants, providers also in- palpating the suture lines, if extra bone edges are felt, a
spect the scalp veins for dilation, which can indicate skull fracture may be present.
chronic intracranial pressure. The scalp should also be Palpation of the cranial bones is done to assess for
inspected for lesions, hair loss, signs of trauma, any areas craniotabes, a softening and thinning of the bones of
of discoloration, and overall hygiene (see Chapter 12). the skull. Craniotabes is normally found in premature
infants and can sometimes be a normal finding in in-
Palpation. Palpation of the head in infants and chil- fants 6 months and younger; the bones become firmer
dren involves assessment of the head for symmetry; as they ossify with age. Craniotabes can also be caused
palpation of the fontanelles (infants and toddlers) and by hydrocephaly, rickets because of vitamin D defi-
cranial sutures; and assessment for edema, tenderness, ciency, congenital syphilis, or osteogenesis imperfecta
masses, depressions, and lesions (see Chapter 4 regarding (Graham, 2006). To assess for craniotabes, the provider
cultural considerations involving touching the head in should palpate the scalp firmly along the cranial su-
children). ture lines in the temporoparietal area. The presence of
The provider uses the finger pads of the second or craniotabes causes the cranial bones to feel pliable and
third fingers to palpate the skull in a circular motion, be- soft; firm palpation often creates an indentation, simi-
ginning at the frontal area, then moving to the temporal lar to pressing on a ping-pong ball.
and parietal areas, and working toward the occipital re- Palpation of the skull also involves assessing for ten-
gion. The skull should first be palpated for contour and derness, masses, edema, depressions, and lesions. Scalp
symmetry (see Inspection). Asymmetry of the skull can tenderness can indicate injury or trauma to the head or
have multiple etiologies (see Inspection). scalp, tension or migraine headache, scalp infections
In infants and toddlers to age 18 months, the provid- (e.g., lice, tinea capitis, cellulitis, herpes zoster, osteo-
er gently palpates the fontanelles for size, tautness, bulg- myelitis), contact dermatitis, and vasculitis caused by
ing, and pulsations (see Inspection). Typically, only the Henoch-Schönlein purpura or Kawasaki disease.
anterior and posterior fontanelles can be palpated. In Depending on the location and character of the
infants 6 months or older, it is best to palpate the fon- mass, palpable masses of the scalp may indicate in-
tanelles with the infant in the sitting position, ideally fection, injury, or a benign variation. Palpable masses
when the infant is quiet, as intense crying can cause the in the postauricular or occipital region may indicate
anterior fontanelle to bulge. In infants 2 months and lymphadenopathy. Palpable, raised, tender boggy
younger, the anterior and posterior fontanelles are pal- masses with scattered pustules on the scalp indicate
pated; in infants and toddlers 18 months and younger, a kerion, a tinea capitis infection of the scalp (see
the anterior fontanelle is palpated. The anterior fonta- Chapter 12, Fig. 12-11). A palpable, localized, easily
nelle is palpated at the juncture of the sagittal, coronal, moveable, nontender mass may be a lipoma. With a
and frontal sutures. The posterior fontanelle is palpated recent history of head trauma, these same findings
at the juncture of the sagittal and lamboidal sutures. can indicate an accumulation of subcutaneous blood
When palpated, the fontanelles should be soft and (i.e., a hematoma).
flat. A fontanelle that is full, bulging, or palpated after Normally, the skin covering the scalp should be
the age at which it should be closed often indicates in- flush against the scalp, without edema. Edema of the
creased intracranial pressure (see Box 13-2). A depressed scalp in a newborn often indicates a caput succeda-
or sunken anterior fontanelle indicates dehydration. neum (i.e., localized subcutaneous edema over the
In infants, the provider palpates the cranial sutures presenting part of the scalp; edema crosses the suture
for separation to determine whether they are open, lines) or a cephalohematoma (i.e., swelling caused by
closed, or overriding. Again, using the finger pads, the subperiosteal collection of blood; does not cross suture
provider palpates the sagittal, coronal, and lambdoi- lines) (see Chapter 11, Fig. 11-5). These conditions
dal suture lines. Normal cranial sutures feel like soft should resolve by 2 weeks. A depression of the scalp can
ridges between the cranial bones. Cranial sutures may be felt over the area of the open fontanelles in infants
overlap in the first 6 months of life; this is a normal (see Palpation) and over the area of a depressed skull
finding if the head circumference is within normal fracture. The provider should also palpate the skull for
limits. In some instances, young infants may develop lesions (see Chapter 12).
Percussion. Percussion of the head assesses for ask the child to follow simple directions such as look-
resonance, which may indicate hydrocephalus or a brain ing up, down, to the left, and to the right, and then to
abscess. Providers tapping the index finger against the touch their chin to the chest and then to look at the
surface of the parietal bone create this resonance; such ceiling. Normally, the child should not experience any
tapping produces a “cracked pot” sound (“Macewen’s pain or limitations in neck range of motion. Limited
sign”). In infants whose fontanelles are still open, this range of motion with lateral movement of the neck
is a normal finding. The presence of Macewen’s sign can indicate torticollis, the result of injury to the ster-
in older infants and children whose fontanelles have nocleidomastoid muscle. This injury can be congenital
closed may indicate a separation of the cranial sutures (cranial nerve IV palsy) or the result of birth trauma,
because of increased intracranial pressure. neck trauma, or spinal cord or cerebellar tumors (Eilert,
2007). Cranial nerve XI (accessory) is tested by asking
Assessment of the Neck children to shrug their shoulders, while turning their
Assessment of the neck involves inspection, palpation, head from side to side. The examiner can assess this ei-
and auscultation. In infants and toddlers, the neck is ther with or without applying resistance to the child’s
examined with the child lying supine either on the ex- shoulders. The child should be able to resist, using the
amination table or on the parent’s lap. With children 3 sternocleidomastoid muscle (see Chapter 22). Pain or
to 4 years of age or younger, the provider must extend resistance to neck flexion may indicate meningeal irri-
the head back slightly to expose the shortened neck tation (positive Kernig or Brudzinski sign) (see Chapter
area. When children are preschool-aged and older, they 22). Opisthotonos, which is extreme hyperextension of
should sit upright in a position that allows them to ro- the neck, occurs with significant meningeal irritation,
tate and extend their head easily. The neck is examined most often because of bacterial meningitis (see Chapter
from medial to lateral and then from front to back. 22). Neck mobility is not assessed in a trauma victim.
Inspection. The provider begins inspection of a child’s Palpation. The mobility of the neck in infants is pal-
neck for size, symmetry, shape, swelling, cysts, or masses. pated, as they are not developmentally able to coop-
In infants, the neck is normally short with visible skin erate with the assessment of the range of motion with
folds; the neck lengthens between 3 to 4 years of age. simple inspection. When palpating to assess neck range
In infants and children, the neck should be symmetri- of motion in an infant, the provider begins by holding
cal with the head centered and the trachea midline. the infant supine and gently holding the infant’s head
Obesity can cause changes in neck size, shape, and with the dominant hand. Mobility of the infant’s neck
symmetry. No swelling should be present. Swelling of is then assessed by turning the infant’s head from side
the neck may be caused by parotitis (mumps) or in- to side, forward for flexion, and backward for exten-
fections in the oral cavity. Diphtheria can also cause sion. Any resistance to these movements should be
edema of the soft tissues of the neck (Leung & Robson, noted, especially flexion, which may indicate torti-
2004). Swelling at midline and immediately above the collis. When palpating the neck in older children, it
thyroid cartilage in a young infant can be a dermoid is best to do so with the child in the sitting position.
or thyroglossal duct cyst (Connolly & Dillard, 2007). Any pain or resistance to range of motion can indicate
Cystic hygroma is the most common neck mass in head or neck trauma, lymphadenopathy, or injury to
neonates; most are evident at birth, but in some cases, the sternocleidomastoid muscle.
may present as late as 2 years (Acevedo, 2007). The provider also palpates the neck for any masses,
The neck is also inspected for any skin infections, cysts, pain, or tenderness. In newborns, cystic hygroma is
lesions, or scars (see Chapter 12). Young infants may the most common type of neck mass. Cystic hygromas
be prone to fungal or bacterial infections of the ante- are typically mobile, nontender, amd nonerythema-
rior neck because of their short neck and folds of skin. tous, with a firm center (Connolly & Dillard, 2007). In
Scars on the neck may be because of past injury or sur- newborns, the clavicles are palpated to assess for any
gery on underlying structures such as the thyroid or fractures that may have occurred during delivery.
trachea. The neck must also be examined for webbing The parotid gland must also be palpated, noting
and extra skin folds. These variations can be caused by any swelling, tenderness, or enlargement. The parotid
Klippel-Feil, Turner, or Noonan syndrome (Elias, Tsai, gland should be nontender and nonedematous. An en-
& Manchester, 2009; Postellon, 2009). Extra skin folds larged parotid gland may result from acute or chronic
are also consistent with Down syndrome. viral infections such as mumps, paramyxovirus, cox-
Providers should assess the full range of motion of the sackieviruses, Epstein-Barr virus, influenza and parain-
neck through inspection. Performing passive range of fluenza viruses, herpes simplex virus, cytomegalovirus,
motion on an infant accomplishes this. To assess neck HIV, or bacterial infections caused by Staphylococcus
range of motion in toddlers, a penlight or an engaging aureus, Mycobacterium tuberculosis, or streptococcal in-
toy can be used while the examiner observes the child’s fection (Singh, Arrieta, Lang, & Ahuja, 2001). The non-
range of motion. In older children, the examiner can infectious causes of parotitis include collagen vascular
diseases, systemic lupus erythematosus, metabolic dis- the provider must be sure to palpate only one at a time,
orders, diabetes mellitus, hypothyroidism, and tumors since these blood vessels supply blood to the brain; oc-
(Singh et al., 2001). Bulimia nervosa can also cause pa- cluding them simultaneously can impede all blood flow
rotid gland swelling (Mandel & Abai, 2004). to the brain. Forceful palpation of the carotid artery can
also precipitate a vagal response, causing bradycardia,
Auscultation. Auscultation of the neck is done to lo- hypotension, or even asystole. Using the fingerpads of
calize the site of airway obstruction and may reveal the second and third fingers, the examiner locates the
a bruit over the thyroid gland if the child has diffuse carotid artery, in the groove between the trachea and
toxic goiter (see Assessment of the Thyroid Gland). sternocleidomastoid muscle. Using gentle pressure, the
provider palpates the carotid artery to assess the rate,
Assessment of the Trachea rhythm, and intensity of the carotid pulse. Normally,
the carotid pulse is synchronous with the radial pulse,
Inspection. It is important for the provider to deter-
palpable, and regular in rhythm. Both carotid pulses
mine the position of the trachea by inspection. The
should be equal in intensity.
trachea should be midline; a deviation in tracheal
position may be because of the presence of a foreign
Auscultation. Using the bell portion of the stetho-
body, neoplasm, or pneumothorax.
scope, providers auscultate the carotid arteries for
bruits (abnormal sounds caused by turbulent blood
Palpation. The trachea is difficult to palpate in chil-
flow). If children are developmentally capable, it may
dren 3 and younger because of their short, thick necks.
be helpful to ask them to hold their breath during the
The purpose of palpating the trachea is to determine
auscultation so that the sound of air movement is not
its position and to assess for any masses. To palpate
confused with a bruit. Bruits may be present in children
the trachea, the examiner should place the thumb and
with hyperthyroidism, anemia or arteriovenous fistula,
forefinger on either side of the trachea and then slowly
or other vascular abnormalities (see Chapter 18).
and gently slide the fingers down the trachea. The tra-
chea should be midline with no palpable masses.
Assessment of the Thyroid Gland
Assessment of the Jugular Veins Inspection. In children, the thyroid gland is inspected
for size, symmetry, shape, and masses. Tangential light-
Using tangential lighting across the neck, the provider ing may help the provider to locate the thyroid gland
inspects the external jugular veins. Inspection of the exter- in children. To begin inspection of the thyroid, the
nal jugular veins allows the provider to assess right atrial provider can ask the child to sit upright on the exami-
pressure indirectly. The external jugular vein is not nor- nation table, then tilt the head back. The size of the
mally distended when the child stands or sits upright. thyroid gland should be noted. An abnormally large
When the child lies down, jugular filling should occur. thyroid gland may be evidence of hypothyroidism, hy-
With the child supine, the jugular veins should appear perthyroidism, or infectious thyroiditis (Ferry & Gold,
full but not bulging, and the jugular venous pulse ( JVP) 2006; Postellon, Bourgeois, & Varma, 2007). Next, the
should be visible. The JVP should be a normal rate, gen- provider should ask the child to take a sip of water, then
tle, nonbounding, and without bruits. It is not normal inspect thyroid gland movement when the child swal-
to be able to observe jugular venous pulsations when the lows; the thyroid should rise as the child swallows.
child is sitting upright. Jugular venous distention or ab-
normal pulsations should be noted; these findings may Palpation. Palpation of the thyroid gland in children
be caused by hypervolemia, right-sided heart failure, can be challenging because young children are often
pericarditis, or mediastinal masses (see Chapter 18). ticklish when the neck area is touched, causing them
to move their shoulders upward and squirm. Providers
Assessment of the Carotid Arteries must be creative in devising age-appropriate strategies
Inspection. It is important for the provider to inspect that facilitates the palpation portion of the thyroid
the carotid arteries. These blood vessels are located in examination.
the groove between the trachea and sternocleidomas- In newborns, the thyroid cannot normally be
toid muscle. The carotid arteries should be inspected palpated. If swelling is noted, the provider first hy-
for amplitude of the pulsation. Carotid pulsations in- perextends the newborn’s head slightly to inspect for
tensify in children after vigorous exercise but may also thyroid enlargement, then palpates with one finger on
be present in children with anemia, hypertension, hy- either side of the gland. If the thyroid gland can be
perthyroidism, patent ductus arteriosus, or aortic in- palpated in a newborn, it is enlarged.
sufficiency (see Chapter 18). In infants and toddlers, the thyroid gland is ex-
tremely difficult to palpate because of their short, thick
Palpation. Palpating the carotid artery in infants and necks. When the provider palpates the thyroid gland
toddlers may be difficult or impossible because of their in children older than 3, size, shape, symmetry, firmness,
short, thick necks. When palpating the carotid arteries, and the presence of any nodules, tenderness, or masses
are noted. The isthmus of the thyroid gland is the only the thyroid gland may cause a systolic bruit on auscul-
portion of that is normally palpable in children. tation if the child has a toxic goiter.
The approach to palpating the thyroid gland can be
from either an anterior or posterior position. In young Assessment of the Lymph Nodes
children, an anterior position is preferred so the child of the Head and Neck
can see the provider; in the school-aged child and The head and neck contain the highest concentration
adolescent, a posterior approach is used. To begin with of lymph nodes in the body. Assessment of the lymph
either approach, the provider first locates the cricoid node’s size, color, location, temperature, mobility, and
cartilage to use as a landmark. Using the anterior ap- consistency may yield assessment findings that can
proach, the provider is in front of the child and then signal a benign localized infection or a possible ma-
places the pads of the second and third fingers on the lignancy in the area draining into that lymph node.
thyroid isthmus. This should feel like a band of tissue Lymphadenopathy in the head and neck is not un-
that crosses over the trachea. Next, the provider places common in young children because of frequent upper
the thumbs on the child’s neck. As the provider’s right respiratory infections in this age group. When lymph-
thumb gently displaces in the anterior region of the adenopathy is assessed, it is important to ascertain from
neck, the left thumb palpates the thyroid isthmus. This which part of the head or neck the lymph node receives
is repeated for both sides of the thyroid. From a poste- drainage; this aids in the diagnosis. For example, cervical
rior position, the provider stands behind the child and, lymphadenopathy can indicate infection of the neck or
with the child’s head tilted slightly forward and to the oropharynx, or it can be a sign of generalized infection
right, uses the pads of his or her second and third fin- or illness, such as tuberculosis or lymphoma. A history
gers to palpate between the trachea and sternocleido- geared to the child’s age (i.e., certain organisms have
mastoid muscle. Again using the cricoid cartilage as a predilections for specific age groups), assessment of as-
landmark, the provider palpates the thyroid isthmus by sociated signs and symptoms (e.g., fever, weight loss),
displacing it with the left hand and palpating with the and a careful physical examination help to determine
right, then repeating on the opposite side (Fig. 13-12). whether an enlarged lymph node is benign or requires
The anterior and lateral lobes of the thyroid are not further evaluation (see Table 13-2).
typically palpable in children; if they are, this indicates
thyroid enlargement (i.e., goiter). A goiter feels firm Inspection. Assessment of the lymph nodes in the head
and is easily moveable and nontender; the enlarge- and neck begins with inspection. The lymph nodes are
ment is symmetrical (Zeitler, Travers, Hoe, Nadeau, & inspected for size, swelling, and color; they are inspected
Kappy, 2009). The thyroid gland is enlarged in children in a front-to-back sequence, beginning with the preau-
with congenital hyperthyroidism, Graves’ disease, or ricular nodes. In children, the lymph nodes normally
Hashimoto’s thyroiditis (Zeitler et al., 2009). In some range in size from 3 mm in the head to 1 cm in the
children with toxic goiter, the thyroid gland may be neck. Lymph nodes that are enlarged and erythema-
mildly enlarged but can also be normal in size, many tous often indicate a localized infection that is proximal
times normal in size, or difficult to palpate (Corenblum, to the affected lymph node. Any nodes that are larger
Adediji, & Killian, 2009). Enlargement of the thyroid than 2 cm should be palpated carefully (see Palpation of
gland or the presence of tenderness or any masses is the lymph nodes). Easily visible swelling of the lymph
considered abnormal and warrants referral. nodes on inspection requires immediate attention; this
often indicates systemic infection. Erythema over a
Auscultation. Auscultation of the thyroid gland is lymph node may reflect inflammation or may not be
done when the provider palpates an enlarged thyroid lymphadenopathy at all but a deep hemangioma.
gland. Using the bell of the stethoscope, the examiner
auscultates over the thyroid. Increased blood flow to Palpation. The lymph nodes are palpated for size, mobil-
ity, warmth, tenderness, consistency, and degree of fixation.
Both superficial and deep palpation should be used.
When palpating the lymph nodes, the provider should
tilt the child’s head slightly upward to have full access to
the lymph nodes in that region (Fig. 13-13). The provider
palpates the lymph nodes, using the distal portion of the
fingers and using gentle but firm pressure in a circular
motion. This circular motion helps to define the charac-
teristics of the lymph node, which is so important when
formulating differential diagnoses. The submental and
submaxillary nodes are palpated bimanually.
The lymph nodes of the head and neck are palpated
FIGURE 13-12. Posterior approach to palpating the thyroid in the following sequence: pre-auricular and postauric-
gland. ular, submaxillary and submental, occipital, cervical,
TABLE 13-4
Causes of Head and Neck
Lymphadenopathy
in Children
LYMPH NODES CAUSES OF ENLARGEMENT
Preauricular Scalp, local skin, eye, or ear
infections
Postauricular Otitis externa, otitis media, or

parotitis
Occipital Scalp infections (e.g., tinea capitis,

pediculosis capitis, impetigo), viral
infections (e.g., varicella, rubella,
roseola), viral respiratory infections
(e.g., respiratory syncytial virus,
rhinovirus), and postimmunization;
also seen in neonates born to
mothers with infection during
pregnancy
Tonsillar Tonsillitis, pharyngitis, stomatitis,

FIGURE 13-13. Palpating the lymph nodes of the head and oral or tooth infections
and neck in a child.
Submandibular Tonsillitis, pharyngitis, stomatitis,
and oral or tooth infections
and then supraclavicular nodes. Normal lymph nodes
are mobile, nontender, and are not warm to the touch. Submental Oral and dental infections and
acute lymphadenitis
In healthy infants and adolescents, lymph nodes of
the head and neck are usually nonpalpable. In young Cervical Viral upper respiratory infections,
children aged 1 to approximately 10 years, small, non- tonsillitis, streptococcal pharyngitis,
tender, moveable lymph nodes up to 1 cm (0.5 in) are infectious mononucleosis, cat
scratch disease, Kawasaki disease,
considered normal (Leung & Robson, 2004).
tuberculosis, rubella, bacterial
Lymphadenopathy is defined as lymph node tissue lymphadenitis, oral or tooth
that measures greater than 1 cm in diameter, although infections; leukemia, lymphoma,
anterior cervical lymph nodes as large as 2 cm are con- or a postimmunization response
sidered to be normal (Kanwar & Sills, 2009). Small, firm,
Supraclavicular Enlargement of a left supraclavicular
rubbery, nontender, mobile lymph nodes (“shotty”) are node often indicates a malignancy
normal and commonly found in children 3 to 10 years in the abdomen or thorax;
of age. When lymph nodes swell (lymphadenopathy) supraclavicular lymphadenopathy
because of infection, the enlargement is painful, and can also be caused by lymphoma,
tuberculosis, histoplasmosis, or
the node is soft and moveable; when lymphadenopa-
coccidioidomycosis.
thy results from metastasis of malignancy, the swelling
is not painful and the lymph node is hard and fixed to
Source: Kanwar, V. S., & Sills, R. H. (2009). Lymphadenopathy.
the underlying tissue (Leung & Robson, 2004). Lymph Retrieved February, 17, 2008, from http://www.emedicine.com/
nodes that are enlarged, firm, warm, and tender are of- PED/topic1333.htm; Leung, A. K. C., & Robson, W. L. M. (2004).
ten indicative of an infection that is proximal to the Childhood cervical lymphadenopathy. Journal of Pediatric Health
Care, 18(1), 3–7.
affected lymph node. The number of lymph nodes
affected should be assessed as well; several enlarged
lymph nodes are usually a sign of systemic disease (i.e.,
infection), whereas single nodes are more often caused
by malignancy. In young children, the cervical lymph
nodes are usually palpable because of the frequency of COMMON DIAGNOSTIC
upper respiratory infections in this age group. STUDIES
The differential diagnosis of lymphadenopathy in
children is broad, but most lymphadenopathy in chil- Various diagnostic tests may be necessary to clarify dif-
dren is benign, self-limiting, and of viral origin (Kanwar ferential diagnoses of abnormal conditions involving
& Sills, 2009). Table 13-4 lists common causes of head the head and neck. These diagnostic studies and their
and neck lymphadenopathy in children. indications are summarized in Table 13-5.
TABLE 13-5
Diagnostic Studies Used to Evaluate Conditions
of the Head and Neck
TYPE OF TEST INDICATION COMMENTS
Biopsy To establish diagnosis with Biopsy should be done on any isolated, non-tender,
lymphadenopathy firm mass greater than 2 cm that does not respond to
antibiotics (Kanwar & Sills, 2009; Leung & Robson, 2004).
Complete blood Helps to diagnose infections of the Leukocytosis with a shift to the left is seen with bacterial
count head and neck (e.g., meningitis, lymphadenitis; atypical lymphocytosis is seen with
bacterial lymphadenitis, cellulitis) infectious mononucleosis; and pancytopenia points
to leukemia (Leung & Robson, 2004).
Computed Assesses head injuries; differentiates Child must remain immobilized during imaging.
tomography scan cysts from solid neck lesions
Culture To isolate causative organism Head and neck infections can spread to underlying
of infection lymph nodes and blood vessels, potentially spreading
to the meninges and causing bacterial meningitis.
Erythrocyte Localized inflammation of skin or This is usually markedly elevated with bacterial
sedimentation rate lymph nodes lymphadenitis (Leung & Robson, 2004).
Magnetic Gadolinium-enhanced MRIs are used Child must remain immobilized during imaging; thus
resonance imaging for circumscribing the invasion of soft sedation is required.
(MRI) tissue by tumor; endocrine tumors are
often enhanced on MRI this way. Also
used to diagnose head injuries and
brain lesions.
Magentic Evaluates vascular lesions (e.g., This is a noninvasive test, but it requires injection of
resonance digital hemangiomas, arteriovenous contrast.
subtraction malformations, vascular tumors) (Chooi,
angiography Woodhouse, Coley, & Griffiths, 2004)
Newborn screening Congenital hypothyroidism Mandatory screening in all 50 states

(for T4; if low, then
obtain thyroid
stimulating
hormone [TSH])
Rapid streptococcal To diagnose streptococcal infections Findings must be confirmed with culture.
antigen test that cause lymphadenopathy of neck
Skeletal To diagnose cranial anomalies It evaluates cranial abnormalities such as brachycephaly,

radiography craniosynostosis, craniostenosis, and micro- or
macrocephaly; cervical radiography is done to rule out
atlantoaxial instability.
Thyroid imaging To evaluate congenital hypothyroidism This is done in conjunction with ultrasonography.
(radionuclide
thyroid scanning)
Thyroid function To diagnose hypo- or hyperthyroidism Thyroid tests should be ordered in any child with
testing (TSH; T4) thyroid enlargement, more than one sign or symptom of
hypo- or hyperthyroidism, new-onset fatigue, acquired
growth failure, unexplained weight loss, or hyperactivity
(Kaplowitz, 2007).
Ultrasonography Evaluates intracranial bleeds in It is a noninvasive test, and it requires no sedation.

neonates; shows cystic versus solid
nature of neck masses (Leung &
Robson, 2004); can be used to evaluate
thyroid masses and diagnose hyper-
hypothyroidism or goiter.
Allergies: None known

DOCUMENTING FINDINGS Current Medications: None
Immunizations: Up-to-date
SAMPLE WRITE-UP: WELL NEWBORN ROS: Unremarkable
Subjective Data
Full-term male, 5 days old Objective Data
Prenatal history: Prenatal care begun in first tri- T: 38.2° C (100.8° F); P: 160 beats per minute;
mester; no history of maternal hypothyroidism R: 32 breaths per minute; oxygen saturation on
Perinatal history: Normal, spontaneous, vaginal room air: 98%; weight: 9 kg.
delivery General: Alert, in no distress
Newborn history: No respiratory distress at birth; Skin: Color pink; no rashes or lesions
Apgars 8 and 9. Nose: Moderate amount of pale green nasal dis-
charge; turbinates pink, slightly edematous
Objective Data Throat: Pharynx pink, no exudate
Head: Normocephalic, slight molding; anterior and Neck: Mass palpated on left side of neck; mobile,
posterior fontanelles open, soft, and flat. Overriding nontender, nonerythematous, no warmth when
sagittal suture. No palpable masses. Head circumfer- palpated. Center of mass firm to touch.
ence 90th percentile. Lymphatics: No nodes palpable
Neck: Supple, full range-of-motion, no masses. Lungs: Vesicular sounds auscultated throughout all
Clavicles smooth. lung fields
Neonatal screening results: Within normal limits Assessment: Cystic hygroma
Assessment: Healthy newborn
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Cystic hygroma. Retrieved November 14, 2009, from http://
Subjective Data www.emedicine.com/PED/topic536.htm.
Chambers, C., & Vaux, K. (2009). Fetal alcohol syndrome. Re-
Healthy 7-year-old girl; PMH noncontributory; no his- trieved November 14, 2009, from http://www.emedicine.com/
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Chooi, W. K., Woodhouse, N., Coley, S. C., & Griffiths, P. D.
(2004). Pediatric head and neck lesions: assessment of vascu-
Objective Data larity by MR digital subtraction angiography. American Journal
Head: Normocephalic; symmetrical, no masses or of Neuroradiology, 25(August), 1251–1255.
Connolly, S., & Dillard, E. (2007). Cystic hygroma. Consultant for
lesions, hair well-distributed; head circumference Pediatrics, 6(8), 479–480.
50th percentile. Corenblum, B., Adediji, O. S., & Killian, P. (2009). Goiter, dif-
Neck: Supple with full range of motion; no swell- fuse toxic. Retrieved November 14, 2009, from http://www
.emedicine.com/med/topic917.htm.
ing, masses; trachea midline. Thyroid gland firm Elias, E. R., Tsai, A. C., & Manchester, D. K. (2009). Genetics and
without nodules or masses. dysmorphology. In Hay, W. W., Levin, M. J., Sondheimer,
Lymphatics: No lymphadenopathy in head or neck J. M., & Deterding, R. R. Current pediatric diagnosis and treat-
ment. (19th ed.). (pp. 982–1052). New York: McGraw-Hill.
Assessment: Well child Ferry, R. J., & Gold, J. G. (2006). Hyperthyroidism. Retrieved
November 14, 2009, from http://www.emedicine.com/ped/
topic1099.htm.
Graham, J. G. (2006). Skull. In Stevenson, R. E., & Hall, J. G.
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Kaplowitz, P. (2007). Thyroid testing: when to worry (not
clinic by his mother for evaluation of a neck mass. often) and when to reassure. Contemporary Pediatrics, 24(1),
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CHAPTER
Assessment of
14 the Ears ELLEN M. CHIOCCA
The ear is a sensory organ of hearing and vestibular leads to the external auditory canal. Anterior to the
equilibrium, consisting of three parts: the external, concha is the tragus, a nodular structure that lies at
middle, and inner ear. Assessment of the ear begins the entrance of the external auditory canal; opposite
with the pediatric health care provider obtaining a the tragus is the antitragus. Below the antitragus is the
thorough and accurate history. The historical findings lobule (earlobe), the fleshy lower portion of the pinna.
guide the provider in obtaining the physical exami- The structures of the external, middle, and inner ear
nation of the external and internal ear. The complete are illustrated in Figure 14-1. Figure 14-2 illustrates
physical examination involves inspection and palpa- the landmarks of the pinna.
tion of the external ear, the otoscopic examination, The external auditory canal, a cartilaginous and bony
and assessment of hearing and speech development. structure, begins at the concha and terminates at the
Early screening to identify risk factors for hearing loss tympanic membrane (see Fig. 14-1). This structure
and to assess speech and language delays is essential further directs sound to the tympanic membrane.
because of the potential impact on a child’s social in- Innervation to the medial portion of the external
teraction and school performance. auditory canal is through the trigeminal nerve (cranial
nerve V). The inner portion of the canal is innervated
by the vagus nerve (cranial nerve X). When the external
auditory canal is cleaned or inspected, coughing may
ANATOMY AND PHYSIOLOGY occur as a result of stimulating the vagus nerve. The
external auditory canal is lined with small hairs, seba-
The ear is composed of three major parts: the external,
ceous glands, and ceruminous glands that secrete ceru-
middle, and inner ear. In addition to hearing and inter-
men, a sticky or flaky substance, the function of which
preting sound, the ears contain the vestibular organs,
is to lubricate and clean the ear canal by trapping dirt
such as the semicircular canals in the inner ear, which
and other debris and to repel water from the tympanic
assist with balance and equilibrium. The ears also con-
membrane (Dimmitt, 2005). In addition to keeping
tribute to the child’s appearance and body image, de-
the ear canal clean, cerumen also has a somewhat low
pending on their size and location on the head.
pH, as well as antibacterial and antifungal properties
(Dancer, 2006), which help to protect the external ear
from infection.
EXTERNAL EAR Two distinct, genetically determined types of cerumen
The external ear is structurally designed to collect exist: dry and wet. Dry cerumen is pale brown to gray and
sound and direct sound waves inward. It is comprised flaky and is found in Asians, Inuits, and Native Ameri-
of the pinna (also called the auricle), the external cans (Petrakis, Pingle, Petrakis, & Petrakis, 2005). Wet ce-
auditory canal (ear canal), and the tympanic membrane rumen is yellowish-brown and moist and is characteristic
(eardrum). The pinna consists of elastic cartilage and of Caucasians and children of African ancestry (Dancer,
skin and is covered with very fine hair. The helix is 2006; Petrakis et al., 2005). The clinical significance of
the outer cartilaginous rim of the pinna; the antihelix this relates to the difficulty of removing cerumen when
is an inner curved rim parallel and anterior to the it becomes necessary to view the external auditory canal
helix. The concha is a hollow, bowl-like structure that and tympanic membrane. Dry cerumen is more difficult
278
C H A P T E R 14 A s s e s s m ent of the E ar • 279
External ear Middle ear Inner ear
Semicircular Cochlear portion

canals Cranial
nerve Vestibular portion
Incus
Tympanic
membrane
Pinna Cochlea
Eustachian
(auditory) tube
Malleus Stapes
Oval window
Vestibule
External Pharynx
acoustic
Ear lobe meatus Mastoid process
FIGURE 14-1. Structures of the external, middle, and inner ear.
to remove than wet cerumen and is more likely than wet MIDDLE EAR
cerumen to become impacted. Cerumen impaction com- The middle ear is an air-filled space inside the temporal
plicates its removal and potentially causes conductive bone, which contains three tiny bones known as ossicles
hearing loss. Cerumen impaction most frequently oc- (see Fig. 14-1). Individually, these bones are the malleus
curs when parents or children use cotton-tipped swabs to (hammer), incus (anvil), and stapes (stirrup). The middle
clean the ear (Dimmitt, 2005). At the end of the external ear begins at the tympanic membrane, an extremely thin,
auditory canal lies the tympanic membrane, which sepa- translucent membrane that is pearly gray to pale pink
rates the external auditory canal from the middle ear. with blood vessels at the periphery. The tympanic mem-
brane can be divided into two major parts: the pars flac-
POSTERIOR
cida and the pars tensa. The pars flaccida is the upper,
ANTERIOR
smaller, triangular portion above the short process of the
Helix
malleus. The pars tensa comprises the remaining portion
Scaphoid Crura of antihelix of the tympanic membrane. The tympanic membrane
Triangular fossa is surrounded by a fibrous border that attaches the
membrane to the temporal bone, called the annulus.
Auricular tubercle
Crus of helix The tympanic membrane is oval and slightly concave
because of the presence of the malleus, which holds the
Helix
Concha membrane slightly inward. This concave shape of the
membrane creates a cone of light when the otoscope light
Antihelix is reflected on the tympanic membrane. Because of the
Antitragus translucency of the tympanic membrane, parts of the
Tragus
malleus are easily seen on physical examination: the
Intertragic notch
umbo where the tympanic membrane meets the tip of
the malleus, the manubrium (handle), which is attached
Lobe of ear to the tympanic membrane, and the short process of the
malleus, an important landmark of the tympanic mem-
FIGURE 14-2. Landmarks of the pinna. brane. Figure 14-3 illustrates these landmarks.
Pars flaccida There are three main structures that lie within the
Incus
bony labyrinth:
• Vestibule: The vestibule leads to both the cochlea and
Short process
of malleus semicircular canals; it contains receptors necessary for
Pars tensa the maintenance of equilibrium and balance.
• Cochlea: The cochlea is a snail-shaped structure
that directly communicates with the middle ear via
the round window. Within the cochlea is the organ
of Corti, the sensory organ for hearing, which con-
tains auditory receptor hair cells. These cells trans-
Handle mit impulses to the auditory nerve (cranial nerve VIII,
of malleus
cochlear branch), to the brainstem, and to the brain
to be interpreted as sound.
Umbo • Semicircular Canals: There are three semicircular
canals; these structures play a role in maintaining
equilibrium by detecting motion and balance. The
Cone of light
semicircular canals are attached to the vestibular
FIGURE 14-3. Right tympanic membrane. branch of the auditory nerve and send impulses to
the brain to maintain equilibrium. The semicircular
canals also keep the eyes still while the head moves.
The malleus (hammer), incus (anvil), and stapes None of the structures of the inner ear can be directly
(stirrup) transmit sound from the external auditory examined, but inferences can be drawn about their
canal to the inner ear when sound waves touch the functions from hearing and neurologic assessments.
tympanic membrane, causing the ossicles to move. The Figure 14-1 illustrates the structures of the inner ear.
stapes attaches to the oval window, a membrane sepa-
rating the middle and inner ear, which also vibrates
with hearing and is in direct contact with the fluids DEVELOPMENTAL
of the inner ear. The round window lies inferior to the
oval window and also communicates with the inner
CONSIDERATIONS
ear, acting as a pressure valve, bulging outward when
The ear begins to develop in utero during the third
fluid pressure increases in the inner ear.
week of embryonic life and should be fully developed
The middle ear is connected by the eustachian
by the end of the third month of gestation. Intrauterine
tube to the nasopharynx (see Fig. 14-1). Normally,
exposure to ototoxic viruses (e.g., rubella), bacteria,
the walls of the eustachian tube are collapsed and
and drugs can cause permanent damage to the organ
valve-like, opening only with swallowing, chewing,
of Corti and impair hearing (Kenna, 2004).
yawning, or forceful inflation such as nose blowing.
During embryonic development, differentiation of
The eustachian tube has three main functions: (a) to
the ears and renal system occur at the same time; any
protect the middle ear from excessively loud sound,
disturbances in utero can be the cause of coincidental
pressure fluctuations, and nasopharyngeal secretions;
abnormalities in both systems. Therefore, malforma-
(b) to drain any secretions from the middle ear to the
tions of the ears should alert the provider to possible
nasopharynx, thus protecting the middle ear from in-
renal disorders in the neonate, and vice versa.
fections; and (c) to equalize pressure on both sides
of the tympanic membrane, thus avoiding membrane
rupture and allowing the tympanic membrane to vi- EXTERNAL EAR
brate freely.
In the preterm infant, lack of cartilage results in the
pinna folding easily and remaining folded; as gestation
progresses, resistance to folding allows the pinna to re-
INNER EAR coil quickly (see Chapter 11). The external auditory ca-
Located within the temporal bone, the fluid-filled inner nal is short and curves inward and upward in children
ear contains the structures that are necessary for both younger than 3; after age 3 the canal points downward
hearing and balance. The inner ear contains the bony and forward. Because the external auditory canal curves,
labyrinth, which is filled with a fluid called perilymph. it must be straightened manually before the provider
Within the bony labyrinth is the membranous labyrinth, examines the canal or the tympanic membrane. The
filled with a fluid called endolymph. Sound waves and bony portion of the external auditory canal ossifies by
vibrations are conducted and transmitted through age 2, straightening the canal and allowing better visu-
these fluids. alization of the tympanic membrane. By school age, the
pinna and external auditory canal should be of adult INNER EAR

size and configuration. The pinna is approximately 80% The inner ear begins to develop at the beginning of the
of adult size by age 4 to 5; the external auditory canal fourth week of gestation. The fetus can hear by approx-
is approximately 1 inch long and 0.25 inch in diameter imately 20 weeks’ gestation, and the auditory nerve
by about 9 years ( Jackson, 2006). function is mature by approximately 5 months. Any
maternal infections (e.g., rubella, cytomegalovirus) or
ingestions (e.g., alcohol, drugs) that are potentially oto-
MIDDLE EAR toxic can damage the developing organ of Corti and
In newborns, the tympanic membrane lies in a more impair the developing fetus’s hearing. Preterm infants
horizontal plane, making visualization of this struc- are especially vulnerable to hearing loss because of
ture more difficult. Until approximately age 2 years, exposure to noise in the neonatal intensive care unit
the eustachian tube is shorter and wider and lies in (NICU), hypoxia, persistent pulmonary hypertension,
a relatively horizontal plane compared to the eu- hyperbilirubinemia, and ototoxic drugs (Kenna, 2004).
stachian tube of an older child or adult (Fig. 14-4).
Thus, fluid in the middle ear cannot drain easily into
the nasopharynx, making infants and toddlers more
prone to middle ear infections and effusions. This is ASSESSMENT OF THE EAR
especially common in preterm infants, infants and
young children with Down syndrome, and those HISTORY
with craniofacial abnormalities such as cleft lip and The reason for the child’s health care visit guides the
palate. provider in deciding what type of data to gather for the
health history. For children who are being examined for
the first time, a complete past medical history (PMH), past
surgical history (PSH), family history, and social history are
obtained. These histories are updated as needed when
the child presents for health maintenance visits, with
special attention to additional episodes of otitis media,
frequent respiratory illnesses, new allergies, new medi-
cations that may have ototoxic side effects, recreation-
al activities (e.g., swimming), and situations (e.g., day
care) that may predispose the child to ear infections.
When assessing children school-aged and younger,
the provider should also inquire about any parental
concerns regarding the child’s ability to hear or the
child’s speech and language development. The provid-
Eustachian tube
er should always ask how many languages are spoken
(adult) in the home, as exposure to more than one language
A
may alter speech development (Goldstein, Fabiano,
& Washington, 2005; Paradis, 2005). A focused history
is required when the child presents with a complaint
related to the ear.

Prenatal and Perinatal History. The PMH specific to
the ear begins with an assessment of the child’s prena-
tal and perinatal course. The provider should inquire
about prenatal maternal infection with pathogens that
can cause congenital sensorineural hearing loss (SNHL)
in the infant. These pathogens include cytomegalovi-
rus, herpes simplex, mumps, rubella (congenital rubella
syndrome), rubeola, parvovirus B-19, human immu-
Eustachian tube nodeficiency virus (HIV), toxoplasmosis, and syphilis
(child)
(Kenna, 2004). The provider should also inquire about
B what prescribed medications were taken by the child’s
FIGURE 14-4. Comparison of the eustachian tube in the mother during pregnancy. Fetal exposure to ototoxic
toddler (A), and the older child (B). drugs increases the risk of SNHL (Table 14-1).
TABLE 14-1
Causes of Sensorineural Hearing Loss in Children
CAUSE OF SENSORINEURAL
HEARING LOSS EXAMPLES
Genetic/syndromic Neurofibromatosis type II
Syndromes: Alport’s, Jervell and Lange-Nielse, Noonan’s, Usher’s, and Waardenburg
Infectious Cytomegalovirus; herpes simplex; rubella, mumps, measles; parvovirus B-19; HIV;
Haemophilus influenzae type B meningitis; Streptococcus pneumoniae meningitis;
congenital toxoplasmosis; and congenital syphilis
Autoimmune/metabolic Juvenile rheumatoid arthritis, systemic lupus erythematosus, Cogan’s syndrome,

hypothyroidism, and type I diabetes
Anatomic Congenital temporal bone abnormalities, otosclerosis, and osteogenesis imperfecta
Traumatic Temporal bone fractures, head trauma, child abuse, sports injuries, noise,
penetrating foreign bodies, and iatrogenic trauma (i.e., radiation therapy, surgery,
ototoxic drugs, ECMO)
Ototoxic exposures Drugs: aminoglycosides; loop diuretics; antimalarial agents, especially quinine
derivatives; antineoplastic agents; anti-inflammatory agents, including aspirin and
naproxen; prenatal exposure to alcohol, isotretinoin, thalidomide, cisplatin, or
aminoglycosides; and hyperbilirubinemia and kernicterus in the newborn
ECMO, extracorporeal membrane oxygenation; HIV, human immunodeficiency virus.

Source: Kenna, M. A. (2004). Medical management of childhood hearing loss. Pediatric Annals, 33(12), 822–832.
Maternal alcohol, tobacco, or illegal drug use that child’s ear or hearing. This includes determining if the
occurred prenatally should also be assessed. Fetal al- child has had frequent upper respiratory illnesses, such
cohol syndrome (FAS) can cause ear deformities, hear- as nasopharyngitis, tonsillitis, and pharyngitis. The
ing loss, and language impairment (Vaux & Chambers, number of episodes of acute otitis media (AOM) should
2009; Williams & Burns, 2009). Smoking during preg- be determined, including whether otitis media with ef-
nancy often leads to low birth weight and prematurity, fusion (OME) has occurred after the acute infections.
both of which can lead to SNHL; prenatal maternal Chronic OME is associated with conductive hearing loss
smoking can also lead to an increased number of respi- in children. The provider should also note whether the
ratory infections, otitis media, and asthma in children child has ever been diagnosed with mastoiditis, menin-
(DiFranza, Aligne, & Weitzman, 2004). The use of co- gitis, or encephalitis, all of which can be complicated by
caine during pregnancy has been associated with renal hearing loss. In young children, disorders of the ear that
disorders such as multicystic renal dysplasia, which disrupt hearing can interfere with speech and language
includes nonrenal malformations such as low-set ears development. The number of episodes of otitis externa
and preauricular pits (Swiatecka-Urban, 2009). should be assessed, and any oral or dental infections
The child’s perinatal course is also important to in- should be noted. Other related assessments include:
vestigate because prematurity, perinatal asphyxia, birth • General: usual state of health; recent and recurrent
trauma, infection, hyperbilirubinemia, and the use febrile illnesses, such as respiratory illnesses and
of ototoxic drugs in the nursery can all lead to SNHL AOM; immunization history; history of chemother-
(Kenna, 2004). The provider should note any congeni- apy for cancer treatment; sleep patterns (poor sleep
tal syndromes, including chromosomal anomalies asso- may be because of ear pain or enlarged adenoidal
ciated with ear deformities, craniofacial abnormalities, tissue); history of congenital syndromes or chromo-
or renal disorders, such as trisomy 18, Down syndrome, somal abnormalities involving the ear; history of
Pierre Robin syndrome, cleft lip and palate, Wilms’ tu- head injuries; and seasickness
mor, or renal agenesis. • Head: microcephaly, facial asymmetry/deformities,
depressed nasal bridge, and absent philtrum, which
Review of Systems. In addition to the prenatal and may indicate FAS
perinatal histories, the pediatric review of systems • Skin: sunburn of pinnae; pruritus or rashes of the
(ROS) relative to the ear involves asking the parent or external ear, which may be caused by otitis externa
caregiver about the child’s usual state of health, focus- or from middle ear drainage; and café-au-lait spots,
ing on common childhood illnesses that may affect the which may suggest neurofibromatosis
• Eyes: eye drainage, swelling, itching, excessive tearing that may have caused contact dermatitis of the ear and
(because of sinusitis), and nystagmus (from vertigo) surrounding area such as nickel jewelry, soaps, sham-
• Ears: number of episodes of AOM; history of OME; poos, hair-styling products, perfumes, or cosmetics.
presence of tympanostomy tubes, or tympanic mem-
brane perforation; otitis externa, cholesteatoma, Hospitalizations. The provider should ask about past
otorrhea, otalgia, and mastoiditis; ear deformities hospitalizations, including dates and length of stay,
(e.g., microtia), ear pits, and history of a foreign focusing on the reason for the hospitalization and
body in the ear; signs of hearing loss such as the whether it bears any relevance to the health of the
need to repeat questions, child speaks loudly, or child’s ear or hearing. For example, a history of hospi-
inattentiveness, especially when the child’s back is talization for bacterial meningitis is important because
turned to the person speaking; hearing aids; cochle- of the possibility of permanent auditory nerve damage
ar implants; and date and results of last objective and subsequent sensorineural hearing loss as a conse-
hearing assessment quence of the infection.
• Nose: nasal congestion or discharge; frequent upper
respiratory infections, which can lead to AOM; and Injuries. It is important for the provider to determine
choanal atresia whether the child has sustained any head, brain, or ear
• Mouth/throat: tooth decay and dental infections, injuries. Injuries to the head or ear may affect the child’s
(which may indicate bottle-propping, can lead to hearing secondary to tympanic membrane scarring, in-
AOM and ear pain); tonsillitis, pharyngitis, and cleft ner ear damage, or intracranial edema. Types of injuries
lip or palate can lead to multiple episodes of AOM. to inquire about include any head trauma, including
• Respiratory: cough, asthma, respiratory illnesses concussion, skull fractures, temporal bone fractures,
(respiratory infections associated with fever or ear or trauma intentionally inflicted on the infant or child
infections), and sinusitis, which can cause otalgia such as forceful shaking or blows to the side of the head.
• Genitourinary: history of congenital genitourinary The provider should also inquire about any direct ear
system malformations (associated with congenital trauma that may be the result of the child placing objects
ear abnormalities), hematuria, and recurrent urinary in the external auditory canal that may cause perfora-
tract infections tion of the tympanic membrane. It is important for the
• Musculoskeletal: Temporomandibular joint (TMJ) provider to investigate whether the child has suffered
pain and bruxism, which may cause otalgia any iatrogenic head trauma (e.g., radiation therapy, sur-
• Neurologic: migraines, nystagmus, vertigo, tinni- gery, extracorporeal membrane oxygenation [ECMO]),
tus, bacterial meningitis, seizure disorders, and brain or chronic exposure to loud noises (Kenna, 2004).
tumors
• Hematologic: jaundice, hyperbilirubinemia, ABO
incompatibility, and history of exchange transfusion
Past Surgical History
• Metabolic: hypothyroidism The provider should ask about any previous surgeries
• Developmental: achievement of language mile- the child has had, including the dates of any surgeries
stones, behavioral problems, school performance, and if there were any complications. Special attention
school absences, and school failure, which may be should be paid to any ear surgery (e.g., myringotomy
because of hearing loss with tympanostomy), nose and throat surgery (e.g.,
tonsillectomy, adenoidectomy), intracranial surgeries,
Immunizations. The provider should assess the child’s excision of a cholesteatoma, or dental surgery. Any of
immunization status to be certain that all age-appro- these surgical procedures, especially if recent, can be
priate immunizations are up-to-date. This is especially the etiology of past or current complaints related to
true of immunizations for Haemophilus influenzae type the ear, such as otalgia or hearing loss. Complaints re-
B and Streptococcus pneumoniae; both of these pathogens lated to the ear may also be an indication for the surgi-
can cause bacterial meningitis, which can lead to per- cal procedure (e.g., chronic otitis media).
manent damage of the auditory nerve and subsequent
deafness. Measles, mumps, and rubella infections can Current Medications
also cause hearing loss in children (Kenna, 2004). The provider should inquire about all medications that
the child is currently taking, noting whether any of the
Allergies. The provider should inquire about aller- drugs have ototoxic or vestibulotoxic side effects. Exam-
gies to medications as well as environmental allergies. ples of these drugs include some antibiotics, especially
Allergic rhinitis can cause nasal symptoms, including the aminoglycosides; loop diuretics, anti-inflammatory
swelling of the nasal turbinates and enlarged tonsillar agents, such as salicylates and some nonsteroidal anti-
and adenoidal tissue, which can predispose children inflammatory drugs (NSAIDs); some chemotherapeutic
to AOM, OME, sinusitis, vertigo, and hearing loss. The agents (e.g., vincristine, cisplatin), and antimalarial
provider should also inquire about any recent exposures agents (e.g., quinine) (Kenna, 2004). Medications that
and iris (e.g., a forelock of white hair, patches of white

TABLE 14-2
pigmentation of the skin, very pale irises, brilliantly blue
Medications That Can irises, irises that are two different colors [heterochromia]),
Cause Tinnitus lateral displacement of the inner canthus of each eye, and
TYPE OF MEDICATION EXAMPLES SNHL (Kenna, 2004, Schwartz, Jozwiak, & Krantz, 2009).
The provider should also assess for any family history of
Analgesics Aspirin and ibuprofen kidney malformations or disorders.
(Lee, Misty, Uppal, &
Coatesworth, 2005)
Social History
Antibiotics Clarithromycin, The social history focuses on aspects of the family’s living
ciprofloxacin, and conditions, lifestyle, and any risk factors that could pre-
tetracycline (Lee,
dispose the child to ear infections or hearing problems.
Misty, Uppal, &
Coatesworth, 2005) These risk factors include crowded living conditions,
secondhand smoke exposure, day-care attendance, and
Anticonvulsants Carbamazepine and bottle propping, all of which increase the incidence of
amitriptyline middle ear and respiratory infections in children. The
(Lee, Misty, Uppal, &
Coatesworth, 2005) provider should also ask whether the infant is breast-fed
or formula-fed. Breast-feeding the infant for at least the
Antihistamines Chlorpheniramine first 6 months of life helps protect against middle ear
(Lee, Misty, Uppal, & infections because of protective antibodies transferred
Coatesworth, 2005)
through the breast milk (American Academy of Pediat-
Chemotherapeutic agents Chemotherapeutic drugs rics [AAP], 2004) and because of the relatively upright
containing platinum position in which the infant is held during breast-feed-
compounds (e.g., cisplatin) ing, which helps to prevent milk from draining into the
(Benson, McGuire, Djalilian,
nasopharynx. The provider should ask if the child or
Hanks & Robbins, 2009)
adolescent is chronically exposed to loud noise, which
Diuretics Furosemide (Lee, Misty, can lead to permanent hearing loss (Kenna, 2004).
Uppal, & Coatesworth, The provider should determine how many lan-
2005) guages the child is exposed to at home, in school, or
in day care. If a young child is exposed to more than
one language during the normal language-acquisition
sequence, this may cause inaccuracies in syntax
can cause tinnitus include some antibiotics, analgesics, (Goldstein, Fabiano, & Washington, 2005; Paradis,
antihistamines, anticonvulsants, diuretics, and chemo- 2005). It is important for the provider to be sure that
therapeutic agents (Benson, McGuire, Djalilian, Hanks, the delay in speech development is a result of a bi-
& Robbins, 2009; Lee, Mistry, Uppal, & Coatesworth, lingual home environment and not a consequence
2005); specific medications are listed in Table 14-2. of hearing loss. It is also important for the provider
Salicylates, aminoglycosides, anticonvulsants, qui- to ask about the child’s school progress or any be-
nine, and loop diuretics can also cause vertigo (Mudd, havior problems reported by either the parent or the
Edmunds, Glate, Campbell, & Rybak, 2008). teacher. Difficulty in school, inattentiveness, or even
school failure may indicate hearing impairment.
Family History The provider should assess the child’s sleep patterns.
Any family history of congenital or acquired hearing loss Poor sleep may be the result of otalgia that is often
or other problems related to the ear is important for the exacerbated when the child is recumbent. Bruxism can
provider to establish. Many of these conditions are ge- also cause TMJ pain, which can be referred to the ear
netic or inherited, such as allergies, which may lead to (Linder, 2005). The provider should ask if the child or
chronic OME. In addition to inquiring about any fam- adolescent is involved in any recreational activities
ily history of allergies, the provider should ask about that could potentially affect the ear, such as swimming,
any family history of congenital syndromes or genetic scuba diving, or boxing. Prolonged contact with water
disorders that are associated with ear conditions or hear- predisposes the child or adolescent to otitis externa;
ing loss such as Down syndrome, FAS, Alport syndrome, boxing increases the risk of direct injury to the ear.
neurofibromatosis type II, congenital rubella syndrome, The PMH relative to the ear is best tailored to the
Pierre Robin syndrome, trisomy 13, and cleft lip or pal- child’s age, as certain assessments are only relevant
ate. Waardenburg syndrome is the most common inher- to that particular age group (e.g., bottle-propping,
ited cause of hearing loss (Kenna, 2004). Characteristics attendance at day care). Table 14-3 summarizes the
of Waardenburg syndrome include hypertelorism (wide- history pertinent to the ear, according to age and
set eyes), alterations in pigmentation of the hair, skin, developmental stage.
TABLE 14-3
Past Medical History for Ear Assessment by Age and Developmental Stage
AGE GROUP SUBJECTIVE DATA TO GATHER
Neonate Is there a history of maternal infection prenatally (e.g., TORCH infections)? Is there a history of
maternal smoking, drug, or alcohol use during pregnancy? Is there a history of maternal diabetes,
Rh incompatibility, or toxemia? Was the neonate born prematurely? What was the infant’s birth
weight? Did the neonate spend more than 48 hours in a neonatal intensive care unit? Was the
neonate treated with aminoglycosides, furosemide, or any other ototoxic drugs? Was the neonate
born with any craniofacial anomalies such as cleft lip or palate or others with morphologic
abnormalities of the pinna and ear canal? Was the neonate diagnosed with any renal disorder at
birth? Did the neonate have hyperbilirubinemia, kernicterus, or an exchange transfusion? Did the
neonate have a history of asphyxia at birth, ECMO therapy, persistent pulmonary hypertension,
sepsis, or bacterial meningitis? What were the results of the newborn hearing screening? Is there a
family history of sensorineural hearing loss?
Infant Has the infant ever been diagnosed with AOM with or without effusion? Was he or she treated
with antibiotics? Is there a history of otorrhea? Does the infant have frequent upper respiratory
infections? Does the infant attend day care? Do the parents use cotton-tipped swabs to clean the
ears? Is the infant breast-fed? If not, is the infant’s bottle propped during feedings? Is there a history
of head trauma in the infant?
Toddler Has the toddler ever been diagnosed with AOM or OME? Have the infections been recurrent? Were
the infections treated with antibiotics? Is there a history of otorrhea? Does the toddler have frequent
upper respiratory infections? Does the toddler attend day care? Has the toddler been diagnosed with
allergies? Does the toddler ever pull on his or her ears or put small objects in them? Do the parents
use cotton-tipped swabs to clean the ears? Does the toddler still drink from a bottle or no-spill sippy
cup? Is the bottle or cup propped? Is there a history of head trauma in the toddler?
Preschooler Has the child ever been diagnosed with AOM or OME? Was the infection treated with antibiotics?
Is there a history of otorrhea? Does the child have frequent upper respiratory infections? Has the
child been diagnosed with allergies? Does the child have a history of surgery for tympanostomy,
tonsillectomy, or adenoidectomy? Does the child attend day care? Does the child pull at or put
small objects in his or her ears? Do the parents use cotton-tipped swabs to clean the ears? Does the
child drink from a bottle or no-spill sippy cup while lying down? Does the child have a history of
head trauma?
School-aged child Has the child or adolescent had frequent upper respiratory infections or been diagnosed with
or adolescent allergies? Any episodes of AOM? If so, were they treated with antibiotics? Does the child or
adolescent have a history of surgery for tympanostomy, tonsillectomy, or adenoidectomy? Is there a
history of otorrhea? Ear pain? Does the child or adolescent swim frequently or been diagnosed with
otitis externa? Does the child or teen use cotton-tipped swabs to clean the ears? Has the child or
adolescent ever complained of dizziness or ringing in the ears? Does the child or adolescent have a
history of head trauma? Does the child or adolescent listen to exceptionally loud music on a regular
basis with or without headphones? Does the adolescent attend rock concerts frequently?
AOM, acute otitis media; ECMO, extracorporeal membrane oxygenation; OME, otitis media with effusion; TORCH, toxoplasmosis,
other (congenital syphilis and viruses), rubella, cytomegalovirus, herpes simplex virus.
History of Present Illness PHYSICAL EXAMINATION

Common complaints related to the ear that are seen Physical examination of the ear includes inspection and
in the pediatric population include otalgia (with or palpation of the external ear; inspection of the external
without fever); otorrhea; hearing loss; and less com- auditory canal and tympanic membrane, including
monly tinnitus, dizziness, and vertigo. If a child otoscopic examination; and auditory acuity testing.
presents with an ear-related complaint, the provider The necessary equipment includes the following:
should obtain a focused history (i.e., history of the • Penlight
present illness [HPI]) to make an accurate diagnosis. • Otoscope with halogen bulb and nickel-cadmium
Relevant questions to ask for the HPI can be found batteries (not alkaline batteries)
in Table 14-4. Questions to ask when the chief com- • Ear specula (4–6 mm tip diameter for adolescents;
plaint is hearing loss are found under Assessment of 3–4 mm for children; 2 mm for infants)
Hearing Acuity. • Rubber squeeze bulb attachment for the otoscope
TABLE 14-4
History of Present Illness: Ear-Related Complaints
SYMPTOM ASSESSMENTS EXPLICATION
Otalgia or ear pain in children Was the onset sudden or AOM is associated with a rapid onset of pain. Both AOM
can be primary, arising from gradual? and otitis externa are associated with a considerable
the ear itself, or secondary, amount of pain. OME does not cause pain.
such as referred pain from areas
near the ear (e.g., the mastoid
bone, mouth, jaw, neck).
What is the duration and Severe, sharp pain occurs with TM rupture, and then
severity of the pain? What the pain subsides. When age-appropriate, a quantitative
is the character of the pain assessment should be done (see Chapter 6).
pain? Is it sharp or dull?
What is the location of Is the pain on the pinna, in the external auditory
the pain? canal, inside ear, or in the mastoid area? Pain only on
the pinna and in the external auditory canal suggests
otitis externa; pain felt inside the ear suggests AOM;
postauricular pain or tenderness suggests mastoiditis.
Does the pain radiate to Pain that radiates to the ear can be because of dental
the ear? disorders, bruxism, mouth infections, TMJ problems,
sinusitis, neck problems, tonsillitis, pharyngitis,
mastoiditis, and temporal bone fractures (Li, 2004).
Neck pain from traumatic injury can refer to the ears.
What is the frequency of Continuous pain suggests AOM. Pain with chewing
the pain? points to otitis externa, dental disorders, or TMJ
problems.
What precipitates the pain Lying down can increase the pain of middle or external
or makes it worse? ear infections, causing an inability to sleep. Pain
precipitated by pressure on the tragus suggests otitis
externa. Pain with AOM worsens with sucking or
swallowing.
What alleviates the pain? The provider should ascertain whether over-the-counter
pain medications are sufficient to alleviate the pain, and
if any non-pharmacologic measures have been used,
such as heat application.
Are there any associated Fever, rhinorrhea, nasal congestion, sneezing, diarrhea,
symptoms? vomiting, loss of appetite, and pulling or tugging at the ear
are associated with AOM. A feeling of fullness in the ear
points to OME. Otorrhea, fever, and itching can indicate
AOM, otitis externa, or chronic suppurative otitis media.
Edema, erythema, pain, and itching of the pinna can
indicate otitis externa.
Fever can also be because of upper respiratory infections,
dental infections, or mastoiditis. Neck pain, swelling,
and erythema of the mastoid area, and a displaced
pinna are associated with mastoiditis.
Neck pain can also be associated with meningitis.
Tinnitus and vertigo with otalgia may be because of
direct trauma to the ear. Hearing loss may be the result
of intracranial infection or OME.
Is there any concurrent Upper respiratory infections predispose infants and

illness? Close contacts young children to AOM.
with similar symptoms?
Has the child experienced Injuries to the face, head, and neck or directly to the ear
an injury? can cause otalgia.

Otorrhea or ear drainage in Was the onset gradual or AOM can cause spontaneous rupture of the TM,
children can be caused by acute sudden? resulting in sudden onset of otorrhea. Otitis externa can
or chronic infections of the also cause acute otorrhea. Gradual onset of otorrhea
external or middle ear, injuries can be because of the presence of a foreign body in the
to the ear, TM, perforation, or external auditory canal (Schroeder & Darrow, 2004).
head trauma.
How long has drainage Otorrhea that lasts more than 14 days can be because
been present? of CSOM, cholesteatoma, or foreign body. Chronic
otorrhea can also be a complication of tympanostomy
tube placement.
Location of otorrhea? The provider should note whether the ear drainage is
unilateral or bilateral. Unilateral otorrhea is likely a
foreign body in the ear; bilateral otorrhea may indicate
TM rupture.
Any recent injury? Direct trauma to the head can cause ear drainage.
What is the color and Clear, mucoid drainage can be because of OME with
character of the ear TM perforation. Clear to purulent otorrhea is associated
drainage? with granular myringitis (Schroeder & Darrow, 2004).
Purulent yellow or green drainage indicates AOM with
perforation or otitis externa; basilar skull fracture causes
clear, watery (CSF) or bloody ear drainage; bloody ear
drainage can also be caused by trauma to the external
auditory canal. Brown otorrhea is likely cerumen.
Does the ear drainage have Malodorous ear drainage can be associated with
an odor? mastoiditis.
Are there any associated Fever, rhinorrhea, otalgia, fullness in the ear, itching,
symptoms? vertigo, tinnitus, and headache are all associated with
ear disorders such as AOM, OME, otitis externa, ear
trauma, and mastoiditis. (see Otalgia above). Dizziness,
hearing loss, or meningitis can be associated with CSF
leaks (Schroeder & Darrow, 2004).
Is there any concurrent Upper respiratory infections predispose young children

illness or injury? to AOM. Cholesteatoma, granulomas, or polyps of the
TM can bleed easily; all potentially cause otorrhea. Basilar
skull fractures can cause clear otorrhea, which is CSF.
Is the child complaining of Itching with otorrhea is associated with otitis externa.
itching?
Does the child or Frequent swimming can predispose the child or

adolescent swim adolescent to otitis externa (“swimmer’s ear”), which
frequently? can cause otorrhea.
How does the parent/child The use of cotton-tipped swabs can injure the external
clean the ears? auditory canal, perforate the TM, and cause cerumen
impaction.
Does the child place things A retained foreign body in the external auditory canal
in his or her ears? can be the cause of the otorrhea; placing sharp objects in
the ear can cause trauma to the external auditory canal
or TM, also causing infection, bleeding, or otorrhea.
Are there any alleviating The provider should ask about any measures used to
factors? alleviate the ear drainage, such as the use of medications
or packing the ear.
Is there anything that Recumbent position may increase otorrhea.

makes the otorrhea worse?
(continued)
TABLE 14-4
History of Present Illness: Ear-Related Complaints (Continued)
Tinnitus or ringing in the Was the onset sudden or Sudden onset tinnitus can be caused by AOM,
ears often precedes SNHL in gradual? nasopharyngeal infections, environmental allergies,
children and adolescents who trauma to the ear, barotrauma, vasovagal syncope,
are chronically exposed to loud head and neck injury, and the current use of ototoxic
noise. drugs. Gradual onset tinnitus can be caused by TMJ
disorders.
Location of the tinnitus? The provider should note if the tinnitus is unilateral or
bilateral.
Is the tinnitus high or low High-pitched tinnitus is associated with SNHL; low-
pitched? pitched tinnitus is associated with CHL.
Are there any associated Nausea, vomiting, otalgia, otorrhea, fever, itching,
symptoms? hearing loss, dizziness, unsteady gait, seizures, and a
feeling of fullness in the ear are all signs and symptoms
seen with AOM, OME, or vertigo, all of which can be
associated with tinnitus.
Is there any concurrent Head trauma, ear infection, ruptured TM, or inner ear
illness or injury? disturbances can cause tinnitus.
Is the child currently Some medications cause tinnitus such as NSAIDs,

taking any medications? certain antibiotics and antidepressants, and
antihistamines.
What precipitates tinnitus Loud noises can precipitate tinnitus, especially if

or makes it worse? chronic.
What makes the tinnitus Certain medications (e.g., sedatives) can improve
better? tinnitus; nonpharmacologic measures such as “white
noise” makers can also help tinnitus.
Vertigo is a type of dizziness When was the onset of Long periods of vertigo are associated with vestibular
characterized by a spinning the vertigo? Is the vertigo disorders, diabetes, or hypothyroidism.
sensation. It is caused constant, or does it come
by inner ear or auditory and go?
nerve (vestibular branch)
disturbances.
What is the severity of the Changes in the activities of daily living and the ability
vertigo? to attend work or school help assess severity.
Was the onset gradual or Sudden onset of vertigo may be because of the rupture
sudden? of the round window in the inner ear.
Are there associated Vertigo in children and adolescents can be because of

symptoms (e.g., fever, motion sickness, migraine, vasovagal syncope, brain
nausea, vomiting, injury, tumors, or infections.
sweating, nystagmus,
tinnitus, otalgia, otorrhea,
hearing loss, visual
disturbances, aphasia,
ataxia, altered LOC,
fainting, headache)?
Is there any concurrent Head trauma, whiplash, or a severe upper respiratory

illness or recent injury? infection can cause vertigo.
Is the child currently Certain drugs can cause vertigo (e.g., aminoglycosides,
taking any medications? loop diuretics, anticonvulsants, analgesics, hypnotics,
antihypertensives).

What precipitates the Vertigo may occur when the child changes positions,
vertigo or makes it worse? coughs, sneezes, or blows the nose.
What makes the vertigo Some medications prescribed for motion

better? sickness (e.g., diphenhydramine) may be helpful;
nonpharmacologic measures such as position changes
may alleviate the vertigo.
AOM, acute otitis media; CHL, conductive hearing loss; CSF, cerebrospinal fluid; CSOM, chronic suppurative otitis media; LOC, level
of consciousness; NSAID, nonsteroidal anti-inflammatory drug; OME, otitis media with effusion; SNHL, sensorineural hearing loss;
TM, tympanic membrane; TMJ, temporomandibular joint.
• Latex or vinyl gloves (to be worn when blood or or abnormal shape of the pinnae, an absent tragus, or a
drainage from the ear is noted) narrow external auditory canal are associated with renal
• Watch with a second hand for the Romberg test disease, some congenital syndromes, and chromosomal
anomalies (Ostrower, Bent, & Austin, 2009).
General Appearance The provider should also inspect the external ear
The provider should begin the physical examination for preauricular skin tags or pits. Small skin tags on
by first inspecting the child’s general appearance. This or anterior to the tragus are most often remnants of
includes observing the child’s gait. An unsteady gait or embryonic development. Preauricular skin tags are not
falling may indicate vertigo or a neurologic problem. clinically significant but merely cosmetic, and they can
If the child is verbal, his or her speech should be not- be surgically removed (Ostrower, Bent, & Austin, 2009).
ed for articulation and intensity. Children who speak Ear pits are fistulas that are located anterior to the tragus
too loudly or cannot clearly articulate speech may be and arise during embryonic development. They can be
suffering from hearing loss. The provider should also unilateral or bilateral. Ear pits may be associated with
assess the child’s response to verbal instructions. If the urinary tract abnormalities (Swiatecka-Urban, 2009) or
child is unable to follow instructions, it may be because congenital syndromes (Ostrower, Bent, & Austin, 2009).
of a language barrier, developmental delay, depression, Ear pits are usually of no consequence unless they be-
or hearing loss. The provider should note any cranio- come infected, which can lead to cellulitis and abscess
facial anomalies, which potentially affect hearing (see formation (Ostrower, Bent, & Austin, 2009).
Assessment of Hearing Acuity). The provider should also inspect the ears for flat-
tening or protrusion. The neonate’s pinnae are normally
External Ear flat against the head. In older infants and children,
Inspection. The provider should begin inspection of the pinna normally extends slightly outward. Flat-
the external ear by examining the pinnae for placement tened ears in older infants may indicate a prolonged
and position. To allow for a proper view of the pinnae, side-lying position; the provider should address infant
the young infant should be held upright or the child stimulation needs with the primary caregiver and
should be seated with the examiner seated or standing assess the child for possible neglect. Protruding ears
at eye level. The provider should measure the height (relative to the size of the concha) may be familial or,
of the pinna by drawing an imaginary horizontal line
from the outer canthus of the eye to the occiput. The
top of the pinna should meet or cross this line, deviat-
ing no more than 10 degrees from a line perpendicu-
lar to the horizontal line (Fig. 14-5). Low-set ears are
associated with renal agenesis, congenital genitouri-
nary disorders, and chromosomal abnormalities such
as Turner syndrome, Down syndrome, and trisomy 18
(Gaylord & Yetman, 2009).
The pinnae should also be inspected for size, shape,
symmetry, and deformity. The pinna should be symmet-
rical and completely formed, with a patent external au-
ditory canal. Excessively small ears (microtia) may indi-
cate a congenital syndrome or congenital hearing loss.
A helix that has an upward or backward slant is within FIGURE 14-5. Ear placement. The outer canthus of the eye
normal limits. Helical-fold abnormalities, asymmetry, should be in alignment with the tip of the pinna.
depending on the degree of protrusion, may indicate assessments. A pneumatic bulb attachment is also neces-
localized swelling because of mastoiditis, mumps, or sary for insufflation of the tympanic membrane. The pro-
postauricular abscess. Children with fragile X syn- vider should wear gloves if any ear drainage is noted.
drome have large, protruding ears ( Jewell, 2009). The Older infants and toddlers are normally very
provider should assess the parent’s pinnae for compari- resistant to the otoscopic examination. Thus, this pro-
son. In some children, the lobule is adherent, which is cedure is best accomplished at the end of the physical
a normal variation. examination for this age group. It may be helpful for
The provider should also inspect the pinnae for any the provider to allow young children to inspect and
lesions, inflammation, or signs of infection. Erythema or touch the otoscope before the examination so that they
flaking of the skin may indicate contact or atopic derma- become familiar with the equipment in an attempt to
titis. Erythema, swelling, or purulent discharge indicates decrease their anxiety. Some providers may use puppets
infection such as the presence of a foreign body or otitis or other toys to prepare young children for this exami-
externa. Any ear piercings should be inspected for signs nation. Having the toddler sit on the mother’s lap can
of infection. greatly reduce anxiety, ultimately making the child
more cooperative. See Chapter 8 for a more in-depth
Palpation. The provider should palpate each pinna, discussion of developmental approaches to examining
pulling it up and down or out and back, noting any young children.
masses or areas of pain or tenderness. Palpation should Proper positioning of the infant or young child dur-
also include pushing on the tragus and applying pres- ing the otoscopic examination minimizes pain and
sure to the mastoid process, noting tenderness. The unintentional injury and maximizes visualization to
pinna should be soft, pliable, and nontender. If palpa- the external auditory canal and tympanic membrane.
tion of the pinna results in pain, the provider should Young infants should be placed on the examination
suspect otitis externa, inflammation of the external table for the otoscopic examination. Older infants and
auditory canal, trauma, or local infection. The pro- toddlers who can sit independently may be placed in
vider should palpate the mastoid process as well as the the parent’s lap, sitting sideways, with the child’s head
preauricular and postauricular lymph nodes. Auricular resting against the parent’s chest. The parent can then
lymphadenopathy often accompanies ear infections assist with gentle immobilization of the child during
(see Chapter 13). Pain elicited with palpation of the the otoscopic examination. Older children may sit on
mastoid process indicates mastoiditis. the examination table.
Cerumen removal is an essential skill for the pediatric
External Auditory Canal health care provider. It is necessary to relieve cerumen
Inspection. To begin inspection of the external impaction and to visualize the tympanic membrane
auditory canal, a penlight can be used to visualize the completely when otitis media is suspected. Cerumen
outer portion of the canal. For optimal visualization of should be removed under direct visualization with an
the canal, when examining children 3 and younger, the otoscope, and the young child must be properly re-
ear should be pulled downward, backward, and out- strained during this procedure to avoid puncture to the
ward. For children older than 3, the pinna should be tympanic membrane. To facilitate the removal of ceru-
pulled upward, backward, and outward. The provider men, ceruminolytic and softening agents may be used,
should inspect for drainage, edema, erythema, exces- such as 1% sodium docusate solution, mineral oil, or
sive cerumen, foreign bodies, and signs of inflammation triethanolamine polypeptide (Cerumenex). Once these
or infection. The provider should note the color and agents are instilled, cerumen can be mechanically re-
consistency of any drainage. Inspection of the outer moved, either with a cerumen spoon or loop or by irri-
portion of the ear canal also helps the provider to de- gation. Irrigation of the ear is contraindicated, however,
termine the correct size of the speculum to place over in patients who have a perforated tympanic membrane
the otoscope tip. Inspection of the internal portion of or a tympanostomy tube in place.
the external auditory canal and tympanic membrane is For the otoscopic examination, the provider should
performed with an otoscope. choose the largest speculum that comfortably fits into
the child’s external auditory canal. The speculum
Otoscopic Examination. The otoscope, an instrument should not be too small, as it can then enter too far into
used to examine the external auditory canal and tym- the canal and potentially cause injury. To visualize the
panic membrane, includes a halogen light, magnifying tympanic membrane fully, the provider should remove
lens, and an appropriately sized ear speculum. Nickel- any obstructing cerumen; lighting must be adequate.
cadmium batteries are preferred over alkaline batteries Holding the otoscope in an inverted position, securely
because as alkaline batteries become weak, the light of braced against the child’s head, the provider should in-
the otoscope becomes yellowish and dim, which can sert it gently no more than one quarter to one half inch
confuse assessment findings. The light of the otoscope into the child’s external auditory canal (Fig. 14-6). To
should be bright and white to make the most accurate enhance the visualization of the tympanic membrane
in children 3 and younger, the provider should grasp otitis externa, a foreign body in the ear, or a ruptured
the pinna and pull gently downward, outward, and tympanic membrane during an AOM infection.
backward, while directing the speculum upward. In
children 3 and older, the pinna should be pulled up- Inspection of the Tympanic Membrane. In the
ward, backward, and slightly away from the head, and newborn, only patency of the external auditory canal
the speculum should be directed downward. can be determined because of its small size; the tym-
panic membrane cannot be visualized because the
Inspection of the External Auditory Canal. Using view is obscured by vernix caseosa. In older infants
the otoscope, the provider should inspect the external and children, the tympanic membrane is inspected for
auditory canal, rotating the otoscope as necessary to ob- color, anatomic landmarks, light reflex, contour, and
tain a complete view. Normally, the external auditory mobility. Normally, the tympanic membrane is pearly
canal is pink, with a small amount of fine hairs and or- gray to light pink. The only blood vessels that are nor-
ange to brown cerumen. If the canal is completely free of mally visible are those on the periphery of the mem-
cerumen, the provider should inquire whether the child brane. Erythema and injection can occur with AOM;
or parent uses cotton-tipped swabs to cleanse the canal; injection alone may occur with allergies. An erythema-
the use of these swabs should be discouraged, as this can tous tympanic membrane can also be seen with fever
lead to cerumen impaction. There should be no signs of or crying; this does not necessarily indicate infection.
infection or inflammation. Abnormal findings during A bluish or purple, bulging tympanic membrane indi-
inspection of the external auditory canal include ery- cates blood in the middle ear, which may be because of
thema, abrasions, scratches, lesions, swelling, drainage, trauma or basilar skull fracture.
scaling, exudate, excessive or impacted cerumen, foreign The landmarks of the tympanic membrane should be
bodies, or foul odor. Inflammation of the external audi- easily visible on inspection, including the cone of light
tory canal can result from the presence of a foreign body, reflex. This reflex is seen at the “5 o’clock” position on
otitis externa, the use of cotton-tipped swabs to clean the right and the “7 o’clock” position on the left. The
the ears, or slapping or hitting the child. Clear or bloody ossicles should also be visible with the umbo near the
drainage from the ear may be cerebrospinal fluid or blood middle of the tympanic membrane, the manubrium
after a head injury; this finding signifies a basilar skull (handle of the malleus) near the membrane margin,
fracture and requires immediate intervention. Bloody and the short process of the malleus, visible at the
drainage may be secondary to scratching or irritation. “1 o’clock” position (see Fig. 14-3).
Purulent discharge from the ear is most often caused by The contour of the tympanic membrane is normally
concave. There should be no bulging, retraction, or
evidence of fluid behind the tympanic membrane.
The membrane should be intact, without perforations;
perforations appear as dark areas or holes in the tym-
panic membrane and most often occur as a result of a
ruptured AOM or trauma. Healed perforations appear
as dark patches on an otherwise normal tympanic
membrane. If the child has had tympanostomy tubes
placed, they will be visible upon inspection.
The presence of a middle ear infection or effusion
can cause the contours and landmarks of the tympanic
membrane to become distorted or absent as a result of
fluid accumulation behind the membrane. For example,
an immobile or discolored tympanic membrane indi-
cates OME. With AOM, the light reflex becomes dull or
absent, the ossicles may not be visible, and the tympan-
ic membrane may be erythematous, opacified, full, or
bulging. Amber-colored bubbles may be visible behind
the tympanic membrane as fluid accumulates behind
this structure; this indicates OME if accompanied by
decreased movement of the tympanic membrane.
The tympanic membrane should also be translucent
when visualized, without scarring, opacity, or other le-
sions. Scarring appears as thickened, white areas on a
pearly gray tympanic membrane and is most often a
FIGURE 14-6. Secure positioning of a young child for consequence of frequent episodes of a ruptured AOM.
otoscopic examination. Bulla on the tympanic membrane, usually accompanied
by tympanic membrane color, contour, and landmark

changes, indicates bullous myringitis, which can also Removable
cause hearing loss (Uliyanov & Schweinfurth, 2009). A speculum
small, white cyst-like lesion on or behind the tympanic Otic head Magnifying glass
membrane indicates a cholesteatoma. in movable window
Pneumatic Otoscopy. The ability to perform pneu-

Light button
matic otoscopy is an important skill for the pediatric
health care provider, as it is used to confirm the diag-
nosis of AOM and OME. The purpose of pneumatic
otoscopy is to assess the mobility of the tympanic mem-
brane, an important indicator of middle ear pressure. To
diagnose AOM accurately, pneumatic otoscopy is neces-
Body or
sary, unless the tympanic membrane is bulging.
handle
Pneumatic otoscopy involves the following: (a) attach-
ing a rubber pneumatic squeeze bulb to the otoscopic
head (Fig. 14-7); (b) squeezing the bulb to create gentle
air pressure in the external auditory canal; and (c) assess-
ing movement of the tympanic membrane. Before the
insufflation of air, it is essential to have an adequate seal Pneumatic
with the speculum and otoscope when it is placed in the bulb
external auditory canal. This is achieved by ensuring that
FIGURE 14-7. Otoscope with pneumatic squeeze bulb
the speculum is large enough to fit snugly in the child’s attachment.
external auditory canal. If the seal is adequate, brisk
movement of the tympanic membrane is seen when air is
injected; reduced or absent mobility suggests a nonpatent be supplemented with tympanometry or acoustic re-
eustachian tube, fluid behind the tympanic membrane, flectometry and confirmed with tympanocentesis (see
or a possible tympanic membrane perforation. Equivo- Diagnostic Testing). Table 14-5 summarizes normal and
cal assessment findings with pneumatic otoscopy can abnormal findings of the tympanic membrane.
TABLE 14-5
Summary of Normal and Abnormal Findings With Inspection of the
Tympanic Membrane
ASSESSMENT NORMAL FINDINGS ABNORMAL FINDINGS
Color Pearly gray to pink; injection at Erythema (red) may indicate fever, crying, infection, trauma,
the periphery of the TM or mastoiditis; a blue TM may indicate accumulation of blood
which is associated with trauma such as basilar skull fracture; a
yellow TM may indicate AOM; a yellow, amber, or orange color
behind the TM indicates OME; white patches may indicate
scarring or tympanosclerosis; a black spot on the TM indicates
possible perforation.
Transparency Translucent, shiny Opacity
Landmarks Light reflex; bony landmarks Decreased visibility of landmarks of TM indicates decreased
(ossicles), pars tensa, and pars transparency or altered contour of TM, which can indicate AOM
flaccida easily seen or OME; prominent landmarks may indicate retracted TM.
Contour Concave Retracted or bulging TM
Integrity Intact Perforated or thickened TM
Mobility Mobile Immobile; the absence of TM movement with the injection of

a small puff of air via pneumatic otoscopy can indicate AOM or
OME; excess mobility can indicate a healed perforation.
Lesions None Scarring; fluid, vesicles (bullae); or cysts (cholesteatoma)
AOM, acute otitis media; OME, otitis media with effusion; TM, tympanic membrane.
Vestibular Testing. The Romberg test is done to eval- during the early childhood stage of language acquisi-
uate the function of the vestibular apparatus in the tion can cause profound speech delay.
inner ear, which helps to maintain balance and equi- SNHL results from damage to the cochlea or auditory
librium. This test also evaluates cerebellar function nerve fibers. The etiologies of SNHL are genetic, infec-
and proprioception (see Chapter 22). To conduct the tious, autoimmune, anatomic, traumatic, ototoxic,
Romberg test, the provider should ask the child or and idiopathic; the most common cause is genetic (see
adolescent to stand still, feet together, first with the Table 14-1) (Kenna, 2004). Risk factors for SNHL in new-
eyes open, then with the eyes closed, and with the borns are summarized in Box 14-1. Sensorineural hear-
arms at the sides. The child or adolescent should be ing loss may be mild to profound, and the treatment
able to maintain this position for 20 seconds with depends on its cause (Kenna, 2004). Sensorineural
minimal or no swaying. (The provider should stand hearing loss is associated with poor school performance
near the child or adolescent in the event that leaning and behavioral problems; it is important for SNHL to
or falling occurs.) A positive Romberg test occurs when be identified and treated (Smith, Bale, & White, 2005).
the child or adolescent cannot maintain balance with Noise-induced hearing loss (NIHL) is a type of SNHL that
his or her eyes closed. If he or she leans to one side, is permanent but preventable and is caused by the
moves the feet apart to prevent falling, or falls, this inner ear’s chronic exposure to extremely loud sounds,
indicates a vestibular or cerebellar dysfunction or loss usually by recreational or occupational noise. Adoles-
of proprioception. Vestibular testing to evaluate inner cents can be at increased risk for NIHL by listening to
ear function can also be done by rotating the child in excessively loud music (especially with headphones)
a complete circle in each direction, then observing for and attending rock concerts frequently. Other sourc-
nystagmus. A normal finding is for the provider to see es of intense noise include firearms (e.g., rifle ranges,
nystagmus in the same direction in which the child is target shooting, hunting), recreational vehicles (e.g.,
rotated and in the opposite direction when the move- motorcycles, snowmobiles) fireworks, and power tools
ment stops. (Kenna, 2004).
Mixed hearing loss refers to a combination of CHL
and SNHL; therefore, a problem exists both in the mid-
dle and the inner ear for both types of hearing loss to
ASSESSMENT OF occur.
HEARING ACUITY Central hearing loss is rare and involves problems
with the auditory pathway or in the brain itself (Cen-
Assessment of hearing acuity in children is a crucially ters for Disease Control and Prevention, 2009).
important component of pediatric health assessment.
Children who cannot hear will not be able to acquire
age-appropriate language skills, and their social and
academic abilities may be adversely affected. Assess- BOX 14-1
ment of hearing involves reviewing the infant’s or Risk Factors for Sensorineural
child’s medical history to identify risk factors for hear- Hearing Loss in Newborns
ing loss; listening to parental concerns about their
child’s hearing, speech, and language skills, or school • An illness or condition requiring NICU admission for
performance; observing the child for behaviors that 48 hours or greater
may indicate hearing loss; and conducting subjective • Stigmata for syndromes known to include hearing loss
and objective screening assessments for hearing acuity. (e.g., Usher’s syndrome, Waardenburg’s syndrome)
• Family history of permenent childhood SNHL
• Perinatal infections (e.g., toxoplasmosis, bacterial
TYPES OF HEARING LOSS meningitis, syphilis, rubella, cytomegalovirus,
herpes virus)
There are four types of hearing loss: conductive, sen-
• Craniofacial abnormalities (especially morphologic
sorineural, mixed, and central. Conductive hearing loss
abnormalities of the pinna and ear canal)
(CHL) is caused by blocked transmission of sound waves
• Ototoxic drug exposure
through the external auditory canal to the inner ear,
prohibiting sound impulses from reaching the auditory • Birth weight less than 1500 g
nerve. The most frequent cause of CHL in children is • Hyperbilirubinemia, causing kernicterus or requiring
AOM and its sequela, OME (Kenna, 2004). Other causes exchange transfusion
include impacted cerumen, allergies, foreign bodies,
a perforated tympanic membrane, cholesteatoma, or NICU, neonatal intensive care unit; SNHL, sensorineural hearing loss.
less frequently, congenital malformations of the pinna Source: Joint Commission on Infant Hearing. (2007). Joint Commission
on Infant Hearing Position Statement. Pediatrics, 120(4), 898–921;
or external auditory canal (Kenna, 2004). Conductive Kenna, M. A. (2004). Medical management of childhood hearing loss.
hearing loss is transient, but recurrent episodes of OME Pediatric Annals, 33(12), 822–832.
HISTORY AND PHYSICAL provider should also ask about any concerns expressed
EXAMINATION by the child’s parent, day-care provider, or teacher
regarding the child’s developmental, speech, hearing,
Speech and language development occur during the
or language abilities. Examples of these concerns may
first years of life and depend on adequate hearing in
include the following: (a) the child asking “what” fre-
the child. Early screening and identification of hearing
quently during normal conversation: (b) the child ask-
loss in a young child is critical to make appropriate
ing for the volume of the television to be increased;
treatment referrals before the critically sensitive period
(c) the child exhibiting learning difficulties in school;
of time has closed for speech and language develop-
or (d) the child speaking later or less clearly than other
ment (see Chapter 2).
children of the same age. The provider should inquire if
the child uses a hearing aid. Any family history of con-
History genital or permanent childhood hearing loss should
Assessment of hearing in children begins with ob- be noted. The provider should also review the child’s
taining a history to determine risk factors for hearing medical record for timing and acquisition of language
loss. The child’s PMH should be reviewed, with spe- milestones and determine the date of the child’s last
cial attention to any history of prematurity, low birth hearing assessment.
weight, hyperbilirubinemia, asphyxia, or intrauterine
or neonatal infection. A history of head trauma, bac- Physical Examination
terial meningitis, cleft lip or palate, mumps, repeated The physical examination includes assessment for syn-
or chronic middle ear infections, exposure to ototoxic dromic features, particularly of the head, face, or neck;
drugs, or chronic exposure to loud noise is important craniofacial anomalies; or deformities of the pinna or ear
to ascertain, as any or all of these conditions may canal. Certain conditions predispose children to CHL,
lead to hearing loss (Box 14-2; see also Box 14-1). The such as cleft palate, which is readily apparent with palpa-
tion. Other etiologies of CHL can often be readily identi-
fied on physical examination with the visualization of
foreign bodies or cerumen impaction or the diagnosis of
BOX 14-2
AOM or middle ear effusion. Children with repeated epi-
Risk Factors for Hearing Loss sodes of AOM or middle ear effusions are at high risk for
in Children Ages 29 Days to CHL. Equipment necessary for the assessment of hearing
2 Years acuity in infants, children, and adolescents includes:
• Parent/caregiver/teacher concern regarding hearing, • Noisemakers (e.g., bells, squeeze toys, rattles, tissue
speech, language, or developmental delay paper)
• Family history of permanent childhood hearing loss • 512 Hz tuning fork
• Stigmata associated with syndromes known to include • Tympanometer
SNHL, CHL, or eustachian tube dysfunction • Audiometer
• Postnatal infections associated with SNHL To assess hearing accurately in infants and children,
(e.g., bacterial meningitis) a developmental approach is necessary (Table 14-6).
• In-utero infections such as cytomegalovirus, herpes,
rubella, syphilis, or toxoplasmosis Newborns. Newborns react to loud sounds with a
• Neonatal indicators (e.g., hyperbilirubinemia startle (Moro) reflex or acoustic blink reflex and react to
requiring exchange transfusion, persistent pulmonary low-frequency sounds by quieting (see Table 14-6).
hypertension of newborn associated with mechanical Fluid or vernix in the external auditory canal of a new-
ventilation, conditions requiring the use of born can affect the newborn’s hearing. This subjective
extracorporeal membrane oxygenation)
hearing screening is not fully reliable; currently, uni-
• Neurodegenerative disorders (e.g., Hunter’s versal newborn hearing screening (UNHS) is required
syndrome) or sensorimotor neuropathies (e.g.,
in 38 states and the District of Columbia (CDC, 2007).
Friedrech’s ataxia, Charcot-Marie-Tooth syndrome)
Universal newborn hearing screening uses objec-
• Syndromes associated with progressive hearing
tive physiologic methods such as auditory brainstem
loss (e.g., neurofibromatosis, Usher syndrome,
osteopetrosis)
response or otoacoustic emission testing. States with-
out a policy for newborn screening may do so selec-
• Head trauma
tively, especially for infants with specific risk factors
• Recurrent or persistent OME for at least 3 months
(see Box 14-2).
CHL, conductive hearing loss; OME, otitis media with effusion; SNHL, Infants. To assess hearing in the infant, the provider
sensorineural hearing loss.
Source: Joint Commission on Infant Hearing. (2007). Joint Commission should begin by selecting noisemakers that make
on Infant Hearing Position Statement. Pediatrics, 120(4), 898–921. sounds of different frequencies. The provider should
TABLE 14-6
Developmental Milestones to Assess Hearing
AGE ASSESSMENTS RED FLAGS FOR HEARING LOSS
Birth to 3 months Startles to loud noise (Moro reflex); acoustic Diminished or absent Moro reflex; does not
blink reflex present; cessation of movement in awaken to noise
response to low-pitched sounds (newborns);
prefers human voice over any other sound;
turns head to sound (when sound made at ear
level (2–3 months); coos vowel sounds
3 to 6 months Recognizes and quiets to parent’s voice; Does not turn to sound; responds only to loud
awakens to loud noises; looks toward sounds noises
(beginning age 3–4 months); babbling,
squealing, and giggling begins
6 to 9 months Turns toward sound (begins at age 8 months); Does not localize sound after age 6 months;
may respond to own name by age 6–8 months; does not babble or babbling stops after age
understands “no” or “bye-bye”; babbles words 6 months; responds only to loud noises
beginning with a consonant
9 to 12 months May repeat simple words; says “mama” or Indifferent to sound; responds only to loud
“dada” with meaning; reacts to music or noises
singing; points to familiar objects
12 to 18 months Locates sound by turning head to side and Speech development slower than peers; speaks
looking up or down; imitates sounds; points to unintelligibly or not at all; talking decreases;
“ask” for things; says about two words, usually, does not respond to name
“mama,” “dada,” “baba,” or “bye-bye”
18 to 24 months Rapid language acquisition; should have Speaks unintelligibly or not at all;
approximately 20–50 expressive word communicates through gestures, especially
vocabulary; puts two words together to “ask” after age 15 months; gets frustrated easily
question; points to body parts when asked; by when trying to communicate; may even
age 18 months, begins to recognize noticeably have tantrums; prefers to play alone; shy and
dissimilar words; 50% of speech intelligible to withdrawn; appears to be “in own world”
strangers
Preschoolers Hearing reaches maturity at age 3–4 years; Speaks unintelligibly or not at all, especially
should be speaking in sentences after age 24 months; communicates through
gestures; does not hear television, telephone,
or doorbell; prefers to play alone; shy and
withdrawn
Focuses on facial expressions when being
spoken to; sits very close to television or turns
the volume up very loudly; appears to be “in
own world”; often asks for statements to be
repeated; hyperactive or inattentive
School-aged Follows directions at school; auditory acuity Focuses on facial expressions when being
children and reaches peak by age 13 years spoken to; sits very close to television or turns
adolescents the volume up very loudly; prefers to play
alone; often asks for statements to be repeated;
inattentive at school; poor school performance
then ask the parent to hold the infant in his or her and younger should display the Moro or blink reflex;
lap, with the infant’s back to the provider. The par- infants age 6 months or older should react by turning
ent should engage the infant visually by showing the their head toward the sound. Infants 9 months and
infant a brightly colored toy or stuffed animal. The pro- older should be able to locate sound heard from below
vider should then stand approximately 2 feet behind and the infant’s side. If the infant does not display any
the infant and make a noise with various noisemakers, of these responses, the provider should consider the
taking care not to bump the examining table as this possibility of hearing loss and refer the child for audio-
can also elicit the Moro reflex. Infants age 4 months metric testing.
Toddlers and Preschool-aged Children. Children Conduction Tests

aged 12 months and older should be able to local- A tuning fork is used to evaluate hearing by assessing
ize all sounds they hear above, below, beside, and be- bone and air conduction of sound. These tests require
hind them when they cannot see where the provider cooperation of the child and are most useful when
stands as he or she makes the noise. Another way to conducted on children school-aged and older who
test hearing in children in this age group is for the understand what is being asked of them during the
provider to stand approximately 2–3 feet (0.6–0.9 m) examination and can follow directions.
in front of the child and ask the child to do some-
thing, such as point to a body part or show the pro- Weber Test
vider a toy, then wait for the appropriate response.
The Weber test is done to differentiate conductive
The provider should always be sure that the child can
from sensorineural hearing loss. To conduct the Weber
understand the language in which he or she is being
test, the provider should begin by gently striking the
addressed.
handle of a tuning fork (512 Hz) with one hand to
make it vibrate, making sure that his or her hand does
School-aged Children or Adolescents. Children not touch the prongs of the tuning fork or the child’s
in this age group are developmentally able to cooper- or adolescent’s head. Next, the provider should place
ate with the whisper test and bone and air conduction the handle of the tuning fork on the top of the child’s
tests (Weber and Rinne tests) (see Screening Tests for or adolescent’s head or in the middle of the forehead
Hearing). (Fig. 14-8). The provider should then ask the child or
adolescent if the sound is heard in the right ear, left ear,
or in the middle of the forehead. Hearing the sound
in the middle or equally in both ears is the normal
SCREENING TESTS FOR HEARING response. If the child or adolescent responds that the
The Committee on Practice and Ambulatory Medicine, sound is heard better on one side, the sound is said to
American Academy of Pediatrics (2000), recommends be lateralized to that side. Sound is lateralized to the
both objective and subjective assessment of hearing in affected ear with conductive hearing loss. With unilat-
children, birth through adolescence. Subjective hear- eral sensorineural hearing loss, sound is not heard on
ing screening is done at specified intervals during well- the affected side but lateralized to the unaffected ear.
child assessments (see Chapter 9). Objective screening
tests are done with UNHS, audiometric testing before Rinne Test
entering school, parental concern about hearing, or The Rinne test compares air conduction (AC) to bone
delayed speech development. conduction (BC) in each ear. To conduct this test, the
provider taps the tuning fork softly to create vibration.
The tuning fork should then be placed on the child’s or
Whisper Test
The whisper test is used as a gross measurement of
hearing acuity in children. This test involves the abil-
ity to repeat words correctly spoken in a whisper. The
child must be old enough to understand the direc-
tions and cooperate with the examination. Children
3 and older are usually able to cooperate developmen-
tally with this assessment. The provider can use his
or her judgment regarding whether the test is appro-
priate for a particular child. To conduct this test, the
provider should stand 8 feet behind the child so he
or she cannot see the provider’s lips. The child should
then be instructed to place his or her finger over the
tragus of the left ear to obscure any sound. The pro-
vider then whispers a word with two distinct syllables
toward child’s right ear, and the child is asked to re-
peat the word. Then the process is repeated for the
left ear. The child should be able to hear the two-syl-
lable word with each ear and repeat it correctly. An
inability to repeat the whispered words may indicate
a hearing deficit, and the child should be referred for FIGURE 14-8. The Weber test to assess sound conduction
audiometric testing. via bone.
A B
FIGURE 14-9. The Rinne test. The stem of the tuning fork is placed on the mastoid process (A), and
the child is asked to signal when the sound stops after the vibrating end of the tuning fork is moved
and placed near the external auditory canal (B).
adolescent’s mastoid process to determine hearing via SAMPLE WRITE-UP: HEALTHY NEONATE
bone conduction (Fig. 14-9). The provider asks if the
sound is heard, then asks the child or adolescent to in-
Subjective Data
dicate when the sound is no longer audible. The tuning History: Infant boy born at 38 weeks’ gestation, NSVD;
fork is then moved, tines facing forward, 1–2 cm in front no complications at birth. No hyperbilirubinemia.
of the external auditory canal (see Fig. 14-9). Sound is No maternal history of prescription drugs, illegal
transmitted via air conduction, so the provider should drugs, alcohol, or tobacco use during pregnancy; no
then ask the child or adolescent if sound is heard again; maternal or neonatal infections. Maternal history
it should be. A Rinne test is normal (positive) when air negative for diabetes, TORCH infections, or eclamp-
conduction is at least twice as long as bone conduction sia. Mother denies family history of hearing loss.
(AC ⬎ BC). With conductive hearing loss, bone conduc-
tion is heard longer than or as long as air conduction Objective Data
(BC ⬎ AC or BC ⫽ AC). With sensorineural hearing loss, Skin: No jaundice observed.
air conduction is heard longer than bone conduction Ears: Pinnae well formed, symmetrical; top of pin-
in the affected ear (AC ⬎ BC), but with less than a 2:1 nae even with outer canthus of eyes. External audi-
ratio. Sound should be heard equally well in both ears. tory canals patent; small amount of vernix seen in
canal; unable to visualize tympanic membranes.
Mouth: Palate intact.
Hearing: Startle reflex elicited by sudden loud noise.
DIAGNOSTIC TESTING Auditory brainstem response audiometry within
normal limits.
Various diagnostic studies may be used to formulate dif-
Assessment: Normal newborn.
ferential diagnoses regarding disorders of the ear. When
investigating hearing loss, diagnostic tests should be
chosen, depending on the type, duration, and progres-
sion of hearing loss in the infant or child (Kenna, 2004). SAMPLE WRITE-UP: HEALTHY CHILD
These studies could include laboratory tests of blood and Subjective Data
urine, tympanometry, tympanocentesis, acoustic reflec- Healthy 5-year-old boy.
tometry, radiographic studies, and various audiologic PMH: History of AOM ⫻ 3 episodes between 12–15
tests. These diagnostic studies and their indications months of age, all treated with amoxicillin; mother
are summarized in Tables 14-7 and 14-8 ( Jacobson & denies hearing problems. No hospitalizations.
Jacobson, 2004; Kenna, 2004). ROS: Noncontributory except for AOM and envi-
ronmental allergies (mold, dust, pollen).
PSH: None.
DOCUMENTED FINDINGS ON Allergies: No known drug allergies; history of envi-
ronmental allergies.
HISTORY AND PHYSICAL Medications: On no medications.
EXAMINATION Immunizations: Up-to-date.
Family History: No history of hearing problems;
The final write-up should include the assessment of positive history of environmental allergies (mother’s
both ears, including assessment of hearing. family).
TABLE 14-7
Diagnostic Studies Associated With the Evaluation of
Hearing and Ear Disorders
TYPE OF TEST INDICATION PROCEDURE COMMENTS
Laboratory studies: Hearing loss (actual or Simple specimen collection Infections such as bacterial meningitis
• Blood cultures potential) may cause permanent hearing loss;
• TORCH titers TORCH infections, hyperbilirubinemia,
• Total and direct and hypothyroidism in the neonate
bilirubin can cause hearing loss and should be
• Thyroid function treated.
Tympanometry Persistent OME; Assesses mobility of the Test not accurate in infants age
equivocal inspection TM and presence of fluid in 6 months and younger because of
findings with otoscopic the middle ear by applying increased flexibility and compliance
examination in child air pressure into external of external auditory canal; ear canal
for whom chronic AOM auditory canal. Pressure must be free of cerumen for test to
has been a problem and is interpreted in a graph be accurate. Tympanogram results
antibiotic use needs to called a tympanogram. are described as follows: type A
be judicious reflects a normal TM; type B suggests
middle ear effusion; type C reflects
negative middle ear pressure and can
be associated with eustachian tube
dysfunction.
Tympanocentesis Chronic, persistent Needle aspiration of middle Usually done by otolaryngologist

otitis media ear fluid through TM for
culture and identification
of pathogen
Acoustic reflectometry To assess for the An acoustic transducer Painless; can be done in primary care
presence of middle ear is placed in the ear to office
effusion measure the amount of
sound reflected back from
the TM; fluid decreases
sound vibrations. The
presence of OME will cause
more sound to bounce
back to transducer to be
displayed as a gradient.
Radiographic studies: May be indicated in As per radiology MRI of head and brain can identify
• MRI the case of chronic ear anatomic abnormalities or injuries;
• Renal ultrasound disease or head trauma renal ultrasound is done to identify
congenital renal abnormalities
that may be associated with pinna
deformities.
AOM, acute otitis media; MRI, magnetic resonance imaging; OME, otitis media with effusion; TM, tympanic membrane; TORCH,
toxoplasmosis, other (congenital syphilis and viruses), rubella, cytomegalovirus, herpes simplex virus.
Social History: Exposed to secondhand smoke in Otoscopic Exam:

home; attended day care for 5 years; currently in Right Ear: TM intact and pearly gray, no scarring or
kindergarten, having no difficulties in school; no lesions; landmarks clearly visible; good mobility of
history of speech delays. TM noted.
Left Ear: TM intact and pearly gray, slightly
Objective Data injected; landmarks and cone of light visible; TM
Ears: Pinnae well formed, symmetrical; top of pin- mobile with insufflation. No scarring or lesions
nae even with outer canthus of eyes. Left external noted.
auditory canal partially blocked with dark orange Hearing: Weber test (512 Hz): Lateralizes equally to
cerumen; right external auditory canal pink without both ears. Rinne test: AC ⬎ BC, both ears.
cerumen. No evidence of masses, erythema, pain, or Assessment: Normal ear examination; normal
tenderness of pinnae or mastoid bilaterally. hearing.
TABLE 14-8
Screening Tests for Hearing in Children
SCREENING CLINICAL
TOOL AGE GROUP DESCRIPTION INDICATION COMMENTS
Subjective Hearing Clinical hearing

Assessments assessments are done as
subjective screening of
hearing in infants and
children at well-child
assessments.
• Moro (startle) Birth to age Infant startles, arms abduct Assesses both Care should be taken not to
reflex 4 months then adduct, and then hearing and bump examining table or
infant (usually) cries in neurologic create air current; this can also
response to an unexpected function elicit startle reflex; abnormal if
loud (70 decibels [dB] or persists beyond 4 months
more) noise.
• Acoustic blink Birth to Provider stands Assesses both Low sensitivity; provider
reflex 12 months approximately 12 in hearing and should avoid creating air
(30 cm) from infant’s head neurologic current; this can also cause
and makes sudden, loud function (cranial infant to blink, confusing
(70 dB or more) noise. nerve VIII) assessment findings. Repeated
Infant blinks in response to attempts to elicit reflex can
loud noise. cause habituation (reflex
disappears). No blink response
should be followed with
objective hearing screening.
• Language Effective once Language screening is Clinical Complete developmental

screening language done to determine whether auditory and assessment may be necessary;
has begun to acquisition of language developmental child may lag in language
develop; see skills is normal (hearing screening milestone achievement
text regarding deficits can affect language because of neglect rather than
bilingual skills). hearing loss.
children.
• Whisper Test Age 3 years See text Clinical auditory Inability to repeat sounds may
and older screening indicate hearing loss; quiet
environment is necessary to
conduct test.
Objective Hearing
Assessments
• Audiometry Children Uses bone or air Objective hearing Must be developmentally

5 years of age conduction in decibels screening in able to cooperate with exam;
and older; play to assess threshold of ambulatory screening audiogram useful for
audiometry hearing. Air conduction pediatrics ambulatory pediatrics; more
can be used audiograms are conducted according to AAP detailed audiograms must be
on children using earphones; bone guidelines done by audiologist. Cerumen
as young as conduction audiograms are or the presence of AOM or
24 months by conducted using a plaque OME can affect results.
using operant placed over the mastoid
conditioning. bone. Pure tone frequencies
are measured in hertz (Hz),
and loudness is measured
in dB.
Hearing loss is diagnosed
when a child needs a
higher decibel to hear
a tone.
(continued)
TABLE 14-8
Screening Tests for Hearing in Children (Continued)
SCREENING CLINICAL
TOOL AGE GROUP DESCRIPTION INDICATION COMMENTS
• Otoacoustic Can be done A rapid series of clicks Universal Most widely used method of
emission on children of are delivered to the ears newborn screening newborns for SNHL;
(OAE) all ages through a probe inserted screening and also can screen for hearing
into the external auditory children of all ages loss because of ototoxicity
canal to record sounds who are unable and NIHL; test takes only
generated by the hair cells to cooperate with 10 minutes; any vernix in
in the cochlea. audiometry ear canal (newborns) or the
presence of a middle ear
effusion can interfere with
recording of otoacoustic
emissions, causing false-positive
results. Specialized equipment
is necessary. Does not detect
severity of cochlear damage;
should be followed by ABR
• Automated All ages Scalp electrodes measure Universal More expensive than OAE but
auditory electrical activity in the newborn fewer false-positive results;
brainstem auditory nerve in response screening identifies type of hearing loss:
response to sound delivered via CHL, SNHL.
(ABR) bone and air conduction
AAP, American Academy of Pediatrics; AOM, acute otitis media; CHL, conductive hearing loss; NIHL, noise-induced hearing loss;
OME, otitis media with effusion; SNHL, sensorineural hearing loss.
SAMPLE WRITE-UP: ILL CHILD Objective Data

Subjective Data Temp: 103.2⬚ F (39.5⬚ C); P: 120; R: 30; weight 26
An 18-month-old girl brought to clinic with irrita- pounds (11.8 kg) (75th percentile); height 31.5 inches
bility and ear pain. (80 cm) (50th percentile).
Chief Complaint: “My child is very cranky and General: 18-month-old African American girl,
keeps pulling at her ears.” alert, sitting on mother’s lap, crying intermit-
HPI: Previously healthy 18-month-old African- tently. Occasional cough. Responds to name
American girl accompanied by her mother. Nasal called.
congestion for past 5 days; nasal drainage for past Skin: Hot, dry, good turgor; no rashes or lesions.
2 days; thick and green in character. Last night, Ears: R ear: TM intact, erythematous, bulging;
child began to “feel hot” and started pulling at her light reflex diffuse, bony landmarks not visible.
ears. No history of vomiting or diarrhea. Poor appe- Pneumatic otoscopy deferred; L ear: TM intact,
tite for solids ⫻ 2 days; drinking “normal amounts” mobile, pearly gray; cone of light and landmarks
of juice, water, and milk. visible.
PMH: AOM ⫻ 4 episodes. Nose: Thick green mucus both nares; turbinates
PSH: None. edematous and bright red.
Medications: Tylenol 120 mg; last dose 12 hours Mouth/Throat: Pharynx pink, no lesions or exu-
ago; no other medications dates, tonsils 2⫹.
Allergies: NKA; NKDA. Neck: Supple, bilateral preauricular lymphade-
Immunizations: Up-to-date. nopathy.
Family History: One brother, age 3, with history Lungs: Breath sounds clear to auscultation bilater-
allergies, asthma, AOM ⫻ 3 episodes; one brother, ally; respirations unlabored.
age 6, with hx allergies, asthma, AOM ⫻ 6 episodes. Heart: S1, S2, regular rate and rhythm; no murmur
Social History: Both parents smoke in the home auscultated.
and in the car. In day care 5 days/week. Speaks in Abdomen: Soft, nontender, nondistended; bow-
two-word sentences. Still drinks from the bottle; el sounds present; small umbilical hernia, easily
takes bottle to bed. reducible.
ROS: Unremarkable except for previous episodes of Diagnosis: AOM, right ear; upper respiratory
AOM ⫻ 4. infection.
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CHAPTER
Assessment
15 of the Eyes ELLEN M. CHIOCCA
It is vitally important for all infants, children, and nerve, ophthalmic artery, and ophthalmic vein from
adolescents to have a regular eye examination and each eye pass to the brain.
vision assessment. Ocular disorders in children, such as The eyebrows consist of coarse hairs and grow lat-
untreated strabismus, can lead to permanent neurologic erally above the eye in an arch shape. The eyebrow
blindness (amblyopia). Early diagnosis, prompt treat- should begin from the inner canthus to just beyond
ment, and referral are essential for all children with the outer canthus. Their function is to protect the
ocular abnormalities; some of these conditions may eyes from debris and foreign objects, prevent perspira-
affect a child’s sight or vision, impair their learning tion from dripping into the eyes, and to shade the eyes
and development, or be associated with life-threaten- from the sun’s rays.
ing conditions. The upper and lower eyelids are two moveable mus-
cular structures that cover the globe; their function is
to cover the eyes during sleep, protect the eye from
light and injury, and to distribute lubrication over the
ANATOMY AND PHYSIOLOGY eye. The upper eyelid is larger and more mobile than
the lower eyelid and, when open, normally covers a
The function of the eye is to perceive near, far, and portion of the top of the iris but not the pupil. When
peripheral visual images and to differentiate colors. closed, the eyelids normally touch. Contained within
Four cranial nerves (CNs) are involved in ocular the upper eyelids are the tarsal plates, small pieces of
function: CN II (optic) mediates visual acuity and connective tissue that give the upper eyelid shape.
peripheral vision; CN III (oculomotor) controls pupil- The tarsal plates contain the meibomian glands, a type
lary constriction, accommodation, and upper eyelid of sebaceous gland that secretes an oily substance to
elevation; and CN III, CN IV (trochlear), and CN VI keep the eyes moist and the lids sealed when they are
(abducens) allow extraocular eye movements into the closed. The lower eyelid normally sits on the lower
six cardinal fields of gaze. The eye can be divided into border of the iris. The longitudinal opening between
two sections: the external eye and the internal eye. the upper and lower eyelid is the palpebral fissure (see
Fig. 15-1). The points at which the upper and lower
eyelids meet at the left and right sides of each eye are
EXTERNAL EYE the inner (medial or nasal) canthus and outer (lateral or
The external eye structures include the bony orbit, temporal) canthus (see Fig. 15-1). The inner canthus
eyebrows, eyelids, eyelashes, conjunctiva, and lacrimal contains the puncta, two small openings that permit
apparatus. Along with these structures, the extraocular the drainage of tears into the nasolacrimal duct, and
muscles function to protect and support the eye. The the lacrimal caruncle, a small, fleshy elevated area that
external structures of the eye are shown in Figures 15-1 contains sebaceous glands. The eyelashes are stiff hairs
and 15-3. that grow out of the eyelid margins; they protect the
The bony orbit (socket) is an opening in the skull that eyes from dirt, debris, and foreign bodies.
surrounds and protects the globe (eyeball). Only the The conjunctiva is a thin, transparent mucous
anterior portion of the eye is exposed; the remaining membrane that lines the surface of the inner eyelids
portion is housed within the skull. Within the orbit is and anterior surface of the sclera. This delicate mem-
the optic foramen, an opening through which the optic brane acts as a protective covering for the cornea. The
302
C H A P T E R 15 A s s e s s m e nt of the E yes • 303
Pupil
Iris Lacrimal gland
Upper eyelid
Pars orbitalis
Pars palpebralis
Sclera
Palpebral Medial
fissure canthus
Eyelash
Lower eyelid
Caruncle
Puncta
Bulbar conjunctiva
Lacrimal punctum
FIGURE 15-1. External structures of the eye. Caruncula
Lacrimal canaliculi
Lacrimal sac
Nasolacrimal duct
conjunctiva has two surfaces: palpebral and bulbar. The

palpebral conjunctiva lines the inner surface of the FIGURE 15-3. The lacrimal apparatus. (Source: The Ana-
tomical Chart Company. [2001]. Atlas of human anatomy.
upper and lower eyelids; it is thin, transparent, and Springhouse: PA: Springhouse.)
vascular. The bulbar conjunctiva forms the transparent
membrane over the sclera up to the limbus (the junc-
ture of the sclera and cornea). The bulbar conjunctiva
is whitish due to its minimal vascularity and to the side of the upper and lower lids at the inner canthus.
white sclera that lies beneath it. Inflammation of the The tears then drain into the lacrimal sac, then into
bulbar conjunctivae results in conjunctivitis. the nasolacrimal duct, then to the inferior meatus of
The lacrimal apparatus consists of the lacrimal glands, the nose.
lacrimal ducts, nasolacrimal ducts, nasolacrimal sacs, and There are six extraocular muscles that attach each
lacrimal punctae (Fig. 15-3). This system produces tears eye to the bony orbit. These voluntary muscles control
to clean, lubricate, and moisten the conjunctivae and movement of the eye in the six cardinal fields of gaze
cornea and to irrigate foreign substances out of the and are innervated by CN III, CN IV, and CN VI. There
eye. The almond-shaped lacrimal gland is located in are four rectus muscles and two oblique muscles. The
the upper, outer corner of the orbit, slightly below the rectus muscles (i.e., medial rectus, lateral rectus, superior
eyebrow in a small depression within the frontal bone. rectus, inferior rectus) are responsible for straight move-
This gland forms tears that wash over the conjunctiva ment of the eye, that is, top to bottom and side to side
through two lacrimal ducts in each eye via the lacrimal (see Fig. 15-2). The oblique muscles (i.e., superior oblique,
punctae, which are four tiny openings on the nasal inferior oblique) regulate diagonal eye movement. Coor-
dinated movements of the extraocular muscles allow
binocular vision.
Superior oblique Orbit
Superior rectus INTERNAL EYE

The eyeball is a spherical structure comprised of three
Sclera
Medial rectus layers: the outer layer (the sclera), middle layer (the cho-
roid), and inner layer (the retina) (Fig. 15-4).
Outer Layer
The outermost layer of the eye consists of the sclera and
cornea (see Fig. 15-4). The sclera (white of the eye) is
an opaque, firm, fibrous tissue that coats the outer eye
Lateral rectus and is visible just beneath the conjunctiva. It contains
nerves and blood vessels and gives the eye its shape. The
Inferior rectus Inferior oblique external ocular muscles insert into the sclera. Contigu-
FIGURE 15-2. The extraocular muscles. ous with the sclera is the cornea, the most anterior aspect
FIGURE 15-4. Structures of the internal eye. (Source: The Anatomical Chart Company. [2001]. Atlas
of human anatomy. Springhouse: PA: Springhouse.)
of the eye. The sclera and cornea meet at the limbus. Inner Layer
The cornea is the transparent, avascular, membranous The innermost layer of the eye is the fundus, which is
covering of the pupil and iris; this structure allows light opposite the lens. It includes the retina, optic disc, retinal
to pass through the eye to the lens and retina. The cor- vessels, macula, and fovea centralis (Fig. 15-5). These struc-
nea is extremely sensitive to touch and pain and is tures can be seen with the ophthalmoscope. The color of
innervated by the trigeminal nerve (CN V). the fundus varies, depending on the child’s skin color.
The retina contains specialized nerve cells, the rods and
Middle Layer cones, which transform neuronal impulses to the brain.
The middle layer of the eye can be divided into two Rods are quite sensitive to light and function best in dim
sections: the anterior portion, which contains the iris light; they also control black and white vision. Cones
and ciliary body, and the posterior portion, which con- function in bright light and regulate color vision.
tains the choroids. The iris is the pigmented portion
of the eye (see Fig. 15-1). The color of the iris is inher-
ited and varies from person to person. At the center
of the iris is the pupil (see Fig. 15-1). The iris contains Fovea
the sphincter and dilator muscles, which allow the centralis
Physiologic
pupil to increase (dilate) and decrease (constrict) in cup
size to control the amount of light entering the eye.
Sympathetic stimuli dilate the pupil; parasympathetic
stimuli cause it to contract. The lens lies behind the Optic
disc
iris; it changes shape to focus light on the retina. This
change in shape is controlled by the muscles of the
ciliary body. The ciliary body controls accommodation
(i.e., near focusing of the eye). The ciliary body also
produces aqueous humor in the posterior chamber, which
is behind the iris and in front of the lens. This fluid
flows from the posterior chamber through the pupil
to the anterior chamber through the canal of Schlemm.
The amount of aqueous humor in the anterior cham- Retinal Macula
vein
ber determines intraocular pressure. The choroid layer
lies between the sclera and retina. It has a rich vascular Retinal
supply that provides necessary blood flow to the retina artery
and prevents uncontrolled light reflection in the eye. FIGURE 15-5. Normal ocular fundus.
The optic disc is where the optic nerve enters the Left visual field Right visual field
eye. It is a round area located on the nasal (medial) Upper Upper Upper
side of the retina that is pale yellow to pink with well- temporal nasal temporal
demarcated margins. The physiologic cup is a small,
Lower Lower Lower
circular, lightly colored area on the optic disc that temporal temporal
nasal
appears somewhat indented. This is the place through
which the optic nerve enters the eye.
The retinal vessels are four sets of arteries and veins Optic Frontal lobe
that emerge from the optic disc and have their greatest nerve Optic
diameter there. These vessels extend outward toward the chiasm
periphery of the fundus, becoming progressively narrower
and lighter in color as they extend (see Fig. 15-5). Optic
The avascular macula is located temporal to the optic tract
disc. It is slightly darker than the rest of the fundus and
is very sensitive to light. The fovea centralis is a pinpoint
depression within the macula and is the area of the
retina with the greatest visual acuity. Cones are densely
concentrated in the fovea centralis. Rods are absent but
increase in number toward the periphery of the retina.
VISION
Visual Pathways
The visual pathway begins as light passes through
the transparent parts of the eye (i.e., cornea, aqueous
humor, lens, vitreous body) and reaches the retina. The
retina then transforms the light into neuronal impulses
FIGURE 15-6. Visual fields and visual pathways.
that move through the optic nerve and optic tract to
the brain, where the images are interpreted. The retinal
image is initially inverted and reversed right to left as it exposure to light in one eye causes the pupil in the
passes through the lens. For example, an image in the contralateral eye to constrict simultaneously. This is
upper temporal visual field of the right eye will reflect a subcortical reflex mediated by CN III to protect the
onto the lower nasal portion of the retina. The point specialized photoreceptor cells of the retina by pre-
at which the optic nerves from each eye cross over to venting excess light exposure.
the opposite side is the optic chiasm (Fig. 15-6). The Accommodation is a reflex that allows the eye to focus
right optic tract contains only nerve fibers from the on near objects; this occurs when the ciliary muscles,
right side of the retina, and the left optic tract has only innervated by CN III contract, thereby causing curva-
nerve fibers from the left half of each retina. Therefore, ture of the lens. This results in the pupils accommodat-
the right side of the brain sees images only from the ing themselves to objects at close range by constricting
left side of view and vice versa. and to those farther away by dilating. This reflex can-
not be directly observed but can be indirectly assessed
Visual Fields when convergence (movement toward) of the eyes and
The visual field or field of vision is the area or range pupillary constriction occur simultaneously.
within which objects are visible to the immobile eye.
The field of vision of each eye can be divided into four
quadrants: upper temporal, lower temporal, upper na- DEVELOPMENTAL
sal, and lower nasal (see Fig. 15-6). The temporal quad- CONSIDERATIONS
rants are slightly larger than the nasal quadrants, and
these visual fields overlap, resulting in a slightly dif- Structure and function of the eye are dynamic processes
ferent view of the same visual field. This allows for pe- that begin in utero and continue throughout child-
ripheral and binocular vision and depth perception. hood. At 22 days’ gestation, the eye appears, and by
8 weeks’ gestation, the eyes are formed. During this
Visual Reflexes time, the developing eye is vulnerable to the effects of
The pupillary light reflex is the constriction of the pupils intrauterine drug exposure and intrauterine infection.
in response to light. This reflex can be seen directly In preterm infants, the eyelids are partially fused. Peri-
when pupillary constriction occurs in the eye when natal hypoxia adversely affects the retina, often causing
exposed to light, and indirectly or consensually, when poor vision or blindness (retinopathy of prematurity).
Asians, Hispanics, and Native American children; they

TABLE 15-1
are also observed in children with Down syndrome. The
Normal Visual Acuity in Infants
eyelids of Asians may not close completely; this is within
and Children normal limits. In dark-skinned children, the sclera may
AGE VISUAL ACUITY have a yellowish tinge, or brown spots may be seen. The
red reflex is also more orange in dark-skinned children.
Newborn to 1 month 20/100 to 20/400
4 to 6 months 20/200 to 20/300

ASSESSMENT OF THE EYE
1 year 20/40 to 20/60
Assessment of the eye in infants and children must
2 years 20/40 to 20/50
include an ocular history, assessment of vision, and
3 years 20/40 inspection of both the external and internal structures
of the eye.
4 years 20/30
5 to 6 years 20/20
HISTORY
To detect vision problems early, a complete past medical
history, family history, and social history are important.
In term infants, the eye and visual pathway system are An ocular history is also essential to identify specific eye
still immature, with most neonates being hyperopic and vision problems. A focused history is required when
(farsighted). Children are farsighted until about age the child presents with an injury or illness related to
7–8, after which they become increasingly hyperopic the eye.
(nearsighted) (Ball & Bindler, 2006). Binocularity is
established by 3–4 months of age. By 4–5 months, in- Past Medical History
fants can fixate on an image with both eyes simultane- Prenatal History. The prenatal history is obtained to
ously with a steady gaze; the ability to distinguish color determine if the child has had any prenatal drug or
begins at approximately 5 months of age. Visual acuity alcohol exposure or has been exposed to any infections
in infants ranges from 20/400 to 20/50. The optic nerve in utero that can cause abnormalities of the eye. Prenatal
is completely myelinated by 2 years and visual acuity alcohol exposure has been shown to cause decreased vi-
reaches 20/40 by this time. Table 15-1 summarizes the sual acuity in infants (Carter, Jacobson, Molteno, Chio-
range of visual acuity in infants and children. do, Viljoen, & Jacobson, 2005). Infants born with fetal
The pupils are small with undeveloped reflexes alcohol syndrome (FAS) have facial dysmorphology that
until about 5 months of age. Transient nystagmus is includes small, narrow eye openings (see Chapter 16).
common in neonates younger than 6 months (Ball & Valproic acid is a teratogen; maternal ingestion of this
Bindler, 2006). Extraocular muscle function is poorly drug during pregnancy causes multiple serious com-
coordinated for the first 6 months of life, resulting in plications, including craniofacial anomalies that in-
intermittent convergent strabismus during this time. volve abnormal epicanthal folds. Isotretinoin is also
Accommodation and convergence should be estab- teratogenic; this drug causes hypertelorism (Wiley,
lished by 18–24 months. There is little pigment in the 2005). Some prenatal maternal infections cause seri-
iris at birth; by 6–12 months of age, pigmentation of ous complications in the eye of the developing fetus.
the eye is complete (Hockenberry & Wilson, 2008). For example, congenital varicella syndrome causes
The lacrimal apparatus is not fully developed at birth. microphthalmia, cataracts, and chorioretinitis (Mehta
A neonate does not produce tears until approximately & Chatterjee, 2009). Congenital toxoplasmosis causes
4–6 weeks of age, and the lacrimal ducts do not open chorioretinitis, strabismus, and blindness (Leblebicioglu
until approximately age 3 months. The young child’s & Hökelek, 2008). Congenital rubella syndrome (CRS)
eye occupies a greater portion of the orbit than an occurs in infants of women who become infected with
adult’s, causing it to be more vulnerable to injury. Both rubella during the first trimester. CRS involves ocular
the corneal and blink reflexes are present at birth. Eye abnormalities such as cataracts, infantile glaucoma, and
size reaches that of the adult by about 8 years. pigmentary retinopathy; in 80% of infants, both eyes
are affected (Ezike & Ang, 2009).
Congenital toxoplasmosis causes chorioretinitis, stra-
CULTURAL AND RACIAL bismus, and blindness (Leblebicioglu & Hökelek, 2008).
VARIATIONS
Perinatal and Neonatal Histories. Detailed peri-
Epicanthal folds (folds of excess skin that extend from natal and neonatal histories are essential to obtain a
the nose to the inner canthus) are a normal finding in full database when assessing the eye. A history of any
episodes of perinatal hypoxia–ischemia, asphyxia, in Congenital glaucoma raises the infant’s intraocular pres-
utero cerebrovascular accidents, developmental brain sure, causing myopia, astigmatism, and anisometropia;
anomalies, hydrocephalus, or infections of the central these refractive imbalances are the cause of reduced vi-
nervous system (CNS), such as meningitis and enceph- sual acuity and, if untreated, blindness (Sands, 2009).
alitis, must be determined; these are the major causes Congenital cataracts can lead to permanent vision loss.
of cortical visual impairment (Good & Hou, 2006). An iris coloboma is a defect of the iris in which a portion
Birth asphyxia is also associated with cerebral palsy; of the pupil is elongated and keyhole-shaped, causing
some type of visual impairment is a clinical feature in part of the iris to be black; this may or may not be as-
most children with this disorder (Jones, Morgan, & sociated with other anomalies. Dacrostenosis can lead
Shelton, 2007). A history of perinatally acquired in- to dacryocystitis or dacryocystocele.
fections that affect the eye must be noted, including
herpes simplex virus, congenital syphilis, Epstein-Barr
virus (EBV), cytomegalovirus (CMV), varicella-zoster
Review of Systems
virus, gonorrhea, and Chlamydia. These infections are The pediatric review of systems (ROS) involving the eye
transmitted from mother to neonate during passage includes asking the parent about systemic conditions
through an infected birth canal, thus infecting the that can cause ocular abnormalities. Some examples
newborn. Neonatal herpes causes eye injection, dis- include the following:
charge, and keratitis (Sands, 2009). Glaucoma is seen • Skin: Hemangiomas, facial nevus flammeus, terato-
with congenital syphilis; gonococcal ophthalmitis re- ma, and hyperpigmented skin lesions (may indicate
sults in copious purulent discharge and eyelid edema tuberous sclerosis)
(Thilo & Rosenberg, 2009). Chorioretinitis results from • Eyes: Poor vision, photophobia, ptosis, diplopia, ex-
CMV, EBV, varicella-zoster virus, and various fungal ophthalmos, glaucoma, cataracts, hyphema, pseu-
infections (Mirza & Guinazu, 2009). Chlamydial con- dostrabismus, strabismus, squinting, conjunctivitis,
junctivitis also causes eye drainage, eyelid edema, and blepharitis, chalazion, hordeolum, nasolacrimal duct
pseudomembrane formation; this conjunctivitis is obstruction, orbital or periorbital cellulitis, and ocu-
chronic and may last for months (Bashour, 2007). lar tumors (e.g., retinoblastoma)
A history of prematurity must be noted, as premature • Cardiac: Subacute bacterial endocarditis (may cause
infants have a higher than normal incidence of eye pa- conjunctival hemorrhages)
thology, including retinopathy of prematurity (ROP), • Respiratory: Upper respiratory tract infections (cause
myopia (nearsightedness), anisometropia (refractive im- eye drainage) and cystic fibrosis (may cause jaundiced
balance), astigmatism, strabismus, amblyopia, glaucoma, sclera)
retinal detachment, and blindness (Bashour, Menassa, • Endocrine: Hyperthyroidism (can cause exophthal-
& Geronitis, 2008). In addition to these pathologies, mos) and type I diabetes
very-low-birth-weight (ⱕ1500 g) infants have a high • Metabolic: Galactosemia and glycogen storage dis-
incidence of poor visual perceptual skills (e.g., visual ease (cause jaundiced sclera)
discrimination, memory; visual–spatial relationships) • Immunity: Juvenile rheumatoid arthritis (may cause
(Davis, Burns, Wilkerson, & Steichen, 2005). It is also es- uveitis), allergic rhinitis (causes redness, swelling,
sential to note any history of hyperbilirubinemia; this itching, tearing), Burkitt’s lymphoma, Kawasaki dis-
will cause the sclera to be yellow. The timing of this find- ease (may cause red sclera), and meningococcemia
ing depends on the cause of the hyperbilirubinemia. (may cause conjunctival hemorrhages)
Any genetic or hereditary conditions are also an • Renal: Nephrotic syndrome, acute glomerulone-
essential component of the history. For example, chil- phritis (may cause periorbital edema), and hematu-
dren with trisomy 21 (Down syndrome) have numer- ria (may indicate Alport syndrome)
ous abnormalities associated with the eye: bilateral • Hepatic: Hepatitis, biliary atresia, and hyperbilirubi-
epicanthal folds, Brushfield spots (spots on the iris), nemia (causes jaundiced sclera)
strabismus, hyperopia (farsightedness), myopia, astig- • Hematologic: Sickle cell disease, leukemia (can cause
matism; excessive tearing from congenital nasolacrimal swelling of optic disc and retinal thickening, retinal
duct obstruction (dacrostenosis), blepharitis, congeni- hemorrhage or detachment), and bleeding disorders
tal cataracts, and pseudopapilledema (Chen, 2009a). (may predispose to hyphema)
Retinopathy is one of the clinical findings in Alport • Musculoskeletal: Osteogenesis imperfecta (causes
syndrome. Horner syndrome, either congenital or blue sclera)
acquired, causes miosis, ptosis, and heterochromia. • Neurologic: Bacterial meningitis, encephalitis, hy-
Retinoblastoma is an intraocular malignancy that can drocephalus (can cause “sunset eyes”), seizure disor-
be inherited. der, traumatic or ischemic brain injury, nystagmus,
A history of congenital ocular disorders or defects brain tumor (can affect vision), migraines, Sturge-
should also be noted; examples include congenital Weber syndrome, neurofibromatosis, and intracra-
glaucoma, cataracts, iris coloboma, and dacrostenosis. nial hemorrhage
• Developmental: Achievement of developmental Past Surgical History

milestones (e.g., delayed gross motor control such as Examples of surgical procedures about which to
head lag may indicate poor vision or cerebral palsy). inquire include surgery for strabismus, cataracts, or an
Attention deficit hyperactivity disorder (ADHD) may injury to the eye. A history of craniotomy should be
interfere with the child’s ability to cooperate with noted, as well as the reason for the procedure. Trau-
vision screening. Gross motor abilities (e.g., stum- matic brain injury and some brain tumors may affect
bling or walking into things) may indicate vision a child’s vision. The date of the surgery and the condi-
problems. tion for which the surgical procedure was done should
be noted and recorded, as well as whether the condi-
Immunizations tion was resolved with surgery.
Assessment of the child’s immunization status is essential
to be certain that all age-appropriate immunizations are Family History
up to date. This is especially true of immunizations for The family history includes information about any
Haemophilus influenzae type B, Neisseria meningitidis, history of genetic or metabolic disorders. Examples
and Streptococcus pneumoniae; all of these pathogens can include congenital glaucoma, congenital cataracts, con-
cause bacterial meningitis, which can lead to cortical genital retinal dysplasia, congenital ptosis, albinism,
visual impairment (Good & Hou, 2006). and retinoblastoma. Other conditions about which
to inquire include a family history of type 1 diabetes,
Allergies strabismus, amblyopia, refractive errors (e.g., myopia,
It is important to investigate whether the child has hyperopia, astigmatism) color blindness, or Marfan
any allergies, particularly environmental allergies syndrome, which can cause myopia, glaucoma, and
or allergic rhinitis. Allergic rhinitis can cause ocular retinal detachment (Chen, 2009b).
symptoms, including conjunctival injection, itching,
tearing, and swelling of the eyes. Anaphylactic reac- Social History
tions can also cause tearing and swelling of the eyes. The social history involves the child’s living condi-
tions, specifically, if any housing safety or sanitation
Hospitalizations concerns exist that would predispose the child to eye
It is necessary to document past hospitalizations for con- injuries or infections. If the child is involved in sports,
ditions involving the eye, such as periorbital or orbital the provider must determine if protective eyewear is
cellulitis; bacterial meningitis may occur as a complica- used. In school-aged children and adolescents, the
tion of these infections. Bacterial meningitis, as well as provider must also screen for street drug abuse; some
encephalitis, traumatic brain injury, and hydrocephalus, drugs have systemic effects that can affect the eye
can lead to cortical visual impairment in children. examination. These effects include miosis; mydriasis;
sluggish, delayed, or absent pupil response; nystag-
Injuries mus; or coma with open eyes (Nanda & Konnur,
It is essential to inquire about a history of any head, 2006). Examples of these drugs and their effects are
brain, or eye injuries. Injuries to the head or brain may summarized in Table 15-2. School-aged children and
affect the child’s vision as a result of damage to the adolescents who wear contact lenses may need to
optic nerve secondary to increased intracranial pres- be asked about their cleaning routine, especially if
sure. Types of injuries about which to inquire include eye infections are frequent. This is also true for teens
traumatic brain injuries, skull fractures, blunt trauma, who wear excessive eye makeup without removing it
penetrating injury to the eye, orbital fractures, eyelid for extended periods of time. Hobbies and occupa-
or conjunctival lacerations, corneal abrasions, chemical tional hazards are also investigated, with attention
burns, cigarette burns of the cornea, and foreign bodies. paid to chronic exposure to dust, chemicals, or metal
Sports-related injuries and fractures to the face and orbit fragments.
may occur, especially if protective gear is not worn.
Injuries to other areas of the body can also cause Developmental History
abnormalities in the eyes. For example, severe shak- Because vision plays a vital role in reading and
ing injury in infants results in retinal hemorrhage learning, an up-to-date developmental history is
(Walls, 2006). Crushing injuries to the chest can raise essential. Attention must be paid to any concerns
intrathoracic pressure to the extent that intraocular voiced by parents, caregivers, or teachers regarding
pressure rises, causing retinal hemorrhages. Ocular the child’s school performance, as this may indicate
injuries may be the result of intentional injuries. Peri- problems with vision. Developmental milestones
orbital ecchymosis, subconjunctival hemorrhages, and must also be assessed, as any delays may be a clue to
hyphemas should be considered suspicious if accom- visual impairment (see Chapter 2 for a guide to devel-
panied by an implausible history (Forbes, 2001). opmental assessment).
TABLE 15-2
Effects of Selected Drugs of Abuse on Eye Examination
DRUGS OF ABUSE EFFECT ON EYE EXAM
Benzodiazepines (e.g., alprazolam [Xanax]; Blurred vision, diplopia, and nystagmus
flunitrazepam [Rohypnol])
Cannabis (marijuana) Conjunctival injection
Club drugs (e.g., stimulants, hallucinogens, Mydriasis (dilation)

dL-3,4-methylenedioxyamphetamine [MDMA, ecstasy])
Hallucinogens (e.g., D-lysergic acid diethylamide [LSD] and Mydriasis

phencyclidine [PCP])
Heroin and opiates (e.g., morphine, codeine, hydrocodone Miosis (constriction)

bitartrate acetaminophen [Vicodin], oxycodone HCl
[Oxycontin])
Inhalants (e.g., n-hexane [glue]) Conjunctival injection
Ketamine Diplopia and nystagmus; also causes an increase in

intraocular pressure (Boswinkel & Litman, 2005).
Sedatives/Intoxicants Nystagmus (alcohol; GHB), delayed or sluggish pupil

(e.g., alcohol, gamma hydroxybutyrate [GHB]) response (alcohol), and loss of peripheral vision (GHB)
Stimulants (e.g., cocaine, amphetamines, Mydriasis

methamphetamines)
Medications longer recommended for children younger than 2

It is necessary for the provider to obtain a complete (U.S. Food and Drug Administration, 2009), health
list of current medications that the child is taking, care providers should still assess for their use. These
including nonprescription over-the counter (OTC) OTC medications are still available for older children
drugs, as well as prescription drugs, such as opiate and adults, and parents or caregivers may unwittingly
analgesics, which cause miosis (pupil constriction) or give them to young children.
methylphenidate for ADHD, which can cause blurred
vision, difficulties with accommodation, cataracts, Ocular History
and glaucoma (Lu, Kuang, & Chou, 2006). Systemic When evaluating vision in children, a thorough
steroids may cause an array of ocular side effects, ocular history is essential. Parents or teachers may
including cataracts, glaucoma, visual disturbances observe behaviors in the child that are not seen by
(Deshmukh, 2007), exacerbation of ocular infection, the health care provider during the health care visit.
and secondary ocular infection. Ophthalmic use of Concerns of parents or teachers about the child’s
steroids can cause transient stinging or burning of the ability to see well, including observations of crossed
eyes, dry eyes, corneal ulcers, and cataracts (Gordon, eyes; frequent blinking, tearing or squinting; eye
2009). Oral contraceptives, diuretics, antiarrhyth- drooping; rubbing the eyes; sitting too close to the
mics, isotretinoin, and the preservatives in topical eye television; holding objects close to see better; dif-
drops cause a deficit in tear production (Foster, Yuksel, ficulty seeing the blackboard; reports of headaches
Anzar, & Ekong, 2009). Many OTC cough and cold caused by reading; or any complaints of stumbling
medications, including decongestants, antitussives, and walking into things require further investiga-
antihistamines, and expectorants also potentially tion. Reports by parents that their infant fails to
cause ocular side effects. The anticholinergic effects blink when objects approach is a red flag for congen-
of antihistamines can cause ocular dryness, mydriasis, ital blindness. Any recent changes in vision or visual
and minimally reactive pupils if the antihistamines disturbances such as blurred or double vision must
are ingested in toxic amounts. Blurred vision can also be noted, as well as whether any visual problems
occur with antihistamines. Mydriasis and nystagmus prevent normal daily activities. The provider should
may be observed with dextromethorphan ingestion note whether the child wears corrective lenses, the
(Gharahbaghian, Lopez, & Oman, 2009). Despite the date of the child’s last vision screening, and the re-
fact that OTC cough and cold medications are no sults of the examination.
History of Present Illness is conducted at 3, 4, 5, and 6 years; again at 8–10 years;

If a child presents with an eye-related complaint, the and once in early adolescence (11–14 years), mid-
provider obtains a focused history (i.e., history of the dle adolescence (15–17 years), and late adolescence
present illness [HPI]) to make an accurate diagnosis. (18–21 years). This vision screening should also be per-
The provider must keep in mind the child’s age and formed any time the child, parent, or teacher expresses
developmental level, concurrent illness, any history concern about vision (AAP, 2007). Children who fail
of recent injury, associated findings, and past health the vision assessment or are at high risk for vision
when considering diagnostic possibilities. Common problems should be referred to a pediatric optometrist
complaints related to the eye that are seen in the or ophthalmologist. High-risk children include those
pediatric population include eye discharge, pain, burn- whose health history is positive for:
ing; eye injuries; and visual complaints. Relevant ques- • Prematurity or low-birth-weight
tions to ask for the HPI can be found in Table 15-3. • Developmental delay or neurologic problems such
Other important issues include a recent history of vi- as cerebral palsy
ral infections, fever, headache, nausea, vomiting, diz- • Systemic disease associated with eye abnormalities
ziness, fatigue, and malaise; recent exposures (ticks, or infections
infections), changes in growth, or any neurologic • Congenital infections such as rubella or varicella,
symptoms must also be noted. toxoplasmosis, syphilis, and gonorrhea
• Family history of vision problems (refractive error,
amblyopia, strabismus, blindness, congenital cata-
PHYSICAL EXAMINATION ract, glaucoma, retinoblastoma)
To detect any ocular abnormalities, the American Acad- • Family history of genetic (Down syndrome, fragile
emy of Pediatrics recommends eye examinations at X) or metabolic disease (Hellerstein, 2004)
every well-child visit, beginning with the newborn visit Different types of eye charts are available to test
(AAP, 2007). A complete examination of the eye in chil- visual acuity in children (listed in order of decreasing
dren includes testing visual acuity and visual fields, ex- difficulty, these are: Snellen Acuity Chart, Tumbling E,
traocular movements, and inspection and palpation of HOTV test, Allen cards, LEA symbols). To maximize the
ocular structures. The internal structures of the eye are cooperation of a young child during the assessment
examined last, using an ophthalmoscope. The following of visual acuity, the examiner must take developmen-
equipment is needed for eye assessment in children: tally appropriate steps to establish rapport with the
• Penlight child. This includes explaining to the child and parent
• Small toy what will be done, ensuring that the parent is nearby,
• Eye occluder allowing the child to sit on the parent’s lap if neces-
• Visual acuity charts (e.g., Tumbling E Snellen chart, sary; using interesting toys or devices to get the child’s
Snellen letter or number chart, HOTV chart, Allen attention, and using positive reinforcement to reward
cards, LEA symbols) cooperation with the exam. To obtain the most accu-
• Color vision charts rate findings, the provider must also ensure that the
• Ishihara color chart (age 4 years and older) child does not peek, squint, or tilt his or her head dur-
• Random Dot E kit ing the vision exam (Hellerstein, 2004).
• Ophthalmoscope Birth to 3 Years. Precise measurements of visual
• Cotton swab acuity are not possible in children under 3. Gross
• Cotton ball measurement of vision can be accomplished by deter-
• Disposable latex or vinyl gloves (if eye drainage or mining the infant’s ability to fix and visually follow
exudate present) an object, first binocularly then monocularly. If the
infant can follow the object as it is moved through
Assessing Visual Acuity (Cranial Nerve II) the six cardinal fields of gaze, extraocular function
The most important assessment of visual function is can be determined. Difficulty with binocular fix and
the evaluation of visual acuity. Visual acuity differs follow after 3 months may indicate eye or CNS ab-
with age; an infant’s or child’s ability to see is affected normalities. Intermittent convergent strabismus is
by his or her immature anatomy, which changes and within normal limits until 6 months. Nystagmus may
develops as the child grows. The testing method used also be noted in the first few weeks of life. The ex-
to evaluate visual acuity in infants and children is aminer also assesses whether the infant blinks in re-
dependent on the child’s age and developmental level, sponse to a bright light, puff of air, or rapid approach
specifically the ability to cooperate, read, and respond of an object (i.e., the blink reflex). A strong blink re-
to questions. flex is normal. Absence of the blink reflex suggests
Subjective vision screening is recommended at all impaired light perception (e.g., congenital cataracts)
well-child visits beginning at birth. Objective screening or a CNS abnormality. The red reflex (pupillary light
TABLE 15-3
Related to the Eye
DIFFERENTIAL
COMPLAINT ASSESSMENTS DIAGNOSES/CAUSES
Blurred vision Results of neurologic assessment? Does Eye or head injury; refractive eye
child take any medications? conditions (myopia, hyperopia,
astigmatism), glaucoma, cataracts,
migraine, uveitis, keratitis, iritis, or side
effect of benzodiazepines
Burning sensation in eyes Itching of eyes? Foreign body sensation? Refractive error, blepharitis,
conjunctivitis, foreign body, or
allergies
Changes in red reflex Asymmetric red reflex? White coloration Asymmetric red reflex seen in
(leukocoria)? strabismus; leukocoria is seen with
retinoblastoma, retinal detachment, or
cataracts
Diplopia Onset? Medical history? Recent head Congenital cataracts, amblyopia, or

trauma or brain injury? blow-out fracture of orbital floor
Discoloration Erythema of eyelid? Periorbital ecchymosis? Eye trauma; periorbital ecchymosis

Hemorrhage? Recent injury? (Battle’s sign) indicates basal skull
fracture.
Dizziness Onset? Associated symptoms? Fever? Refractive error, vertigo, dehydration, or

Vomiting? cerebellar disease
Dry eyes Does child or teen wear contact lenses? Irritation, exophthalmos, or
Does the child take any medications? dehydration; use of isotretinoin or
Recent illness? Past medical history? diphenhydramine
Excessive blinking Itching of eyes? Foreign body sensation? Irritation, foreign body, infection, or tic
Allergies? Does child wear glasses or contact
lenses?
Eye drainage Is conjunctiva red? Tenderness, erythema, Allergies (clear), viral (mucoid) or
or edema over inner canthus? Is discharge bacterial conjunctivitis (purulent;
purulent? Crusting of discharge? Fever? crusting upon waking), dacroscystitis
Current upper respiratory infection? (purulent); upper respiratory infection,
School or day-care exposure to bacterial blepharitis (crusting), or keratitis
conjunctivitis (“pinkeye”)? Does child or (purulent)
teen wear contact lenses?
Eye pain Degree of pain? Location of eye pain? Foreign body; corneal abrasion (pain is
Foreign body sensation? Fever? History of exquisite), orbital or periorbital cellulitis;
recent injury? head trauma, eye injury, sinusitis,
keratitis, uveitis, or iritis (orbital or
periorbital pain)
Eyelid edema Fever? Eyelid inflammation? Periorbital Blepharitis, conjunctivitis, orbital

inflammation? Eye drainage? Eyelashes or periorbital cellulitis, nephrosis,
matted with drainage? nephritis, or SLE
Fever Recent or current URI? Eye drainage? Orbital or periorbital cellulitis, uveitis
Type, character, and amount of drainage? (infectious cause), viral conjunctivitis
Eyelid edema? Conjunctival injection? (occurs with URI); rubeola, rubella,
Immunizations up to date? varicella, mumps, and influenza all have
ocular manifestations
Foreign body sensation in eye Type of sensation? Recent injury? Foreign body; blepharitis, corneal
abrasion, or conjunctivitis (especially
with sand-like sensation)
(continued)
TABLE 15-3
Related to the Eye (Continued)
DIFFERENTIAL
COMPLAINT ASSESSMENTS DIAGNOSES/CAUSES
Head tilt Facial turning? Watching television with Myopia or strabismus
head turned? Head chronically positioned
up or down?
Headache Visual changes? Sudden or progressive Myopia, hyperopia, migraine, increased

vision loss? On any medications? Results intracranial pressure (tumor, cerebral
of fundoscopic exam? Recent head injury? edema, hydrocephalus, idiopathic
Nausea and vomiting? Fever? Respiratory [pseudotumor cerebri]), viral illness, or
symptoms? sinusitis
Intractable crying Age of child? Recent injury? Foreign body (especially in preverbal
children)
Inflammation of conjunctivae Any eye discharge? Type? Is it watery? Allergies, corneal abrasion, viral or
Purulent? Any blurred vision? bacterial conjunctivitis, foreign body,
Photophobia? Complaints of seeing spots marijuana smoking, iritis, keratitis, or
or floaters? Any eye pain? Does child or uveitis
teen wear contact lenses?
Inflammation of eyelid Any itching? Eye irritation? Do eyes feel Allergies, blepharitis, conjunctivitis, dry
dry? Fever? eyes, or foreign body
Itching Burning of eyes? Eye discharge? Type of Allergies, blepharitis, conjunctivitis, dry
discharge? eyes, eye fatigue, or foreign body
Lacrimation Age of child? Conjunctival injection? Allergic rhinitis; blepharitis, corneal

Emotional state? abrasion, nasopharyngitis, dacrostenosis,
laughing, or crying
Nasal discharge Type of discharge? Watery? Purulent? Onset Allergic rhinitis, sinusitis, orbital or
sudden or gradual? Duration? Aggravating periorbital cellulitis
factors? Fever? Cough? Sneezing, itching
or watery eyes? History of allergies? Does
congestion interfere with sleep? What
relieves nasal congestion? Is child taking
any prescribed or OTC medications for the
nasal congestion?
Nystagmus Onset? Results of neurologic examination? Ocular structural abnormalities, congenital

Past medical history? blindness, retinal diseases, optic nerve
diseases, cataract, glaucoma, albinism,
Down syndrome, or idiopathic nystagmus
Photophobia Onset? Eye pain? Associated fever or flu-like Corneal abrasion, blepharitis, glaucoma,
symptoms? cataracts, viral or bacterial meningitis,
uveitis, keratitis, or iritis
Ptosis Time of onset? Associated strabismus, Congenital ptosis, ocular tumor, or

amblyopia, refractive errors, astigmatism? neurologic disorders
Results of neurologic examination?
Subconjunctival hemorrhages Onset? Recent injury? Past medical history? Bleeding disorders, eye trauma, ruptured
Immunization history? Medication history? globe, chest trauma, meningococcemia,
scarlet fever, measles, shaken baby
syndrome, or anticoagulant drugs
Vision changes Changes in visual acuity? Double vision or Blepharitis, orbital or periorbital cellulitis;
blurred vision? Loss of visual field? Does migraine, retinal detachment, retinal
child see flashes or floaters? Eye pain? hemorrhage, glaucoma, cataracts, CNS
Tearing or eye drainage? Loss of vision? disease (e.g., brain tumor, bacterial
Results of neurologic examination? meningitis), eye trauma, keratitis, or
uveitis (spots and floaters)
CNS, central nervous system; OTC, over the counter; SLE, systemic lupus erythematosus; URI, upper respiratory infection.
20
50
20
30
20
20
A B
FIGURE 15-7. A. Allen Cards show pictures of common items that are easy for toddlers to identify.
B. The Snellen “tumbling E” chart is used for children who cannot read but are able to indicate the
direction in which the “E” is pointing.
reflex; Bruckner test) and pupil response are also as- 3 Years and Older. Objective visual acuity testing is
sessed (see Assessment of Internal Eye Structures and recommended for all children starting at age 3 (AAP,
Ophthalmoscopic Examination). 2007). From age 3–5, the Snellen Tumbling E or HOTV
Toddlers with language skills may be able to cooper- chart can be used to test visual acuity. Using the Snel-
ate with visual acuity testing, using pictures such as len Tumbling E, the examiner asks the child to indicate
Allen cards or LEA symbols. Allen cards use pictures of in which direction a series of progressively smaller “Es”
common items to assess vision in children as young as point (Fig. 15-7b). With the HOTV chart, the child
2 (Fig. 15-7a). When these pictures are viewed at a dis- matches the letters on a wall chart placed 10 feet away;
tance of 20 feet, 20/30 vision is present (AAP, 2007). To four of five symbols must be correctly matched before
conduct the Allen card test, the cards are first shown to progressing to the next line. Beginning at age 5, the
the child to ensure familiarity with the objects shown Snellen letter or number charts are the preferred methods
on the cards and to be sure that the child can verbally of screening for visual acuity (Fig. 15-8). If the child
identify the objects. Then testing begins with one eye wears glasses, he or she should wear them during the
occluded, using only the cards the child has been able screening. To use the Snellen chart, the child stands 10
to identify. feet from the chart, covers one eye with an occluder
Because toddlers may not be able to cooperate with (Fig. 15- 9), then reads the largest line of letters, mov-
the visual occlusion, the eye occluder is held by the ing to smaller lines of print until the child fails to read
parent, or stick-on occluder patches are used. The test- a line. To pass the Snellen test, the child must read
ing starts at a near distance. The examiner then walks four of six letters on a line correctly. The results are
backward, 2–3 feet at a time, showing the cards to the recorded as a fraction next to smallest line that the
child, two at a time, and continuing to do so until the child is able to read; the top number is the distance
toddler is unable to identify an object. To calculate at which the child could read the line of letters; the
the child’s visual acuity, the distance (in feet) at which bottom number is the distance at which a child with
the child could identify the picture accurately is the normal vision could read the line. The procedure is re-
numerator; 30 is the denominator because a child at peated for the other eye. Visual acuity norms are listed
this age with normal vision should be able to see the in Table 15-1.
picture at 30 feet (AAP, 2007). Accuracy in visual acuity assessment in children
LEA symbols require that the child identify familiar is very important. If a 3-year-old child is not able to
pictures on spiral-bound flash cards. This test is con- cooperate with visual acuity testing, the child is re-
ducted at a distance of 10 feet, and visual acuity is de- tested in 4–6 months; a 4-year-old who cannot coop-
termined by the smallest symbol that the child can see erate is retested in 1 month (AAP, 2007). If the child
at a distance of 10 feet (AAP, 2007). Four of five sym- is still uncooperative, a referral is made to a pediatric
bols must be correctly matched to pass the line. ophthalmologist.
Screening for color blindness is conducted only in

boys, once between age 4–8. This can be done by us-
ing Ishihara’s test, which is a series of cards that have
imbedded colors arranged in a shape, number, or let-
ter on a contrasting colored background. The child
is then asked to identify the figure seen in each card.
The green and red bars of the Snellen chart could also
be used, with the child asked to identify these colors
(after ensuring that the child knows his colors); chil-
dren should be able to differentiate colors by 5 years
of age. A child with normal color vision will be able to
identify each pattern. A color-blind child will not be
able to identify the pattern on the cards or see the red
or green color on the Snellen chart.
Assessing Peripheral Visual Fields

Assessment of peripheral visual fields evaluates func-
tion of the retina, visual pathways to the brain, and
CN II function. Children typically need to be pre-
school-aged and older to be able to cooperate fully
with field of vision assessment. In an infant or tod-
dler, an overall assessment of peripheral vision can be
made by watching the child’s reaction to the introduc-
tion of an interesting object (e.g., bottle, toy, stuffed
animal) into the visual fields. To assess field of vision
FIGURE 15-8. The Snellen eye chart, used for children 5 and in older children, the examiner conducts the confron-
older. tation test. To perform this test, the examiner stands
approximately 2 feet in front of the child, face to face,
at eye level. Next, the examiner asks the child to look
Assessing Color Vision straight ahead, holding the head and eyes steady. The
Color blindness is a recessive X-linked disorder or may child then covers his or her left eye with an occluder
occur as a result of optic nerve disease. Red–green color as the examiner covers his or her own right eye. The
blindness is the most common type. Inherited color examiner then slowly moves a small object such as
blindness affects only males, and they cannot distin- a pencil, penlight, or toy toward the child in an arc,
guish shades of red and green. This can affect school moving clockwise, and beginning at the nose, mov-
performance as well as present safety issues once the ing to the temples, then over the top of the head to-
child is old enough to drive. Visual acuity is normal. ward the nose, and then from below upward toward
the nose (Fig. 15-10). The child is asked to say “now”
as soon as he or she can see the object each time.
This process is repeated for the other eye. The exam-
iner then estimates the angle at which the object first
FIGURE 15-9. For many eye assessments, one eye must be FIGURE 15-10. The confrontation test to assess visual fields.
occluded in order for the assessment to be accurate. (Copyright of B. Proud.)
enters the child’s peripheral vision. Normal peripheral

visual fields are approximately 50 degrees upward, 90
degrees laterally, 70 degrees downward, and 60 degrees
medially. Areas of blindness in the peripheral visual
field (scotoma) can be caused by migraine, retinal dis-
ease, optic neuritis, or amblyopia (Blanda & Wright,
2009; Carter, 2008; Gupta, 2007).
Assessing Extraocular Muscle Function. The im-

portance of assessing extraocular muscle function and
ocular alignment in children cannot be overstated.
Untreated ocular misalignment (strabismus) can lead
to amblyopia and permanent vision loss. Intermittent
strabismus is within normal limits until 6 months be-
cause of undeveloped neuromuscular control of the
eyes. After that time, strabismus may be caused by a
variety of amblyogenic conditions involving the struc-
tures and pathways of the visual system; CN III, CN IV,
or CN VI damage; or by increased intracranial pressure
(Nield, Mangano, & Kamat, 2008). With this assess-
ment, it is important to distinguish strabismus from
pseudostrabismus, which is the presence of asymmet- FIGURE 15-12. Symmetrical corneal light reflex (Hirschberg test).
rical epicanthal folds that create the illusion of crossed
eyes (Fig. 15-11).
Extraocular muscle function is evaluated primar- To perform the cross-cover test, the child must focus
ily through assessment of ocular alignment. This is on an object that is approximately 10 feet straight
achieved via assessment of the corneal light reflex (the ahead. In young children, holding up an interesting
Hirschberg Test), performance of the cross-cover test, and toy may be helpful. The examiner then covers one
evaluating the six cardinal fields of gaze. Abnormal find- eye with an occluder for 10 seconds as the child stares
ings in any of these examinations necessitate a referral ahead at the fixed object. The occluder is then removed
to pediatric ophthalmology. as the examiner observes for any movement of the un-
The corneal light reflex test (Hirschberg test) is test- covered eye; it should not drift. This test is repeated
ed by standing directly in front of the child from a with the other eye. If the uncovered eye moves as it
distance of 18–24 inches, then shining a penlight or attempts to refocus on the object, it indicates extraoc-
ophthalmoscope light on the child’s cornea as he or ular muscle weakness (strabismus) (Fig. 15-14). Move-
she looks straight ahead, gaze fixed on the light. The ment of the uncovered eye outward indicates that the
examiner then determines whether the light shines eye was deviated inward when covered (esotropia). If
symmetrically on both corneas. The light reflection the eye moves inward, it was deviated outward when
appears as a small white dot on the cornea. The light
should be reflected in exactly the same place on both
corneas; this determines if the child’s eyes are in a
conjugate position (Fig. 15-12). Nasal displacement
indicates exotropia; temporal deviation indicates eso-
tropia (see Fig. 15-13). These conditions can lead to
amblyopia, which, left untreated, leads to permanent
blindness.
FIGURE 15-11. Pseudostrabismus caused by the presence of FIGURE 15-13. Esotropia (eye tuns nasally); exotropia (eye
epicanthal folds. deviates temporally).
A B
FIGURE 15-14. The cross-cover test. A. First the eye is occluded. B. Next, the eye is uncovered.
(Copyright of B. Proud.)
covered (exotropia). Either of these findings warrants children as young as 3. If the child wears glasses, this
referral to a pediatric ophthalmologist. test must be done with the corrective lenses in place.
In older preschool-aged children through adoles- To perform this test, the child first places stereo glass-
cence, assessment of extraocular muscle strength is es on; if the child wears glasses, the stereo glasses are
conducted to evaluate the six cardinal fields of gaze. This placed over the child’s glasses. With the raised E tar-
assessment also tests the functionality of CN III (oculo- get and nonstereo target cards held 16 inches from the
motor), CN IV (trochlear), and CN VI (abducens), which child’s eyes, he or she is asked to look at both cards
innervate the ocular muscles. To conduct this assess- simultaneously and point to the one with the raised E.
ment, the examiner stands approximately 12 inches in This process is repeated up to six times; the child must
front of the child as he or she looks straight ahead. The distinguish the raised E correctly four of six times. Fail-
child must not move his or her head; with young chil- ure to do so indicates a binocular abnormality and de-
dren, the examiner can hold the child’s head still by fective visual acuity, likely arising from strabismus or
cupping the child’s chin with the free hand or by plac- amblyopia (Hope & Maslin, 2007).
ing his or her free hand on the child’s forehead while
keeping the other hand free to conduct the examina- Inspection
tion. Once positioned, the child is asked to follow the External Eye Structures. The external eye includes
examiner’s finger through the six cardinal fields of gaze, the eyebrow, eyelashes, eyelids, eyeballs, conjunctivae,
as the examiner traces the following path: left and right sclera, and lacrimal apparatus. Inspection of the exter-
lateral gaze, left and right lateral inferior gaze, and left nal eye begins with the eyebrow. The examiner inspects
and right lateral superior gaze (Fig. 15-15). The child’s the size and shape of the eyebrows, noting placement,
eyes should move in a smooth, even, parallel manner. the distribution of hair, and whether the eyebrows are
An inability to move the eye in all directions is likely symmetrical. The eyebrows should extend just beyond
a result of eye muscle weakness or cranial nerve abnor- the outer canthus and are normally full with an even
malities. A few beats of nystagmus may be noted during distribution of hair. Hair loss in the eyebrows may re-
the upward and lateral gaze; this is within normal lim- sult from excessive hair plucking for cosmetic reasons,
its. Marked nystagmus is caused by neurologic abnor- fungal infection, or trichotillomania (hair pulling).
malities and must be investigated. The eyebrows are also inspected for the presence of lice
Lastly, convergence is tested. This is the simultaneous or nits. The skin beneath the eyebrow is also inspected;
movement of the eyes inward to maintain binocular it normally matches the skin of the rest of the face and
eye alignment as objects move from far to near. This is free of lesions. If the child is developmentally able
function is mediated by the medial rectus muscle, to cooperate, function of CN VII can be determined by
which is innervated by CN III. Convergence can be asking the child to raise and lower the eyebrows; this
tested when the examiner moves his or her finger to- movement should be symmetrical.
ward the bridge of the child’s nose while asking the Next, the eyelashes are inspected. The eyelashes are
child to state when he or she can first see two targets. normally full and evenly distributed, extending outward
The child should be able to maintain fixation on the along the entire eyelid margin. No crusts or infestations
object and both eyes should converge. Lack of conver- should be seen. Crusting, scaling, or loss of eyelashes
gence indicates some degree of strabismus. are signs of infection. Bacterial conjunctivitis causes a
Convergence is necessary for stereopsis (binocular mucopurulent discharge, which may mat the eyelashes.
depth perception). Stereopsis can be evaluated using Tiny, white oval specks on the eyelashes are likely nits
the random dot E stereo test; this test can be used in (lice eggs), resulting from a pubic louse infestation.
FIGURE 15-15. The six cardinal fields of gaze.
The eyelids are inspected for symmetry, color, lesions, protrusion of the eye globe (exophthalmos), which is
edema, inflammation, and discharge. The upper and seen with hyperthyroidism. This can also occur when
lower eyelids and palpebral fissures are normally sym- a portion of the sclera is seen above the irises in the
metrical. In children of African or European ancestry, case of increased intracranial pressure (“setting sun
the palpebral fissure is horizontal; in Asian children sign”) (see Chapter 22, Fig. 22-7); it is also a normal
or children with Down syndrome, it slants slightly variation in neonates when the infant is moved from
upward. Short palpebral fissures are seen in children a sitting to a supine position. Inversion of the eyelid
with FAS. The upper eyelids should completely cover (entropion) is a normal finding in Asian children. If
the superior limbus of the iris (i.e., where the cornea eyelashes do not cause corneal abrasions, entropion is
and sclera meet), but not the pupil. The lower eye- not a significant finding. Ectropion occurs when the
lid should extend to, or slightly below, the inferior lower eyelid turns outward; this can lead to conjuncti-
limbus. Inner canthal distance should be approxi- vitis. Drooping of the upper eyelid (ptosis) may be the
mately 1 inch; the outer canthus should be aligned result of birth trauma, damage to CN VII, myasthenia
with the tips of the pinnas (see Chapter 14, Fig. 14-5, gravis, botulism, encephalitis, and Horner syndrome
and Chapter 16, Table 16-2). The eyelids should fully (Fig. 15-16). Unilateral ptosis is concerning because it
approximate when closed. Neonates often hold the can result in amblyopia. Children with ptosis require
eyelids tightly shut, especially when crying. The eye- ophthalmic evaluation.
lids of children with epicanthal folds may not close There should be no discoloration, swelling, drain-
completely; this is a normal variation. Incomplete age, lesions, or inflammation of the eyelids. The eye-
closure of the eyelids can also result from abnormal lids are normally the same color or slightly darker than
FIGURE 15-18. Blepharitis.

FIGURE 15-16. Ptosis of the right upper eyelid.
the child’s surrounding skin. Generalized swelling the child’s face to note placement of the eyes, com-
of the eyelids may be caused by hyperthyroidism or paring one side of the face with the other. In chil-
fluid overload. Dehydration results in sunken eyelids. dren preschool-aged and older, the examiner stands
Painless swelling of the margin of the upper eyelid is at the child’s eye level; 1–2 inches from the child’s
likely caused by blockage of the meibomian gland, face, and instructs the child to look straight ahead at
which causes inflammation, erythema (chalazion) the examiner’s nose. The child’s gaze should be sym-
(Fig. 15-17), or blepharitis (Fig. 15-18). Painful red- metrical and focused directly on the examiner. The
ness and swelling of the eyelid margin is a sign of eyes should be horizontal, symmetrical, and in line
infection of the sebaceous glands at the base of the with the top of the pinna; they should not protrude
eyelash (hordeolum or “stye”) (Fig. 15-19) or dacro- beyond the frontal bone. Shape and spacing are as-
cystitis. Salmon patches (“stork bites”) are commonly sessed, noting whether the eyes are wide set (hyper-
seen on the upper eyelids in newborns; these normal- telorism) or close set (hypotelorism). Hypertelorism
ly disappear by 1 year. Capillary hemangiomas of the is seen in children with Down syndrome; hypo-
eyelid may also be seen in newborns (see Chapter 12, telorism may be a normal variation, indicate mental
Fig. 12-5B,C). Ambylopia complicates this condition retardation, or may be a dysmorphic feature of a ge-
in 43%–60% of affected infants (Seiff, Zwick, DeAn- netic disorder, such as holoprosencephaly (Tegay &
gelis, & Carter, 2009). Atopic pleats (Dennie-Morgan Cohen, 2008).
lines) are folds seen in the lower eyelid (Fig. 15-20), Next, the conjunctivae and sclera are inspected. To
which occur with allergic rhinitis (AR). “Allergic shin- inspect the bulbar conjunctivae, the examiner asks the
ers” also occur with chronic AR; this is bluish discol- child to look up, down, and side-to-side, while gently
oration that causes dark circles under the eyes (see pulling the child’s lower lids down for easier inspec-
Fig. 15-20). tion. The bulbar conjunctivae are normally smooth,
Position, placement, and a gross assessment of clear, moist, and whitish. No drainage should be seen.
ocular motility and alignment of the eyeballs are as- Generalized redness or inflammation of the conjunc-
sessed next. The examiner begins by first looking at tiva may indicate fatigue, eyestrain, conjunctivitis,
allergies, foreign body, or marijuana use. Subconjunc-
tival hemorrhages may be seen in the newborn after
FIGURE 15-17. Chalazion. FIGURE 15-19. Hordeolum.

To inspect the palpebral conjunctivae, the examiner

begins with the lower eyelid. The child is asked to look
upward while the examiner gently places his or her
gloved finger on the skin just below eyelashes of the
lower lid of each eye and pushes downward. Healthy
palpebral conjunctivae are red because of their rich
supply of tiny blood vessels. A pale pink color may in-
dicate anemia. The palpebral conjunctivae should also
be moist and free of lesions. The palpebral conjunctiva
of the upper eyelid is inspected only when a foreign
body or other lesion is suspected because of the dis-
comfort this examination causes. This examination
requires skillful maneuvering with a sterile, cotton-
tipped swab to evert the eyelid (Fig. 15-21).
Inspection of the lacrimal apparatus involves assess-
ment of the lacrimal glands and the punctae. Both the
area over the lacrimal glands and the punctae should
be free of swelling, erythema, or drainage, and the
punctae should be clearly visible. Edema of the lac-
rimal gland or any exudate or erythema around the
FIGURE 15-20. Atopic pleats in the lower eyelid and allergic punctae may be due to nasolacrimal duct obstruction
“shiners.” (dacrostenosis) or infection (dacrocystitis). Persistent
tearing may be caused by allergies, dacrostenosis, dac-
rocystitis, or congenital glaucoma.
a precipitous or traumatic vaginal delivery. Watery
drainage is associated with allergic rhinitis, dacroste- Internal Eye Structures. The internal eye includes
nosis, substance abuse, and hordeolum (stye). Purulent the cornea, lens, pupil, and iris. Assessment of the inter-
drainage occurs with bacterial conjunctivitis. The sclera nal eye begins with inspection of the cornea and lens.
is white, smooth, clear, and glistening. In infants, the To begin, the examiner stands at the child’s side and
sclera is thin and may have a slightly blue undertone. shines a penlight to inspect the cornea; it is normally
A noticeably blue sclera is part of the clinical picture of clear, round, and smooth, without opacities. Any cor-
Marfan’s syndrome and osteogenesis imperfecta (Roy, neal injection, which may result from infection or al-
2002; Elias, Tsai, & Manchester, 2009). The sclera may lergies, must be noted. Irregularities, such as opacities,
have a yellowish tinge in children with dark skin; no- abrasions, or lacerations, must also be noted. Opacity
ticeably yellow sclera is due to jaundice. of the lens occurs with cataracts. Corneal abrasions or
FIGURE 15-21. Eversion of the upper eyelid for inspection.

Pupil Gauge (mm) Pupils are also assessed for accommodation. Pupils ac-
commodate to objects at close range by constricting
and to those at long range by dilating. The pupils also
converge (move together) as an object is moved toward
the face. The examiner can test for pupillary accom-
1 2 3 4 5 6 7
modation and convergence by holding a pen approxi-
FIGURE 15-22. Pupil gauge measurements in millimeters. mately 12 inches from the child’s face and asking the
child to follow it with his or her eyes. As the examiner
slowly moves the pen toward the child’s nose, the pu-
lacerations may not be easily visible; thus, a fluoresce- pils should constrict and converge. It is customary to
in stain can be used to highlight any corneal injuries. document pupils that are equal, round, and react to
The corneal reflex can be elicited by gently touching the light and accommodation as “PERRLA.”
cornea with a wisp of cotton. CN V carries the afferent The iris is inspected for color and shape. For the first
sensation to the brain, and the facial nerve (CN VII) 6 months of life, the iris is blue to grayish in light-
carries the efferent message that elicits the blink. The skinned infants and muddy brown in dark-skinned
corneal reflex is not routinely tested during examina- infants. The iris transitions to its permanent color by
tion of the eye but may accompany an assessment of 12 months; the colors include variations of blue, green,
neurologic function. and brown. Occasionally the irises are different colors
The pupils are inspected for size, shape, reaction to (heterochromia); this can occur with Horner syndrome
light, and accommodation. Pupils are normally round or may be a normal finding. Mild-to-complete absence
and equal in size, with size affected by ambient light- of pigment of the iris occurs in albinism; the degree of
ing; age and certain drugs can also affect pupil size pigmentation depends on the type of albinism (Boissy
(see Table 15-2). Pupil size is measured against a stan- & Nordlund, 2009; Sands, 2009). The iris should be cir-
dardized size gauge; the normal range in infants and cular. Any coloboma should be noted. Brushfield spots
children is 2–6 mm (Fig. 15-22). Infants normally have are tiny white spots on the iris, usually arranged in a
miotic (constricted) pupils. Children normally have concentric circle around the pupil. These spots are seen
larger pupils than infants or adults (Sands, 2009). If the in Down syndrome and tuberous sclerosis (Chen, 2009a;
examiner notes asymmetrical pupils, the size should Nambi, 2009). Pale brown nodules (Lisch nodules) may
be noted. Anisocoria, or asymmetry of pupil size, is be seen on the iris; these occur with type I neurofibro-
within normal limits if less than 1 mm; in this case, it matosis and appear during late school age. Aniridia (ab-
must be documented to establish a baseline assessment sence of the iris) may occur with autosomal dominant
for the child in the event of a future neurologic injury. transmission or with Wilms’ tumor (Sands, 2009). An-
If the asymmetry is greater than 1 mm, this may be a iridia causes poor vision and is associated with corneal
sign of neurologic disease and requires a referral. opacities, cataracts, and glaucoma (Lueder, 2008).
Using a penlight and in a darkened room, the pu-
pils are assessed for reaction to light and accommoda- Palpation of External Eye Structures
tion. First, both pupils are observed for direct response
The bony orbit, eyebrows, lacrimal apparatus, and preau-
to light when the examiner shines the light directly
ricular lymph nodes are gently palpated for tenderness,
on each pupil and then quickly removes it. The pu-
swelling, or masses. Gloves are worn when palpating
pils should react briskly to light. Pupils that display
the nasolacrimal duct. The eye itself should feel firm
a sluggish reaction to light may indicate a neurologic
and nontender. There should be no tenderness, masses,
abnormality. Unilateral pupillary dilation and lack of
or movement of the bone. The lacrimal glands should
responsiveness to light is an ominous sign, often in-
be nonpalpable and nontender. No drainage should be
dicative of eye trauma or severe neurologic injury.
expressed from the puncta when palpating the naso-
Next, the examiner assesses the pupils for direct (same
lacrimal duct; this may indicate dacrostenosis. Tender-
side) and consensual (opposite side) response by block-
ness, erythema, and exudate occur with dacrostenosis
ing the light from the eye not being examined, either
and dacrocystitis.
by holding a hand down the midline of the eye or by
asking the child (if developmentally able to cooperate)
to hold an occluder between his eyes and parallel to his Ophthalmoscopic Examination
nose. Next, the examiner shines the light on the right The ophthalmoscopic examination enables the exam-
eye, observing both the right and left pupils for prompt iner to inspect the ocular fundus. It involves inspection
constriction. The procedure is then repeated for the left of the red reflex, optic disc, retinal vasculature, and macula.
eye. If CN III is intact, both pupils should respond by This assessment requires cooperation from the child,
constricting. Constriction of the pupil into which the who must be still and keep his or her eyes open during
light is shone is a direct response to light; in the other pu- the examination. In preterm infants, this examination is
pil, it is considered a consensual response to light. done by a pediatric ophthalmologist and requires the use
of a dilating agent and lid speculum for adequate view

of the fundus. In healthy, full-term infants, only the red
reflex is elicited, and full ophthalmoscopy is deferred.
Symptomatic older infants and toddlers should be ex-
amined while supine with the parent holding the child
securely. The ophthalmoscopic examination should be
part of the routine assessment beginning at age 3.
The ophthalmoscope provides illumination and
magnification to view the inner eye anatomy. Details
on the technique for using an ophthalmoscope in
children are given in Box 15-1. The first step of the
ophthalmoscopic examination is assessment of the red
reflex. From about 12–15 inches away, the beam of the
ophthalmoscope light is shined on the pupil. This elic-
its a reflection of the retinal background, the red reflex FIGURE 15-23. Elicitation of the red reflex.
(Fig. 15-23). The red reflex should be seen in both eyes.
Each pupil should be reddish orange in light-skinned
children, and brownish red in dark-skinned children. An absent red reflex suggests cataracts, glaucoma, or
retinopathy of prematurity. An absent or white reflex
(leukocoria) may indicate retinoblastoma or retinal de-
BOX 15-1 tachment. Absence of the red reflex requires an imme-
Pediatric Ophthalmoscopic diate referral to a pediatric ophthalmologist.
Examination The red reflex is then assessed simultaneously in
both pupils (Bruckner test). In a darkened room, from
• Keep parents nearby to hold and comfort child. a distance of approximately 2–3 feet, the examiner
• Position infants and toddlers in the supine position, views both pupils simultaneously through the oph-
held securely by parent. thalmoscope as the child fixates on the light. The red
• Children preschool-aged and older can sit on the reflex in each eye should be equal in color, bright-
examination table, facing the examiner. ness, and size. An asymmetrical red reflex may be
• With children preschool-aged and older, explain caused by cataracts, retinoblastoma, refractive errors
procedure to child, providing reassurance that (e.g., myopia, hyperopia, astigmatism), or strabismus;
ophthalmoscopy is not painful. an asymmetrical red reflex also requires a referral.
• If the child wears glasses, ask him or her to The next step is to examine the fundus. To facilitate
remove them. this, the examiner asks the child to focus on a distant
• Do not open the child’s eyes forcibly; this will focal point, such as a picture on the wall, while keep-
exacerbate the child’s fear, discomfort, and agitation, ing his or her eyes as still as possible. Approaching
thus inhibiting or precluding the examination. the child from a distance of about 12 inches and at a
• Ask the child to remain as still as possible. 15-degree angle, the provider centers the light from
• Darken the room so the pupils dilate, exposing more the ophthalmoscope on the child’s eye. The lens set-
of the retina for examination. Explain to the child why ting on the ophthalmoscope should be adjusted as
the room is darkened to alleviate fears. necessary to focus properly. The first structure that is
• Start by using the smallest round light beam on the located is the optic disc, which is normally light yel-
ophthalmoscope, and then adjust the beam to the low to pink and is round and flat with distinct edges.
maximum brightness that the child can tolerate. The physiologic cup is a small depression just lateral
• Ask the child to look at something at eye level on a to the center of the optic disc, slightly lighter in color
far wall. than the disc. The shape, size, and color of the cup are
• Set the lens of the ophthalmoscope to 0 diopters. noted. A pale white optic disc is seen in meningitis,
• Approach the child from about 12 inches away, optic neuritis, or encephalitis. Swelling of the optic
gradually moving closer, adjusting the focus on the disc is evident when the disc margins are blurry or
ophthalmoscope as needed. obliterated and the physiologic cup cannot be seen
• To magnify the structures of the eye, adjust the lens (papilledema). This is caused by increased intracranial
of the aperture as needed. pressure, which, if untreated, may lead to optic nerve
• The examiner uses his or her right hand and right eye atrophy and blindness. Papilledema is rarely seen in
to examine the child’s right eye, and left hand and children younger than 2 because their cranial sutures
left eye to examine the child’s left eye.
are not fully fused. The optic disc and physiologic cup
• The procedure is done on both eyes. are compared for size; the cup should be no greater
then one third the size of the disc, and the cup-to-disc
ratio should be compared in both eyes for symmetry.

TABLE 15-4
Increased intraocular pressure (e.g., glaucoma) causes
Summary of Well-Child Eye
the size of the physiologic cup to increase.
The four sets of arteries and veins that emerge from
Examination Screening
the optic disc are inspected next. The arteries are thin- AGE ASSESSMENTS
ner and a brighter red than the veins, which are larger
and darker. The arteries reflect light; the veins do not. Neonate • External (penlight)
examination for lesions,
The normal retinal arterial-to-venous ratio is approxi-
edema, and discharge
mately 2:3 in children. A change in this ratio may signal • Red reflex (pupillary light
a vasoconstricting disease. The retinal background is reflex; Bruckner test)
also inspected; it is normally red-orange or dark brown- • Pupillary examination
ish red, depending on the child’s skin color. A lighter • Inspect ocular alignment
(corneal light reflex)
area is normally seen near the optic disc. Any areas of
• Assess for congenital
hemorrhage or exudate are noted. Retinal hemorrhages, cataracts
which may result from head trauma, including shaking
injuries, appear as red lesions. Retinal telangiectasis can 6 months to 3 years As for neonate (above) plus:
cause dilation of the retinal vessels and exudation (white • Ability to fix and follow
light, face, or small toy
lesions), giving the retina a pale yellow appearance, and • Assess ocular alignment
in some instances, leukocoria. Exudate can be either hard (corneal light reflex,
(made of protein or fat) or soft (tiny retinal infarctions; Hirschberg test, cover-
often termed “cotton wool exudates”) (Orient, 2005). If uncover test)
the exudate accumulates near the macula, blindness re-
3 to 5 years As for neonate through age 3
sults. Inflammation and exudate in the retina can also years plus:
be caused by toxoplasmosis, cytomegalovirus, herpes • Visual acuity (Allen cards,
simplex virus, varicella, measles, leukemia, diabetes, HOTV, Snellen Tumbling E)
congenital syphilis, or rubella infections (Orient, 2005). • Ophthalmoscopic
examination (red reflex,
Retinopathy is also seen in premature infants and in
funduscopic exam)
children with diabetes or sickle cell disease (Sands, 2009;
Phillpotts, Duong, Shapiro, Castro, & Fiscella, 2009). 6 years and older As for neonate through age
The avascular macula is then located. It should be 5 years plus:
the same size as the optic disc, located approximately • Visual acuity (Snellen
letters or numbers)
3 mm from the optic disc’s temporal edge, and have a
bright spot in the center, the fovea centralis. The mac-
ula is very sensitive to light; blinking and tearing result
when light from the ophthalmoscope is directed onto
the macula, causing pupillary constriction and making
further assessment difficult. Therefore, the macula is COMMON DIAGNOSTIC
examined last. Figure 15-24 shows a normal fundus. A STUDIES
summary of the components of the eye examination
for well children is given in Table 15-4. Laboratory and radiologic studies are not a routine
component of the evaluation of the eye and vision
in a child. For children with dysmorphic features,
chromosomal studies are indicated. A finding of ex-
ophthalmos may necessitate thyroid function tests
to evaluate the child for hyperthyroidism. Screening
for Lyme disease is necessary for children who present
with CN VI or CN VII palsy and who live in or have
a recent history of travel to an area where Lyme dis-
ease is endemic. In children who may be exhibiting
signs of bacterial meningitis, a complete blood count,
blood culture, and cerebrospinal fluid culture are nec-
essary. Imaging studies are indicated for children with
a suspected brain mass, with MRI being the preferred
study to detect intracranial abnormalities that may be
the cause of acutely acquired strabismus. A CT scan
FIGURE 15-24. Normal ocular fundus. For a full-color of the head, with and without contrast, is useful in
example, please refer to Figure 15-24 on page C3. emergency situations to diagnose intracranial masses,
infections, fractures, or vascular injuries. An orbital CT hyphema noted; no active bleeding from eye,
scan can reveal orbital fractures, infections, and abnor- nose, or mouth. No clear drainage from nose.
malities of the extraocular muscles (Nield, Mangano, Cornea and iris intact; sclera white; conjunctiva
& Kamat, 2008). clear. Pupils equal, round, and reactive; pupils OD
(right eye) 3/3 ⫽ 3/1 OS (left eye). EOMs (extraoc-
ular movements) restricted with downward gaze.
Tympanic membranes intact without hemotym-
DOCUMENTING FINDINGS panum bilaterally.
Assessment: Maxillofacial CT scan shows right
SAMPLE WRITE-UP: WELL CHILD inferior orbital blow-out fracture without facial
Subjective Data fracture.
A 15-year-old boy denies difficulty with vision; does
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CHAPTER
Assessment of the
16 Face, Nose, and

Oral Cavity ELLEN M. CHIOCCA
Assessment of the face, nose, and throat is an essential organ for smell. The upper third of the external portion
skill for the pediatric health care provider. Upper of the nose is composed of bone, and the lower two
respiratory infections, allergies, oral or facial trauma, thirds is composed of cartilage. The nose can be divided
dental caries, and pharyngitis are common diagnoses into four areas: the superior bony portion or nasal
in children. When obtaining the history and physical bridge; the cartilaginous middle of the nose or vault;
examination of the face, nose, and throat in children, the inferior corner or “tip” with two oval openings
the health care provider can also identify parent and called the nares (nostrils); and immediately inside each
child teaching opportunities, for example, encouraging naris, the interior vestibule.
regular dental care, compliance with antibiotic therapy The internal nose, or nasal vestibule, is comprised of
for streptococcal pharyngitis, and the consistent use of two cavities separated by the bony and cartilaginous
sports safety gear to avoid oral and facial injuries. nasal septum. It extends from the opening of the nares
to the nasopharynx. Commonly, the nasal septum is
not perfectly straight and may deviate toward one
side. The anterior portion of the nasal septum contains
ANATOMY AND PHYSIOLOGY Kiesselbach’s plexus, a highly vascular area that is a
common site of nosebleeds. The lateral wall of each
THE FACE nasal cavity has three bony projections known as the
The face is composed of 14 bones, which are illustrated superior, middle, and inferior turbinates, which are highly
in Figure 16-1. Each of these bones articulates at su- vascular and lined with cilia and mucous membranes.
tures except for the mandible, which is able to move The structure of the turbinates serves to increase surface
up and down and side to side at the temporomandibu- area to warm and humidify inhaled air. Secreted mucus
lar joint. The bones of the face include the two nasal and cilia function to filter inhaled air by trapping small
bones, which form the bridge of the nose, the two infe- particles. Under each turbinate is a cleft, or meatus. The
rior conchae, two palatine, two lacrimal, and one vomer middle meatus drains the sinuses and the inferior meatus
bones. The zygomatic arch (two bones) creates the cheek drains tears from the nasolacrimal duct. The olfactory
prominence; the maxilla (two bones) forms the upper receptors are found on the mucosa along the superior
jaw on either side of the face. The upper surface of the turbinate and upper third of the nasal septum. These
maxilla comprises the floor of the orbit; the lower por- smell receptors trigger cranial nerve I, (olfactory) to
tion forms most of the hard palate. The unpaired man- transmit impulses to the temporal lobe of the brain for
dible (one bone) forms the lower jaw. interpretation. Figure 16-2 illustrates the structures of
the internal nose.
THE NOSE
The nose is the entry point for the respiratory system. THE NASOPHARYNX
It has four main functions: (a) to act as the main site The nasopharynx forms the superior portion of the
for air entry, inspiration, and expiration; (b) to warm, pharynx (throat) and is continuous with the oropharynx.
moisten, and filter inhaled air; (c) to allow for sound It is located above and posterior to the nasal cavity and
resonation with speech, and (d) to act as the sensory extends inferiorly to the uvula. The pharyngeal tonsils (ad-
325
Bones of the skull and face: Coronal suture Squamous suture

Frontal
Parietal
Sphenoid
Temporal Lacrimal
Nasal
Maxilla
Occipital
Zygomatic
Mandible
Lambdoid
suture
Conchae
Mastoid
process
Vomer Perpendicular
plate of ethmoid
Nasal septum Hyoid Ligament Styloid process

FIGURE 16-1. The bones of the face.
enoids) are located on the superior posterior wall of the • The maxillary sinuses, the largest of the maxillary si-
nasopharynx and the openings to the eustachian tubes are nuses, lie in the maxillae along the side walls of the
located along the lateral walls. The inferior portion of the nasal cavity, under the eyes.
nasopharynx is formed by the soft palate; the remaining • The ethmoid sinuses are located between the nose
portion of the nasopharynx is surrounded by bone. and orbits.
• The sphenoid sinuses lie in the sphenoid bone, be-
hind the eyes and nose and under the pituitary gland
THE PARANASAL SINUSES deep within the skull.
The paranasal sinuses are air pockets on either side The sinuses communicate with and are lined with
of the nasal cavity. They are named according to the the same ciliated mucous membrane as the nasal
cranial bones within which the sinuses lie (Fig. 16-3): cavity. Sinuses lighten the weight of the skull, serve as
• The frontal sinuses are located in the frontal bone resonators for sound production, and produce mucus
superior and medial to the orbits, just above the that drains into the nasal cavity. The sinus openings
eyebrows. are narrow and occlude easily, often leading to inflam-
mation or sinusitis.
Olfactory
bulb
Olfactory
nerves
THE MOUTH
Superior The mouth, or oral cavity, has several functions: to act
nasal turbinate
as an additional airway for the respiratory system; to
Middle function as a starting point for the digestive system,
Superior nasal turbinate
nasal meatus encompassing taste, mastication, salivary secretion,
Inferior
nasal and swallowing; and to form sounds for normal
Middle turbinate speech articulation. The oral cavity is composed of the
nasal meatus
lips, cheeks, hard and soft palates, tongue, teeth, salivary
glands, and pharynx (Fig. 16-4). The mandible and
Inferior Nasal maxilla comprise the bony structure that supports the
nasal meatus vestibule
oral cavity.
The lips act as an entranceway into the mouth,
lying on the anterior border of the oral cavity. The lips
FIGURE 16-2. Lateral view of the nasal cavity. (Source: The
Antomical Chart Company. [2001]. Atlas of human anatomy. are quite vascular and are sensitive to temperature.
Springhouse, PA: Springhouse.) The cheeks form the lateral border of the oral cavity
C H A P T E R 16 A s s e s s m e n t o f th e Face , No s e , an d Or al C avity • 327
Frontal sinus
Ethmoid sinuses
Maxillary sinus
FIGURE 16-3. The paranasal sinuses.
and are lined inside with buccal mucosa. The lips and are necessary for normal speech articulation. The
cheeks are innervated by cranial nerves V (trigeminal) uvula also functions by closing the nasopharynx
and VII (facial). These cranial nerves control sucking, during swallowing.
swallowing, chewing, biting, and talking. The tongue is a muscle that lies at the floor of the
The palate separates the nasal and oral cavities and oral cavity and is attached to the hyoid bone and
forms the roof of the mouth. The palate is divided mandible. The dorsal surface and sides of the tongue
in two parts: the hard palate and soft palate. The hard are covered with papillae, which contain taste buds.
palate comprises the anterior two thirds of the palate The ventral surface of the tongue is covered by a thin
and is made of bone. The posterior third of the palate mucous membrane with multiple visible blood vessels.
is the soft palate, which is composed of muscle and The tongue is attached to the floor of the mouth by
is part of the lateral pharyngeal wall. Extending from mucosal tissue, the lingual frenulum. The muscu-
the soft palate is the uvula, a vertical muscular struc- lar movement of the tongue allows for mastication,
ture that hangs from the middle of the soft palate. The swallowing, and the formation of speech. The tongue is
soft palate and uvula receive motor innervation from innervated by cranial nerves IX (glossopharyngeal) and
cranial nerve IX (glossopharyngeal); this motor ability X (vagus) for sensation and taste, and cranial nerve XII
is essential for the creation of the palatal sounds that (hypoglossal) for motor function.
There are three paired salivary glands in the mouth,
all of which secrete enzymes that begin the first step in
digestion. Saliva also aids in mobilizing and destroying
Superior lip Superior labial
frenulum oral bacteria that can lead to dental caries and tooth
decay. The largest pair of salivary glands, the parotid
Gingiva (gums) glands, lies on the side of the face anterior to the ear.
These glands become inflamed with parotitis (mumps).
Hard palate
The parotid glands secrete saliva into the Stensen’s ducts,
Anterior pillar
which open into the buccal mucosa opposite the upper
Soft palate Inferior pillar second molar. The submandibular glands are the second
Palatine tonsil largest and lie on the floor of the mouth, secreting
Cheek
saliva through the Wharton’s ducts, which are found
Uvula Posterior on either side of the frenulum. The smallest salivary
pharyngeal wall
glands, the sublingual glands, are located on the floor
Tongue Lingual frenulum of the mouth beneath the tongue. In addition to these
three pairs of major salivary glands, there are hundreds
Inferior labial of very small salivary glands scattered throughout
frenulum Opening of duct of the oral cavity, lining the mucous membranes and
submandibular gland
oropharynx.
Inferior lip
(pulled down) Gingiva (gums) Between the ages of 6 to 8 months, the first
deciduous or primary teeth begin to erupt. Each tooth
FIGURE 16-4. Structures of the oral cavity. consists of a root, which is embedded in gingival tissue
UPPER and encased in bone, and the crown, the visible part
Central incisor of the tooth that is white and covered in enamel,
8–12 months the most calcified tissue in the body. The first teeth
Lateral incisor to erupt are the central mandibular incisors, followed
9–13 months
by the maxillary central incisors, then the mandibular
Cuspid
and maxillary lateral incisors. Figure 16-5 illustrates
16–22 months
the normal sequence of primary tooth eruption. By
First molar 30 months, all 20 deciduous teeth should have erupt-
13–19 months
ed except the second molars; these should be in place
Second molar by 3 years. Nutritional, genetic, and environmental
25–33 months
factors can affect the timing and sequence of tooth
eruption in children.
LOWER The deciduous teeth exfoliate between 6 and 12 years
Second molar of age, and the mandible and maxilla grow. By 12 years,
25–33 months the child should have all 32 permanent teeth. Figure 16-6
depicts the normal sequence of the eruption of perma-
First molar
nent teeth.
13–19 months
Cuspid
16–22 months THE PHARYNX
Lateral incisor The pharynx, or throat, located behind the mouth
9–13 months and nose, is divided into three parts according to
the anatomic area: the nasopharynx, oropharynx, and
Central incisor hypopharynx. The upper part is the nasopharynx,
8–12 months which is posterior to the nasal cavity; below the soft
FIGURE 16-5. The normal sequence of primary tooth palate lies the oropharynx, and below the oropharynx
eruption. lies the hypopharynx. Masses of lymphoid tissue,
Upper Teeth Erupt

Central incisor 7–8 yrs.
Lateral incisor 8–9 yrs.
Canine (cuspid) 11–12 yrs.
First premolar (first bicuspid) 10–11 yrs.
Second premolar (second bicuspid) 10–12 yrs.
First molar 6–7 yrs.
Second molar 12–13 yrs.
Third molar (wisdom tooth) 17–21 yrs.
Lower Teeth Erupt

Third molar (wisdom tooth) 17–21 yrs.
Second molar 11–13 yrs.
First molar 6–7 yrs.
Second premolar (second bicuspid) 11–12 yrs.
First premolar (first bicuspid) 10–12 yrs.
Canine (cuspid) 9–10 yrs.
Lateral incisor 7–8 yrs.
Central incisor 6–7 yrs.

FIGURE 16-6. The normal sequence of permanent tooth eruption.
the palatine tonsils, are located on either side of the the twelfth week of gestation, with fusion of the pri-
oropharynx, just behind the arches of the soft palate. mary and secondary palates. Failure of fusion during
The palatine tonsils form the anterior and posterior this process is known as cleft palate. The mouth of a
tonsillar pillars (see Fig. 16-2). The lingual tonsils are young infant is short and smooth with a longer soft
found at the base of the tongue and the pharyngeal palate. This proportionately larger soft palate in the
tonsils, or adenoids, are located in the roof of the na- young infant increases the risk of airway obstruc-
sopharynx. Only the palatine tonsils are visible on tion. By 6 months of age, the mouth is proportioned
inspection. like that of an adult. Salivary secretions increase at
approximately 3–4 months of age. This, coupled with
an underdeveloped swallowing reflex, explains the
increased drooling noted in infants in this age group
DEVELOPMENTAL (Hockenberry & Wilson, 2007).
CONSIDERATIONS Both sets of teeth, temporary and permanent, begin
developing in utero between the sixth and eighth
The facial structures begin to develop between the weeks of gestation. Calcification of the primary teeth
fourth and eighth weeks of gestation. From the eighth takes place during the fourth month of gestation and
week of development until birth, facial development is complete by 1 year of age. Permanent molars calcify
occurs slowly and primarily involves changes in posi- between ages 18 months to 3 years. Teething is nor-
tion and proportion of the facial structures. mally preceded by a period of increased drooling, local
The nose begins to develop in utero during the gingival inflammation, and irritability. Teething is not
fourth week of gestation, and is completed by the associated with fever or diarrhea.
twelfth week of gestation. In the newborn, the nose Infants normally have a large tongue in propor-
is comprised mainly of cartilage, making the nose soft tion to the size of their mouth; this persists until age
and malleable; the position of the fetus in the uterus 8–12 years, when the mandible has a growth peak
can result in temporary deformities of the nose that (Swamy & Mallikarjun, 2004). The rooting, gag, suck,
resolve spontaneously after birth. Infants have a flat and extrusion reflexes persist until age 4 months.
narrow nasal bridge and are obligate nose breathers The sense of taste is immature at birth but quickly
until they are 4 months of age. Because of this, young develops around age 2–3 months as the taste buds
infants with nasal congestion can develop respiratory mature. The sense of taste is not fully developed until
distress quite rapidly, and their ability to breathe is approximately age 2.
impeded during feedings. Until approximately 6 years The palatine tonsils are normally large in young
of age, the inferior meatus does not function except children (size 2⫹ to 3⫹) and continue to enlarge
for draining the nasolacrimal duct; this explains the gradually over the first 8–10 years of life, at which time
increased nasal drainage in children when crying or the tonsils begin to shrink.
with ocular inflammation. The nasal septum ossifies by
3 years; by adolescence, the nose becomes triangular
and develops a bony structure. Sense of smell is poor
at birth but develops with age. CULTURAL AND ETHICAL
Adenoids (nasopharyngeal tonsils) begin forming CONSIDERATIONS
in the third month of fetal development and are fully
formed by the seventh fetal month. The adenoidal Certain conditions occur more frequently in certain
tissue begins to shrink in late childhood. The function racial or ethnic groups, depending on cultural prac-
of adenoids decreases commensurate with the decrease tices, environmental and socioeconomic factors, or
in size. in some instances, genetics. Cleft lip and cleft pal-
The ethmoid and maxillary sinuses form during ate, for example, occur most commonly in Asians
gestational month 3–4 and, thus, are present at birth. and Native Americans and least commonly in blacks
The ethmoid sinuses develop rapidly between age 6 and (Tinanoff, 2007). A bifid uvula, a condition in which the
8, and again during adolescence. The sphenoid sinuses uvula is partially or completely split, is more common
are fully formed by age 5; the frontal sinuses develop in Native Americans and Asians (Heathcote, 2005).
at approximately 7 to 8 years of age but are not fully Cultural factors may influence the health of a child’s
developed until late adolescence (American Academy teeth. Lack of knowledge regarding the importance of
of Pediatrics, 2001). Generally, full development of the primary teeth, fear of the dentist, health beliefs about
paranasal sinuses occurs from ages 8–14 years as the disease causation and prevention, and multiple ex-
cranial bones enlarge at that time, roughly equaling tended family caregivers, especially elders, affect ac-
adult size (McClay, 2008a). cess to preventive dental care (Hilton, Stephen, Barker,
During the seventh and eighth weeks of gesta- & Weintraub, 2007). Hispanic children have the high-
tion, the palate begins to form and is completed by est rate of dental caries in the United States; this is
because of multiple factors, including parental health feeding, or breathing through the nose. Examples of
beliefs and knowledge deficits, delays in seeking den- conditions about which to inquire include:
tal care, and economic and social factors (Barker & • Face: Encephalocele and FAS
Horton, 2008). African American children also have • Nose: Choanal atresia, choanal stenosis, and nasal
a higher incidence of dental caries and gingivitis than dermoid cysts
Caucasian children (Satcher, 2000). Dental caries in • Mouth: Cleft lip, cleft palate, adontia (congenital
young children that occurs as a result of being put to absence of teeth), oligodontia (partial absence of
bed with sweetened drinks in a bottle or sippy cup teeth), neonatal teeth, Epstein’s pearls, and ankylo-
(early childhood caries) is more prevalent in Hispanic, glossia (tongue tie)
Native American, and Alaskan-native children and
Some congenital syndromes include clinical findings
among children of recent immigrants (DenBesten &
that involve the face, nose, or mouth. For example,
Berkowitz, 2003).
Marfan syndrome involves a high-arched palate with
crowded dentition; cleft lip or palate may occur as part
of trisomies 13 and 18; and cleft palate occurs alone
ASSESSMENT with Pierre Robin sequence (Elias, Tsai, & Manchester,
2009). Nasal polyps are seen with cystic fibrosis. It
HISTORY is also important to inquire about prolonged oral or
When obtaining the history of the face, nose, and nasal intubation in the neonatal period, as this can
mouth, the focus is on the presence of any congenital cause tissue trauma to the alveolar ridge.
syndrome involving craniofacial abnormalities, a his-
tory of trauma to the face or mouth, or a history of Review of Systems
frequent upper respiratory infections, particularly The pediatric review of systems, involving the face,
group A streptococcal infections and sinusitis. nose, and mouth, includes asking the parent about
specific conditions with signs and symptoms that
Past Medical History manifest in these anatomic regions. Some examples
In addition to the standard information gathered in include the following:
the pediatric past medical history (see Chapter 6), it is • General: Usual state of health; recent and recur-
important to ascertain the following information. rent febrile illnesses; and a history of any congenital
syndromes that are associated with oral or facial
Prenatal History. The provider determines if the anomalies
child has a history of any prenatal exposures that • Skin: Atopic dermatitis (comorbid condition with
can cause abnormalities of the face, nose, or mouth. allergic rhinitis)
This requires inquiries about maternal prenatal use of • Head and Face: Facial asymmetry or deformities, de-
anticonvulsants, specifically phenytoin, which may pressed nasal bridge, or absent philtrum, which may
cause cleft lip and palate in the fetus (Elias, Tsai, & indicate FAS
Manchester, 2009). Prenatal maternal smoking and • Nose: Frequent upper respiratory infections, nasal
alcohol consumption also increase the risk for cleft lip congestion or discharge (including characteristics);
or palate, while folic acid may have a protective effect allergic rhinitis, nasal stuffiness, recurrent epistaxis
(Carnici, Rullo, Farina, Morano, Festa, Mazzarella, et al., (nosebleeds), sinusitis, foreign body in the nose,
2005). The findings gleaned from one study revealed snoring, trauma to the nose, or regular use of nasal
that consanguinity is a risk factor for these congeni- sprays
tal malformations ( Jamilian, Nayeri, & Babayan, • Mouth and Throat: Cleft lip or palate, frequent sore
2007). Prenatal alcohol exposure causes distinctive throats, pharyngitis, stomatitis, tonsillitis, retropha-
facial abnormalities in the fetus, including midface ryngeal abscess, peritonsillar abscess, toothaches,
hypoplasia, a long philtrum, and a short nose with difficulty chewing, dental caries, dental infections, gin-
anteverted nares (fetal alcohol syndrome or FAS) (see givitis, dental malocclusion, dental injuries, eruption
Chapter 13). Maternal use of inhalants such as glue has cysts, chronic mouth breathing, difficulty swallowing,
a similar effect on the developing fetus (Elias, Tsai, & hoarse or nasal voice quality, benign migratory glossitis
Manchester, 2009). (geographic tongue), herpes stomatitis, coxsackievirus,
recurrent aphthous ulcers, or oral candidiasis
Neonatal History. The neonatal history involves • Respiratory: Upper and lower respiratory infections;
reviewing the child’s past medical history for congenital cystic fibrosis, which is associated with nasal polyps;
disorders that cause abnormalities of the face, nose, or asthma (comorbid condition with allergic rhinitis)
and mouth. The provider must pay particular atten- • Immunity: Allergies, tonsillitis, pharyngitis, or facial
tion to any conditions that cause difficulty sucking, cellulitis
Immunizations Family History

A child’s immunization status is particularly relevant The family history is elicited by asking about congen-
to assessment of the face, nose, sinuses, or oral cavity. ital syndromes, cleft lip or cleft palate, nasal polyps,
Several diseases for which children are immunized can snoring, mouth breathing, allergic rhinitis, atopic der-
cause medical conditions, involving these structures. matitis, asthma, or frequent upper respiratory infections
Diphtheria can cause a membranous covering over the in other family members.
upper airway, causing obstruction and respiratory dis-
tress, and tetanus can cause contraction of the facial Social History
muscles. Poliomyelitis causes muscle weakness or
As part of the social history, the provider must determine
paralysis, resulting from altered function of the cranial
the type of housing, how many people are living in the
nerves, which causes an asymmetric soft palate that, in
home with the child, and if they practice good hygiene
turn, causes difficulty swallowing and speech disorders
(e.g., frequent hand-washing). These are particularly
(Raucci, Whitehill, & Sandritter, 2004). Haemophilus
important assessments to make if a child presents with
influenzae type b (Hib) can cause epiglottitis; this con-
frequent respiratory infections and nasal discharge.
dition causes acute respiratory distress, including nasal
Because pet dander is an allergen, the presence of any
flaring and mouth breathing as a result of severe air
pets in the home must be noted. Children with cystic
hunger (see Chapter 17). Streptococcus pneumoniae can
fibrosis or asthma are especially vulnerable to recurrent
lead to sinusitis.
respiratory infections. Infants can also present with
oral infections if household hygiene is inadequate. An-
Hospitalizations other important assessment is to determine if the child
It is important to inquire about past hospitalizations is exposed to environmental tobacco smoke, which can
for acute or chronic illnesses or infections, involving cause inflammation of the nasal passages and frequent
the face, nose, or oral cavity. Examples include facial respiratory infections in children, especially those who
trauma or cellulitis; conditions that cause difficulty live with “indoor smokers” (U.S. Department of Health
swallowing and consequent dehydration, including and Human Services, 2006). With the parent out of the
tonsillitis, retropharyngeal or tonsillar abscess, stomati- room, adolescents can be asked in a nonjudgmental
tis, or infectious mononucleosis. Any condition requir- manner about their use of cigarettes, marijuana, or
ing endotracheal intubation is also noteworthy; oral inhaled cocaine or methamphetamine, all of which
intubation can result in injury to the teeth. are respiratory tract irritants. The provider must also
ask the teen about the use of chewing tobacco; this
Injuries can cause gums to recede, leukoplakia (white patches
Injuries to the face and mouth in children are not on the buccal mucosa), and oral malignancy (Nanda &
uncommon and occur in the course of the child’s Konnur, 2006). Inhaled cocaine use is associated with
play activity or as a result of a lack of developmentally nasal perforation and epistaxis. Methamphetamine
appropriate supervision. Some injuries to the face and use is associated with bruxism and severe tooth decay
mouth in children result from intentional injury or (McGrath & Chan, 2005). It is important to inquire
child abuse (see Chapter 23). Injuries about which to about whether the child or teen is involved in any type
inquire include burns, falls, motor vehicle collisions, of sports, during which injuries and fractures to the
or intentional trauma that affect the face, nose, or face, teeth, and mouth may occur, especially if protec-
mouth. It is important to ascertain if there is a history tive gear is not worn.
of animal or insect bites to the face, as these injuries
can result in cellulitis. Providers must ask the parents Medications
of older infants and toddlers about a history of foreign Knowledge of current prescribed and over-the-counter
bodies placed in the nose, which can cause bleeding, (OTC) medications or home remedies the child is taking
chronic irritation, and nasal drainage. is essential; the indication for the drug or remedy may
explain an abnormality in the face, nose, or mouth. For
Surgical History example, antibiotics, which may have been prescribed
Examples of surgical procedures about which to inquire to treat acute or chronic sinusitis, may cause yeast
include tonsillectomy, adenoidectomy, nasal septum re- overgrowth in the oral cavity (e.g., thrush, oral can-
construction, nasal polyp removal, or cleft lip or palate didiasis); this manifests as adherent white plaques
repair. It is also important to inquire about dental ex- on the buccal mucosa. Certain anticonvulsants (e.g.,
tractions. The date of the surgery and the condition for phenytoin) may cause gingival hyperplasia. Antihista-
which the surgical procedure was done should be noted. mines, decongestants, intranasal corticosteroids, and
The provider must also ask the parent (or child if age ap- nasal cromolyn are often prescribed to treat seasonal,
propriate) if the condition was resolved with surgery. perennial, or episodic allergic rhinitis. It is important
for the provider to ask the parents of teething infants must be asked whether the child still drinks from a
if they have been applying OTC, topical lidocaine to bottle or no-spill sippy cup, how often, what type of
treat teething pain. The provider must advise parents liquid is in the bottle or cup (i.e., juice, milk, soda
to apply this medication sparingly, especially with pop), and if the child goes to sleep with the bottle
older infants who frequently place objects in their or cup. This is an important question, as prolonged
mouths as local anesthesia that extends to the poste- use of a bottle or sleeping with a bottle or sippy cup
rior pharynx may lessen the gag reflex, thus increasing is associated with an increased risk of tooth decay
the infant’s risk for choking. (early childhood caries) and middle ear infection
(Edelstein, 2005).
Allergies • Assessing dietary habits. The provider asks about
It is important to investigate whether the child has any the consumption of cariogenic food, snacks, and
allergies, particularly environmental allergies or aller- treats such as crackers, bread, presweetened cereals,
gic rhinitis. Allergic rhinitis causes nasal symptoms, dried fruits, cookies, gum, and candy. Beginning at
including rhinorrhea, swelling of the nasal turbinates, 6 months, infants should receive fluoride supple-
and enlarged tonsillar and adenoidal tissue. Allergies ments if exclusively breast-fed or if the water used to
can also lead to chronic mouth breathing, dental prob- mix the formula is not fluoridated (American Dental
lems (overbite), abnormalities of the palate, and the Association, 2005). In older children, the provider
formation of nasal polyps (Sheikh, 2008). notes whether the child drinks fluoridated water. The
parents of young children are asked if they share uten-
sils, cups, spoons, or toothbrushes with the infant or
Dental and Oral History young child or if the parents put the pacifier in their
The oral and dental history is a particularly important own mouths before giving it to the infant. These
portion of the pediatric oral examination. Essential practices can lead to the infectious process of dental
elements include: decay by transmitting Streptococcus mutans from the
• Determining if the child has a dental home. It is caretaker to the child’s mouth (Berkowitz, 2006).
important to determine the child’s source of regular • Assessing harmful oral habits. The provider must
dental care; a “dental home” should be established also inquire about any harmful oral habits such as
soon after the first tooth eruption or by 12 months. sucking the thumb or finger after age 5 or pacifier
The provider must determine the frequency of den- use beyond 18 months, which can affect dental arch
tal visits as well as the date of the last dental visit. development, resulting in malocclusion (Hagan,
Children should be seen by a dentist every 6 months Shaw, & Duncan, 2008). Dipping the pacifier in sugar,
or more frequently if needed (American Academy of honey, or other sugary substances can cause dental
Pediatric Dentistry, 2007). decay; this practice must be assessed and discouraged.
• Determining the timing of eruption and shedding Preteens and adolescents should also be asked about
of primary teeth and the eruption of permanent smoking and the use of smokeless tobacco, both of
teeth. The presence of mixed dentition should be which increase the risk or periodontal disease and
noted; this may cause complications such as plaque oral cancer.
accumulation, gingival irritation, and malocclusion. • Determining if there is a history of eating disor-
A history of natal teeth, dental fractures, or tooth ders. The repetitive self-induced vomiting associated
avulsions is also important. with bulimia nervosa can wear tooth enamel, resul-
• Determining oral hygiene habits. The teeth should ting in tooth decalcification, erosion, and decay; the
be brushed and flossed at least twice a day. Providers self-induced starvation that characterizes anorexia
must ask parents of infants if they clean the baby’s nervosa leads to vitamin deficiencies, causing po-
teeth after feeding and what they use to clean the tential injury to the teeth (Bernstein, 2008).
teeth. Fluoridated toothpaste should not be used in • Determining if there is a history of oral injury,
children younger than 2 (American Dental Associa- infection, or other dental problems. Orofacial trau-
tion, 2005). Providers must ask adolescents who wear ma can occur when the child or adolescent is involved
braces about oral hygiene practices; diligent cleaning in contact sports; the provider asks about the child or
is essential to avoid decay. teen’s participation in such sports and asks if mouth
• Assessing feeding practices. The frequency of bottle guards are worn. Adolescents may have their tongues
and breast-feeding is determined; frequent breast- pierced; any history of hemorrhage or infection as
feeding of infants who have begun teething can lead a result of the piercing is noted. Oral sexual activity
to tooth decay. The provider must ask if the infant can lead to infections in the mouth. Any history of
is held for all feedings; a bottle should never be bruxism or malocclusion is also noted.
propped in the infant’s mouth, as this leads to tooth • Determining a family history of dental caries,
decay and otitis media and can cause the aspiration noting the rate of dental caries or other dental
of liquids. Parents of toddlers older than 12 months problems.
this examination difficult. In infants and toddlers, this

BOX 16-1
examination should be deferred until after the heart,
Pediatric Oral Health Risk
lungs, and abdomen are auscultated and after the ear
Assessment has been inspected. If the child is crying, the health care
The following children are considered to be at high risk provider should take the opportunity to inspect the oral
for oral health problems: cavity at that time. Proper positioning of the child is
• Children with special health care needs essential to ensure comfort and avoid accidental injury.
• Children of mothers with numerous dental caries The best choice for securing the young child is to place
the child on the examination table while the parent or
• Children with visible plaque, dental caries,
demineralization, or staining caregiver secures the child’s arms by his or her sides and
supports the head. Preschool-aged children are less re-
• Children who breast-feed while sleeping or sleep with
a bottle sistant to this portion of the physical examination and
may even find it fun to open their mouth and stick out
• Children from families of low socioeconomic status
their tongue. If the child is indeed cooperative, he or
Children meeting these high-risk criteria should be
she can be examined while sitting on the examination
referred to a dentist as early as 6 months and no later
than 6 months after the eruption of the first tooth, or table, facing the provider. If the child is not cooperative,
age 12 months, whichever comes first (Hale, 2003). he or she can be placed on the parent or caregiver’s lap
with the head held at the forehead and arms secured at
the sides (Fig. 16-7). If the child is quite uncooperative,
the parent or caregiver may need to secure the child’s
legs between their own legs. Another option is for the
In 2003, the American Academy of Pediatrics parent or caregiver and the provider to sit knee-to-knee
recommended that the primary health care provider and place the child on the lap that this position creates.
conduct an oral health risk assessment. The criteria for The parent or caregiver can secure the child’s head while
this assessment are listed in Box 16-1 (Hale, 2003). providing reassurance to the child and the provider can
then lean forward and directly inspect the child’s nose
History of Present Illness and mouth. Assessment of the face, nose, and mouth in
When a child presents with a complaint related to the children school-aged and older can be done in a head-
face, nose, or mouth, the provider obtains a focused his- to-toe sequence with the child sitting upright on the
tory (i.e., history of present illness [HPI]). It is important examination table in front of the examiner.
to gather details of all presenting symptoms, including The following equipment is necessary to examine
information about onset (sudden or gradual), duration, the face, nose, and oral cavity in children:
and progression (see Chapter 6). Common problems • Penlight
related to the face, nose, and throat in children include • Tongue blades
general complaints such as nasal drainage or conges- • Gloves
tion, sore throat, sneezing (with or without fever), pain • Otoscope with halogen light and short wide-tipped
(facial, throat, and tooth), and epistaxis (nosebleeds). nasal speculum attachment
Conditions include nasopharyngitis, sinusitis, pharyn-
gitis, streptococcal pharyngitis, and stomatitis. Assessment of General Appearance
Injuries to the face, nose, or mouth are considered
Examination of the face, nose, and mouth begins with an
closed head injuries, and relevant precautions must be
overall assessment of the infant’s, child’s, or adolescent’s
taken, including stabilization of the cervical spine if
general appearance. This helps the provider focus on areas
the child has a history of loss of consciousness. The
of assessment that require more thorough investigation.
mechanism of injury must be ascertained and deter-
For example, when the provider enters the examination
mination of airway patency is essential. Injuries to the
room, facial symmetry, mouth breathing, nasal flaring,
nose and mouth often cause profuse bleeding with
and nasal discharge are often readily apparent and assist
possible bone or tooth fractures, all of which may
in directing the focus of any detailed examination.
obstruct the child’s airway. Relevant questions to ask
for the HPI can be found in Table 16-1.
Examination of the Face
Assessment of the face involves primarily inspection
PHYSICAL EXAMINATION and palpation.
Examination of the nose and mouth in infants and
young children is challenging. The area that needs to Inspection. Inspection of the face includes assessment
be examined is not easily visualized, and young infants of the skin, facies, and facial features; facial expression;
and toddlers are frequently resistant to the internal symmetry of facial movements (cranial nerve VII); and
examination of the nasal and oral cavities, making any involuntary movements.
TABLE 16-1
History of Present Illness: Abnormalities and Complaints Related to Face,
Nose, and Mouth
COMPLAINT ASSESSMENTS DIFFERENTIAL DIAGNOSES/CAUSES
Cough Onset sudden or gradual? Productive? Paroxysmal Upper or lower respiratory tract infection,
cough? Color of sputum? Associated fever? Sick viral pharyngitis, sinusitis, tuberculosis
contacts? Nasal discharge? Aggravating and (paroxysmal cough), or asthma
alleviating factors?
Dry mouth Onset sudden or gradual? History of prolonged Thirst, mouth breathing, dehydration,
(xerostomia) mouth breathing? Refusal to swallow liquids? diabetes, or mumps; may be associated with
On any medications? What type? Any illicit drug use
drug use?
Dysphagia Onset sudden or gradual? Past medical history? Viral or bacterial pharyngitis, peritonsillar or
Child’s immunization status? Severity of retropharyngeal abscess, epiglottitis, GERD,
dysphagia? Precipitating and alleviating factors? cleft palate, or cerebral palsy
Dyspnea Onset sudden or gradual? Child’s immunization Peritonsillar or retropharyngeal abscess;

status? Fever? Precipitating and alleviating epiglottitis, trauma, upper or lower
factors? Associated symptoms? Nasal flaring? respiratory tract disorders, or infections
Neck or throat pain? Any swelling of the face
or neck?
Epistaxis Onset sudden or gradual? Unilateral or bilateral Trauma (intentional or unintentional),

bleeding? Frequency? How long do nosebleeds bleeding disorders, nose-picking,
last? Is bleeding prolonged or profuse? nasopharyngitis, foreign body in the nose,
Precipitating factors? Alleviating factors? Is child allergic rhinitis, or illicit drug use
on any medications?
Facial pain Onset? Duration? Location? Degree of pain? Any Trauma (intentional or unintentional);
pressure? Fever? Sneezing or nasal drainage? sinusitis (acute or chronic); headaches; or
Characteristics of nasal drainage? Recent upper migraines
respiratory infection? History of allergies? What
alleviates the pain or pressure?
Gingival Past medical history? Onset? On any Phenytoin or cyclosporine-induced gingival

hyperplasia medications? hyperplasia or idiopathic or familial gingival
hyperplasia
Gum recession On any medications? What type? Dental hygiene Vigorous tooth brushing; poor oral hygiene,
habits? Halitosis? Toothaches? Bleeding gums? or tooth decay; may be caused by chewing
Gums red, tender, and swollen? tobacco
Halitosis Medical history (e.g., chemotherapy, diabetes)? Poor oral hygiene, tooth decay, gingivitis,
Type of odor? Associated symptoms? Any harmful oral candidiasis, postnasal drip, sinusitis,
oral habits? Dental hygiene habits? On any tobacco use, xerostomia, or fecal impaction
medications?
Lesions on buccal Type of lesions (i.e., ulcers, vesicles, Koplik’s Herpangina, coxsackievirus, enterovirus
or labial mucosa spots, thick, white deposits on buccal mucosa)? (hand, foot, and mouth disease), aphthous
Onset sudden or gradual? Color, location, or ulcers; oral candidiasis, or herpes virus I or II
lesions? Are sores painful? Sick contacts? Fever?
Poor appetite? Precipitating and alleviating
factors? Signs of dehydration? Sore throat?
Malaise? Lesions or rash elsewhere on body?
Does child attend day care? Recent antibiotics?
Is child on any medications? Any oral piercings?
Sexual practices?
Nasal congestion Onset sudden or gradual? Duration? Aggravating Allergic rhinitis, nasopharyngitis, sinusitis, or
factors? Fever? Cough? Sneezing, itching, or foreign body in the nose
watery eyes? History of allergies? Does congestion
interfere with sleep? What relieves nasal
congestion? Is child taking any prescribed or OTC
medications for the nasal congestion?

Postnasal drip Onset? Associated cough? Fever? Aggravating and Allergic rhinitis, nasopharyngitis, sinusitis, or
alleviating factors? Painful or erythematous throat? foreign body in the nose
Rhinorrhea Onset? Acute or chronic? Bilateral? Unilateral? Foreign body in the nose (unilateral), allergic
Continuous or intermittent? Precipitating rhinitis (clear, watery discharge from both
factors? Character of nasal drainage? Associated nares), nasopharyngitis (green-to-yellow
symptoms (e.g., fever, facial pain; sneezing, itchy drainage, both nares), or sinusitis; chronic
or watery eyes)? Is child on any medications? rhinorrhea may be caused by inhalant use
Sore throat Onset? Duration? Frequency? Severity of sore Viral or bacterial pharyngitis. tonsillitis, or
throat? Fever, hoarseness, rash, pharyngeal, or seasonal allergies
tonsillar exudate? Difficulty swallowing? Sick
contacts? What alleviates the throat pain? What
makes it worse? On any medications?
Tonsillar Onset? Any fever? Difficulty swallowing or Viral or bacterial pharyngitis, tonsillitis, or
enlargement breathing? infectious mononucleosis
Tooth decay Last dental visit? Visible caries? Associated sore Tooth decay associated with sore throat may
throat? Any mixed dentition? Does child drink be caused by self-induced vomiting, poor
from bottle or sippy cup? oral hygiene, or early childhood caries
Tooth pain Onset sudden or gradual? Location of pain? Last Tooth avulsion or fracture or tooth decay
dental visit? Visible caries or tooth discoloration?
Gingival exudate or hyperplasia? Halitosis?
History of oral injury?
Trauma Mechanism of injury? Areas of active bleeding? Sports-related injury, intentional or

Lacerations? Abrasions? Bruising? Evidence of unintentional injury due to falls or play, or
fractures? Visible hematomas? Nasal obstruction child abuse and neglect
caused by swelling or bleeding? Nasal discharge?
Type? Does nasal discharge test positive for
glucose? Is child able to open mouth? Move
mandible? Any malocclusion? Fractured or
missing teeth? Results of eye (vision; extraocular
movements) and neurologic examinations?
GERD, gastroesophageal reflux disease; OTC, over-the-counter.
Assessment of the face begins with inspection of the delivery; forceps marks should also be noted. Facial ede-
skin for color, lesions, and signs of trauma or edema. The ma can be marked with face presentation deliveries and
skin should be pink and free of lesions (see Chapter 12). associated soft tissue swelling can distort the facial fea-
In the neonate, the examiner should note any bruising tures. With marked facial edema, the newborn should
from birth trauma, especially with a face presentation be re-examined in 24–48 hours to assess for resolution
of the swelling and to assess the facial features without
the edema. Swelling of the face in older infants and chil-
dren may be by caused chronic use of corticosteroids
(Cushing’s syndrome) or by acute injury. Swelling of
the face due to injury is most often accompanied by
injuries to the skin, such as burns, bruises, lacerations,
abrasions, or puncture wounds. All injuries to the face
must be evaluated to determine whether the injuries
were accidental or intentional (see Chapter 23). In old-
er children and adolescents, facial puffiness or swelling
around one or both eyes or eyebrows may indicate si-
nusitis (AAP, 2001). Allergic shiners (dark, bluish circles
under the eyes) are a result of vasodilation or nasal
congestion and are often seen in children with allergic
rhinitis. The parotid gland may be swollen as a conse-
quence of viral infection (e.g., parotitis or “mumps,”
FIGURE 16-7. Securing a young child for examination of the human immunodeficiency virus [HIV]), or bacterial
oral cavity. infection (e.g., dental infections). An infected parotid
gland also causes facial erythema and produces puru-

TABLE 16-2
lent saliva if infected with bacteria (Templer, 2008).
Physical Measurements of
With bulimia nervosa, bilateral parotid gland swelling
Facial Features in Term is seen (Mandel & Abai, 2004).
(38–40 weeks) Infants The facies are also inspected, including the overall
MEASUREMENT RANGE (cm) facial proportions, while noting the size, shape,
symmetry, and spacing of facial features. Abnormal facial
Interpupillary distance 3.3–4.5 proportions (e.g., high or low forehead, receding chin)
may be indicative of a syndrome or may be familial.
Palpebral fissure 1.5–2.1
Forehead size can also result from neonatal conditions.
Inner canthal distance 1.5–2.5 For example, premature infants often have small,
narrow foreheads, but neonates with hydrocephalus
Outer canthal distance 5.3–7.3
present with an enlarged forehead. Table 16-2 lists the
Philtrum 0.6–1.2 normal physical measurements for facial features in
term infants. Some congenital and genetic disorders
Source: Elias, E. R., Tsai, A. C., & Manchester, D. K. (2009). Genetics present with distinctive dysmorphic features or abnor-
and dysmorphology. In Hay, W. W., Levin, M. J., Sondheimer, J. M.,
& Deterding, R. R. Current pediatric diagnosis & treatment. (19th ed.). mal proportions; some examples of these syndromes
(pp. 982–1052). New York: McGraw-Hill. are given in Table 16-3. The child’s facial expression
TABLE 16-3
Genetic and Congenital Abnormalities Associated with Dysmorphology of
the Face, Nose, or Oral Cavity
DISORDER FACIAL ABNORMALITY/DYSMORPHOLOGY
Beckwith-Wiedemann syndrome Macroglossia (enlarged tongue), facial dysmorphism (hypertelorism), and cleft
palate
Cleft lip and cleft palate Cleft lip may be unilateral or bilateral; it may occur alone or with cleft palate.
Palate cleft may involve just anterior and gingival ridge or extend into the
posterior palate.
Congenital hypothyroidism Low hairline, coarse facial features, and macroglossia
Fetal alcohol syndrome Flat midface, thin upper lip, absent philtrum, and micrognathia
Fragile X syndrome Oblong facies and prominent jaw
Marfan syndrome Long, thin facies; slanting palpebral fissures; high, arched palate; and crowded
dentition
Pierre-Robin sequence Micrognathia, glossoptosis (tongue falls to back of throat), and cleft palate;
macroglossia and ankyloglossia occur more rarely.
Sturge-Weber disease Facial nevus; can involve upper part of face or include lower part of face, mouth,
lip, neck, and torso (Moe, Benke, & Bernard, 2007)
Trisomy 13 syndrome Anophthalmia, colobomas, and cleft lip and palate. The abnormal facies associated
with trisomy 13 can be viewed at: http://medgen.genetics.utah.edu/photographs/
pages/trisomy_13.htm
Trisomy 18 syndrome Dysmorphic features including a characteristic face. The abnormal facies associated
with trisomy 18 can be viewed at: http://medgen.genetics.utah.edu/photographs/
pages/trisomy_18.htm
Trisomy 21 (Down syndrome) Up-slanting palpebral fissures; epicanthal folds; midface hypoplasia; short, flat
nose; protruding tongue; and macroglossia
Williams syndrome Coarse, elfin-like features, prominent lips
Source: Elias, E. R., Tsai, A. C., & Manchester, D. K. (2009). Genetics and dysmorphology. In Hay, W. W., Levin, M. J., Sondheimer, J. M., &
Deterding, R. R. Current pediatric diagnosis & treatment. (19th ed.). New York: McGraw-Hill.
must also be noted. A lack of emotional expression the external nose begins by the provider assessing the
(e.g., blunted or flat affect) may indicate depression, quiet child for flaring of the nares. Nasal flaring occurs
schizophrenia, or child abuse. with vigorous crying, when one naris is not patent, or
The provider should observe the newborn and older with respiratory distress (see Chapter 17). The external
infant or child while the child is crying or smiling to nose is also inspected for shape, symmetry, and mid-
assess for symmetry of facial movements. Any facial line placement on the face. Normal placement of the
asymmetry may indicate facial nerve (cranial nerve VII) nose can be determined by drawing an imaginary line
paralysis or facial fracture. In children who are deve- down the center of the child’s face, between the eyes,
lopmentally able to cooperate, the provider asks the to the top of the child’s upper lip. The nose should
child to raise his or her eyebrows, smile, frown, and be symmetric and in the center of the child’s face. A
open his or her eyes against resistance, noting strength flattened nasal bridge is a normal finding in African-
and symmetry of the facial muscles. These maneuvers American and Asian children; a flattened nose may
assess function of cranial nerves V (trigeminal) and VII. indicate a congenital syndrome. A cleft lip or palate
Any involuntary movements of the face may be caused may extend through the alveolar ridge, through the
by tics, seizures, or athetoid cerebral palsy. Involuntary upper lip and into the nose; this may be unilateral or
tremors may be a result of mercury poisoning (Diner bilateral. Nasolabial folds are also inspected. When
& Brenner, 2009). Involuntary contraction of the facial the child smiles or cries, the nasolabial folds should
muscles can also occur in children with hypocalcemia be symmetric; asymmetry can be due to injury to the
or tetany. Facial grimacing and twitching are also seen facial nerve (cranial nerve VII).
in children with chronic nasal itching from allergic The examiner should also note any lesions, swelling,
rhinitis. inflammation, excoriation, or bleeding of the external
nose. In the newborn, small, white cysts (milia) are
Palpation. Gentle palpation of the face is necessary normal findings and resolve spontaneously. Inflamma-
if any swelling is noted upon inspection or if there tion and swelling are abnormal findings of the external
is a history of facial injury, prolonged upper respira- nose. These findings are often seen with nose pierc-
tory infection, sinusitis, or parotitis. With a history of ing or can result from an insect bite or local infection,
injury to the face, the examiner should systematically such as impetigo. Excoriation of the external nose is
palpate the facial bones, specifically the orbital rims, seen with frequent nasal drainage and nose wiping. A
nasal bones, and temporomandibular joints to assess horizontal crease (allergic crease) across the lower third
for tenderness, crepitus, or irregularities in bone con- of the nose may be present in children with allergic
tour. Reduced sensation below the eye with palpation rhinitis; it is caused by the frequent upward rubbing of
suggests damage to the infraorbital nerve, which can the nose (allergic salute) to alleviate itching and to wipe
occur with a blowout fracture of the orbit (Brukner & nasal drainage (see Fig. 15-20). Bleeding of the external
Khan, 2006). Crepitus or midface instability may be nose can occur as a result of the child simply picking
appreciated by stabilizing the child’s forehead with at a sore or from trauma.
one hand, while gently pulling on the maxillary inci- To inspect the internal nose, an external light source
sors with the other gloved hand. Bimanual palpation is used, such as a penlight or otoscope with a nasal
of the mandible and maxilla with a gloved hand re- speculum attachment. When examining infants and
veals instability or tenderness of these bones. Mobility young children, the provider uses a penlight because it
of the hard palate during this maneuver indicates a is less invasive and requires less cooperation from the
maxillary fracture (Brukner & Khan, 2006). With a his- child. When an otoscope is used to inspect the internal
tory of repeated or prolonged URIs or sinusitis, facial nose, the child must be still and breathe out of his or
tenderness upon palpation suggests acute sinusitis (see her mouth during the nasal inspection; for this reason,
section on examination of the paranasal sinuses). An an otoscope with a nasal speculum is only used for
acutely inflamed parotid gland feels exquisitely tender older, cooperative children. However, the nasal specu-
on palpation (Templer & Liess, 2009). lum with an otoscope attachment provides better light
and magnification during inspection. When using a
Examination of the Nose penlight, the examiner should gently push the tip of
Although it is a brief portion of the assessment, physi- the infant or young child’s nose to inspect the internal
cal examination of the nose in children yields impor- nose. When using a nasal speculum, the older child
tant findings that provide clues to genetic or congenital should first tilt his or her head back slightly. Using the
disorders, respiratory distress, allergies, and other com- thumb of the nondominant hand, the examiner then
mon pediatric respiratory problems. In children, exam- lifts the tip of the child’s nose while the remaining por-
ination of the nose includes inspection and palpation. tion of the examiner’s hand rests on the child’s fore-
head to keep it steady. The speculum is then inserted
Inspection. Inspection of the nose involves observing gently about 1 cm into each naris, while avoiding the
both the external and internal nose. Examination of sensitive nasal septum.
Inspection of the internal nose begins by inspecting the nares as a result of chronic irritation from the child
the nares for patency. The nares are normally patent “picking.” More noticeable bleeding may be caused by
and free of any blockage or obstruction. This is par- the presence of a foreign body, allergies, or conditions
ticularly important for infants 4 months or younger, that affect blood clotting such as leukemia or other
who are obligate nose breathers and do not instinc- blood dyscrasias. Frank blood draining from the nose is
tively open their mouths to breathe (see Chapter 11). caused by head or facial trauma. Epistaxis (nosebleed)
Patency of the nares in older children can be deter- can be caused by facial or nasal trauma, foreign bodies,
mined by occluding one nostril and observing how the allergic rhinitis, forceful nose blowing, sneezing,
child breathes out of the other nostril, repeating on infection, the use of nonsteroidal anti-inflammatory
both sides. Breathing should be smooth, effortless, and drugs, chronic use of nasal steroids, or coagulation dis-
without noise. Another way to assess for nasal patency orders. Epistaxis is common in children school-aged
is for the examiner to hold a small mirror under both and younger; this is because of the anterior location
nares and then observe the circles of condensation of Kiesselbach’s plexus, which is easily irritated dur-
that form as the child exhales. Condensation circles ing nose-picking or low humidity. Cocaine use may
that vary in size may indicate a partial nasal obstruc- cause epistaxis in adolescents (Gluckman, Barricella,
tion; absent condensation demonstrates complete Quraishi, & Lamba, 2008).
obstruction of that naris. Lack of patency of either naris The examiner also inspects the nasal septum for align-
in older infants and children may indicate a deviated ment, perforation, bleeding, or lesions. The nasal septum
septum, swelling of the nasal turbinates, or discharge should be straight and midline. Deviation of the nasal
caused by upper respiratory infection or allergic rhini- septum can be congenital or result from facial trauma;
tis, polyps, nasal trauma, or the presence of a foreign significant deviation can interfere with breathing. Per-
body. Unilateral nasal flaring occurs when one naris foration of the nasal septum is apparent if light shines
is not patent; this is frequently a sign of foreign body through the perforation into the opposite naris. This
obstruction in a young child or choanal atresia in the is an abnormal finding and can result from intranasal
neonate. steroid, amphetamine, or cocaine use; digital trauma; or
The provider then inspects the inferior and middle the insertion of a foreign body into the nasal vestibule
nasal turbinates, beginning with determination of color (Shermantaro & Charnesky, 2007). Septal erythema, fri-
and the presence of swelling. The nasal mucosa is nor- ability, excoriation, or bleeding is often a consequence
mally pink and without edema; the nasal turbinates of low humidity, chronic nose-picking, or cocaine use.
should be firm, pink, and moist. A small amount of Children with chronic respiratory conditions (e.g.,
thin, clear, watery nasal discharge is normal. Boggy allergy, cystic fibrosis) often develop nasal polyps,
(chronically edematous), pale, or bluish nasal muco- which are moist, shiny, grape-like sacs that are a gray-
sa or turbinates indicate allergic rhinitis. Bright red, to-green color and protrude into the nasal vestibule.
edematous nasal mucosa indicates inflammation, Polyps can cause nasal obstruction, in which case
which accompanies upper respiratory infections. The surgical removal is warranted (McClay, 2008).
color, character, and amount of any nasal drainage
should be noted and described. A small amount of Palpation. The external nose is palpated for pain or
clear, thin, watery nasal discharge (rhinorrhea) may be tenderness. The bridge of the nose normally feels firm;
normal, especially if the child was recently crying; it the remaining area of the external nose should feel soft.
can also be a result of cold ambient air temperatures. The child or adolescent should not feel any pain or
Rhinorrhea in large amounts can be attributed to al- tenderness upon palpation. Painful or tender nasal tis-
lergic rhinitis. If the child has recently suffered head sue may result from sinusitis, infection, inflammation,
trauma, any rhinorrhea must be tested for the presence or injury.
of glucose, which confirms that the drainage is cere-
brospinal fluid. Nasal drainage from an upper respira- Assessment of Smell
tory infection is often a yellow-to-green color, thick Assessment of smell (cranial nerve I) is usually tested
in consistency, and draining from both nares. Thick, in children as part of the neurologic assessment. See
yellow-to-green nasal drainage accompanied by ery- Chapter 22 for a discussion of testing olfaction in
thematous nasal mucosa indicates bacterial sinusitis; children.
purulent drainage from the middle meatus is diagnos-
tic for acute sinusitis (Leung & Kellner, 2004). Purulent Examination of the Paranasal Sinuses
nasal drainage from only one naris indicates the pres- The paranasal sinuses are assessed in children 2 and
ence of a foreign body, especially when the drainage older. Only the frontal and maxillary sinuses are
has a foul odor. accessible for physical examination. Assessment of the
The examiner also inspects the internal nose for any paranasal sinuses involves inspection, palpation, per-
signs of bleeding. Often, dried blood may be present in cussion and, in some instances, transillumination.
Inspection. The sinuses cannot be directly inspected, is present in acute sinusitis (Leung & Kellner, 2004);
but the facial area over the sinuses is evaluated for crepitus upon palpation suggests the presence of an
periorbital edema or erythema; these findings may accumulation of exudate in the sinuses, also an indica-
indicate sinusitis (AAP, 2001; Leung & Kellner, 2004). tion of acute or chronic sinusitis.
Palpation. Palpation of the paranasal sinuses is done Percussion. Percussion of the sinuses is indicated if the
in children school-aged and older. This assessment child experienced pain upon palpation of the sinuses
includes evaluation of the frontal and maxillary sinuses. or if the child has a history of prolonged upper respi-
Palpation of the frontal sinuses is done by placing the ratory infection or postnasal drainage. The provider
thumbs on the child’s forehead at the orbital ridge, then gently percusses the paranasal sinuses by lightly tap-
pressing gently upward to assess for tenderness. The ping over the frontal and maxillary sinuses (Fig. 16-9).
maxillary sinuses are then palpated by pressing up un- The sinuses should be resonant on percussion and the
der both zygomatic arches with the thumbs (Fig. 16-8). child should not feel any pain or discomfort. Dullness
When palpated, the sinuses are normally nontender or tenderness on percussion may indicate sinusitis or
and nonedematous bilaterally. Tenderness or swelling allergic rhinitis.
A
A
B B
FIGURE 16-8. Palpating the sinuses. A. Frontal. B. Maxillary. FIGURE 16-9. Percussing the sinuses. A. Frontal. B. Maxillary.
Transillumination. If tenderness is noted on palpation

or percussion of the sinuses, transillumination may be
indicated. Transillumination of the sinuses does not
yield useful data in children younger than 10 because
of their undeveloped sinuses, but it may be helpful in Low nasal
adolescents. If the light transillumination is normal, bridge
sinusitis is unlikely; if absent, sinusitis is likely (AAP, Epicanthal
2001; Wald, 2003). folds
Short palpebral
To transilluminate the sinuses, the provider first fissures Minor ear
abnormalities
darkens the room. Transillumination of the frontal Short nose
sinuses involves placing a very bright light directly Flat midface
Thin upper lip
below the medial supraorbital ridge (i.e., under the
eyebrow), pointed upward. The examiner then covers Receding jaw
the light source with the nondominant hand over
the child’s eye to shield the light, observing for light
illumination at the anterior frontal sinus. Both sides
FIGURE 16-10. Typical facies noted with fetal alcohol
are compared. Normally, sinuses should be air-filled; syndrome. Note the thin upper lip and long philtrum.
this will be seen as a dim red glow. If the red glow is ab-
sent, the sinuses are likely filled with fluid or purulent
drainage, which indicates sinusitis (AAP, 2001). with cyanosis. A dark, cherry red color to the lips is seen
To transilluminate the maxillary sinuses, the ad- with acidosis or carbon monoxide poisoning.
olescent should first slightly extend the neck back. The child’s lips should be moist and smooth. Dry,
Then, the examiner places the bright light source cracked lips may be the result of living in a dry climate,
(again, shielded from the examiner) over the infe- chronic mouth breathing, habitual lip-licking or biting,
rior orbital rim (cheekbone), below the inner aspect dehydration, or fever. Fissures of the lips most often
of the eye, just lateral to the nose. The adolescent appear at the corners of the mouth; these may indicate
should then open his or her mouth as the examiner deficiencies of riboflavin or niacin. Swelling of the lips
shines the light downward. The examiner then looks may occur with injury to the mouth, allergic reactions,
for light transmission through the hard palate with insect bites, local infection, or generalized edema.
the adolescent’s mouth open. Both sides of the face The lips are normally symmetrical when relaxed or
should be transilluminated. A dim red glow should crying or when the child speaks. Asymmetry of the lips
be seen on the hard palate; if absent the maxillary or excessive drooling may indicate facial nerve impair-
sinuses are likely filled with fluid or purulent drainage ment. A thin upper lip accompanied by a long phil-
(AAP, 2001). trum suggests fetal alcohol syndrome (FAS) (Fig. 16-10).
A cleft in the upper lip is easily visible on inspection in
Examination of the Oral Cavity newborn infants and older children when not yet sur-
gically repaired; surgical scars are seen once the cleft
Examination of the oral cavity includes assessment of
lip has been surgically closed (Fig. 16-11). A cleft lip
the lips, buccal mucosa, gums, teeth, tongue, palate, uvula,
may be unilateral or bilateral and may extend past the
pharynx, and tonsils.
upper border of the lip and into the naris (Fig. 16-12).
Lesions on the lips should be inspected closely. Young
Inspection infants will often have a small callus or blister on the
Lips and Perioral Area. Inspection of the oral cavity upper lip due to vigorous sucking. Other lesions may
begins with inspecting the exterior of the mouth, indicate oral infections, such as impetigo; vesicles on
specifically the lips and perioral area. The lips should be or around the lips may indicate herpes simplex infec-
inspected for color, moisture, texture, fissures, swelling, tion (herpetic gingivostomatitis).
symmetry, lesions, or clefts. The perioral area is inspec- The skin around the lips (perioral area) is also
ted for color, lesions, rashes, or excoriation. inspected; it should be pink, clean, and clear, without
The lips are normally a darker pink color than the rashes, lesions, or excoriation. Circumoral pallor in chil-
surrounding skin. Lips are pink in light-skinned children dren can result from streptococcal pharyngitis, scarlet
and pale bluish gray in dark-skinned children. Lips that fever, erythema infectiosum (Fifth disease) (Servey,
are pale pink can be indicative of anemia. Lips that are Reamy, & Hodge, 2007), anemia, or shock. Circumoral
a blue-to-purple color may simply be an indication of cyanosis can occur in infants after feeding; this is tran-
temporary vasoconstriction resulting from cold ambient sient and considered normal. Circumoral cyanosis can
temperature or be a sign of cyanosis. Blue or purple lips also indicate hypoxemia. Oral infections may spread
also indicate cyanosis in fair-skinned children; in dark- from the mouth to the perioral area, as with herpetic
skinned children, the lips become a more ashen color gingivostomatitis, which causes visible lesions. The
Buccal Mucosa. Using a penlight and tongue

depressor, the provider inspects the buccal mucosa for
color, moisture, lesions, and ulcers. The Stensen’s ducts
are also inspected. In light-skinned children, the buc-
cal mucosa should be pink; in dark-skinned children,
the buccal mucosa is bluish. Erythema of the buccal
mucosa results from infection or inflammation.
Pallor of the buccal mucosa may be the result of ane-
mia, shock, or vasoconstriction; cyanosis results from
hypoxemia, though cyanosis may not be visible in an
anemic child. The buccal mucosa should also be moist
and free of lesions. Dry oral mucosa can result from
prolonged mouth breathing, prolonged nasal conges-
tion, or from moderate-to-severe dehydration. White,
curd-like patches on the buccal mucosa that cannot be
scraped off with a tongue depressor and that leave the
mucosa erythematous and bleeding indicate oral candi-
diasis, which may occur in infants and young children
after oral antibiotic therapy or in children with HIV/
acquired immunodeficiency sydrome (Fig. 16-13).
FIGURE 16-11. Cleft lip. Tiny bluish white dots surrounded by red halos on the
buccal mucosa are Koplik’s spots; these are considered
pathognomonic for the onset of measles (Fig. 16-14).
perioral skin may also become inflamed, scaly, and Petechiae on the buccal mucosa may be a result of biting
excoriated with repetitive licking of the lips (“lip or can indicate blood dyscrasias or infection. Vesicles
lickers’ dermatitis”). on the buccal mucosa or tongue may be caused by cox-
sackievirus, especially if the lesions also occur on the
Breath. Next, the child’s breath is assessed; it should hands and feet. Vesicles that rupture quickly, leaving
smell clean; breath odor often indicates pathology. shallow ulcers surrounded by an erythematous halo,
Foul breath odor (halitosis) may be due to bacterial are caused by herpes simplex type I. Similar ulcers on
accumulation between the teeth and on the tongue the buccal or labial mucosa that were not preceded by
with infrequent tooth brushing, lack of flossing, vesicle formation are aphthous ulcers (canker sores),
or with tooth decay. Other causes of halitosis in painful lesions that take approximately 1–2 weeks to
children and adolescents include prolonged mouth heal. Aphthous ulcers can be caused by stress, mild
breathing, tobacco use, sinusitis, nasal polyps, nasal trauma, or food allergies (Plewa, 2009). The openings to
foreign body, tooth decay, dental abscesses, chronic the parotid glands, or Stensen’s ducts, should be visible
constipation, diabetic ketoacidosis, and streptococcal upon inspection. These ducts are located opposite the
pharyngitis. upper second molar and appear as a small indentation.
A B
FIGURE 16-12. A. A cleft lip may be minimal or extend past the upper border of the lip or may be
unilateral or bilateral and extend into the nares (B).
resolve without treatment. If the lesion shows signs of

infection, an immediate dental referral is warranted.
The Teeth. The teeth should be inspected for number,

type, and condition. Occasionally, an infant will be born
with teeth; these are termed natal teeth; teeth that erupt
in the first 30 days of life are called neonatal teeth. It is
important to assess these teeth for mobility because
loose teeth present the risk of aspiration; tooth mobil-
ity greater than 1 mm is an indication for extraction.
Gingival inflammation may also be present with natal
FIGURE 16-13. Oral candidiasis. For a full-color example, or neonatal teeth (Ritwik & Musselman, 2007). Natal
please refer to Figure 16-13 on page C3. or neonatal teeth occur in normal newborns or may
occur with cleft palate (Rao & Mathad, 2009).
Beginning at 4 months, the alveolar ridge is
Normally, the Stensen’s ducts are not erythematous or inspected for the eruption of teeth. Once teeth have
edematous, and saliva should be visible in the oral cav- erupted, they should be inspected systematically and
ity. The opening to the Stensen’s ducts is erythematous in good light, beginning with the upper teeth, then
with parotitis (mumps). moving to the lower teeth. The number of primary
and permanent teeth is determined; the child should
The Gums. The gums are inspected for color, swelling, have all 20 primary teeth by age 3. A child with com-
and lesions. The gums are normally pink in light- plete permanent dentition has 32 teeth. Exfoliation of
skinned children and bluish or pale in dark-skinned primary teeth and eruption of permanent dentition
children, with areas of concentrated melanin along begin at about 6 years and occur in the same sequence
the gingival margin. Erythematous, bleeding gums can as eruption of primary teeth. Variations in the number
indicate poor oral hygiene, gingivitis, malnutrition, or of expected teeth should be assessed, noting any devia-
oral infection. Gingival hyperplasia can occur as the side tions in patterns of tooth eruption, such as permanent
effect of certain drugs such as phenytoin, cyclosporine, teeth erupting before primary teeth have exfoliated;
nifedipine, and certain calcium antagonists (Mejia & this requires a dental referral. The color and condition
Lozada-Nur, 2009). Gingival hyperplasia can also occur of the teeth are assessed; teeth should be uniformly
during puberty and in pregnancy (Clocheret, Dekeyser, white without variations in the surface. Dental plaque
Carels, & Willems, 2003). An eruption cyst may be noted; is sticky areas of accumulated clear-to-white film seen
this is a soft, clear fluid-filled cyst that occurs on the on the teeth; large amounts indicate poor dental hy-
gums in children who are teething. Eruption cysts are giene. Brown or black teeth indicate dental caries; to-
caused by an accumulation of fluid between the tooth bacco use may result in brown or yellow teeth. Brown
and overlying gum tissue and are most commonly seen or black spots seen primarily on the maxillary central
in the mandibular molar area. An eruption hematoma incisors suggest early childhood caries (Fig. 16-15).
differs from an eruption cyst in that it is filled with Erosion of tooth enamel is seen with bulimia nervosa.
blood rather than clear fluid. An eruption hematoma Loose teeth may be normal as a result of exfoliation
appears as a bluish vesicle-like swelling on the alve-
loar ridge, especially with the first and second molars.
Because the tooth erupts through these lesions, they
FIGURE 16-14. Koplik’s spots. For a full-color example, please FIGURE 16-15. Early childhood caries. For a full-color
refer to Figure 16-14 on page C3. example, please refer to Figure 16-15 on page C3.
or be caused by trauma, dental infection, or gingivitis.

Any malocclusion is also noted. This is assessed by ask-
ing the child to bite down while the examiner notes
any marked misalignment or protrusion of the teeth.
Malocclusion can occur as a result of thumb-suck-
ing, cleft palate, or micrognathia. Worn areas on the
chewing surfaces of the teeth can be due to bruxism or
misaligned teeth.
The Tongue. The tongue is inspected for movement,

color, texture, moistness, size, and lesions. If the child
is developmentally capable, the examiner asks the
child to stick out his or her tongue for inspection. The
tongue should be midline. The ability to stick out the FIGURE 16-16. Strawberry tongue. For a full-color example,
tongue verifies an intact cranial nerve XII (hypoglossal) please refer to Figure 16-16 on page C3.
function. In infants and young children who are not
able to stick out their tongue on command, an abil-
This is a benign condition known as geographic tongue
ity to suck or speak allows the examiner to assess
(benign migratory glossitis) (Fig. 16-17). The etiology is
adequate tongue movement; tongue movement can
unknown, but it is thought to be inherited; it also occurs
also be visualized when the infant or young child cries
with increased frequency in persons with allergies or pso-
vigorously. Ankyloglossia (tongue-tie) is the complete
riasis (Kelsch, 2009). An enlarged tongue (macroglossia)
or partial fusion of the lingual frenulum to the floor of
is seen in Down syndrome, hypothyroidism, and Pierre-
the mouth, thus restricting movement of the tongue.
Robin syndrome (Elias, Tsai, & Manchester, 2009). The
This condition occurs in newborns and makes breast-
ventral surface of the tongue is a thinner layer of skin
feeding difficult or impossible because of the inability
than the dorsum, with easily visible blood vessels. This
of the tongue to reach the palate. Signs of complete
surface should be pink and moist.
ankyloglossia are evident when the tongue does
not protrude past the alveolar ridge, cannot rise to
Hard and Soft Palates. In infants and toddlers, a
touch the hard palate, cannot move laterally, and the
tongue blade is needed to open the mouth and examine
tongue appears heart-shaped when extended (Martin
the palate unless the child is vigorously crying. Children
& Schwartz, 2008).
preschool-aged and older are able to cooperate by open-
The dorsal portion of the tongue is normally pink to
ing their mouth and saying “ah.” If the child shows
pale pink, moist, and without lesions. Changes in the
any signs of epiglottitis, such as absence of spontane-
color of the tongue can result from recent consumption
ous cough, drooling, or agitation, neither the palate
of colored food, drinks, or medications. An erythema-
nor throat should be examined in any way; this may
tous tongue can result from glossitis, an acute or chronic
stimulate the gag reflex, thereby precipitating complete
inflammation of the tongue that can be caused by viral
obstruction by inducing a reflex laryngospasm.
infections (herpes simplex), trauma, or injury (bites or
Once the oral cavity is open, the examiner shines a
burns), exposure to irritants such as tobacco, alcohol, or
light on the palate to obtain a full view. The hard and soft
hot food; or by a localized allergic reaction. Aphthous
ulcers or erythema multiforme (Stevens-Johnson syn-
drome) can also cause glossitis. Streptococcal scarlet fever
and Kawasaki disease are associated with a “strawberry
tongue” in which the tongue first has a white coating
through which erythematous papillae project, then the
white coating peels, leaving an inflamed tongue with
erythematous papillae, mimicking the appearance of a
strawberry (Fig. 16-16). A yellow color to the tongue,
particularly the ventral surface, indicates jaundice; this
is often the first area where jaundice is identified in a
dark-skinned child. A dry tongue can indicate mouth
breathing or may result from dehydration. The dorsal
surface of the tongue will appear rough from papillae.
In some children, painless, inflamed, irregularly shaped
furrows and grooves may be noted, often extending to
the lateral areas of the tongue. These lesions are red, FIGURE 16-17. Geographic tongue. For a full-color example,
with whitish borders and absent papillae in the center. please refer to Figure 16-17 on page C3.
palates should be inspected for color, shape, intactness,

TABLE 16-4
and lesions; the soft palate is also evaluated for move-
ment. The hard palate is normally pale pink, smooth,
Grading Tonsillar Size
dome-shaped, and contiguous with the soft palate. A in Children
high-arched palate may be caused by chronic mouth- GRADE DESCRIPTION
breathing and is also seen with Marfan syndrome. The
soft palate is pinker than the hard palate, moist, and 0 Atrophic tonsils
soft. The soft palate and uvula normally rise symmetri-
1⫹ Tonsils slightly visible
cally and at midline when the child says “ah.” Both pal-
ates and the uvula should be intact without clefts (bifid 2⫹ Tonsils enlarged; meet halfway between
uvula). Both the hard and soft palates may be cleft and tonsillar pillars and uvula
the openings may be small or may involve the entire 3⫹ Tonsils almost touching the uvula
palate (see Fig. 16-12). Symmetrical movement of the
soft palate and uvula indicates intact function of cra- 4⫹ Tonsils touching each other at midline
nial nerve X (vagus). Deviation of the uvula may indicate
damage to cranial nerve X, poliomyelitis, diphtheria,
or peritonsillar abscess. Touching the uvula elicits the
gag reflex; this also tests the function of cranial nerves
IX (glossopharyngeal) and X. In a jaundiced child, the The Tonsils. The tonsils are inspected for size, color,
hard palate is yellowish. White patches that bleed when exudate, pitting, enlarged crypts, or membranous coverings.
scraped with a tongue depressor indicate oral candidia- The tonsils should be equal in size; tonsillar size should
sis. In the newborn, small (1–3 mm), white cystic nod- be quantified, according to the scale presented in Table
ules or papules noted along the juncture of the hard and 16-4 and illustration in Figure 16-18. This quantitative
soft palates are Epstein’s pearls; these are not significant guideline is especially helpful when examining children
and resolve spontaneously through exfoliation within with chronic tonsillar enlargement. Tonsils that are
the first few weeks of life (Flaitz, 2005). Petechiae on unequal in size usually indicate the presence of a peri-
the palate are seen in bleeding disorders, streptococcal tonsillar abscess. The tonsils are normally the same color
infections, and with infectious mononucleosis, where as the buccal mucosa. Tonsils that are erythematous and
palatal petechiae are typically seen at the juncture of enlarged are seen with humoral changes, allergies, and
the hard and soft palates (Omori, 2009). infection. Tonsillar hypertrophy can cause obstructive
sleep apnea in adolescents, particularly in teens who are
The Pharynx. The pharynx, or throat, is inspected obese. Enlarged, erythematous tonsils with or without
for color, swelling, and lesions. The tonsils are also
inspected. In young or uncooperative children, it may
be necessary to depress the tongue with a tongue blade
to view the pharynx and tonsils fully, while avoiding
the posterior pharynx and uvula to prevent eliciting
the gag reflex.
Normally, the pharynx is pink, moist, and without
exudate or lesions. Pharyngeal erythema occurs when
purulent nasal discharge drips and causes chronic ir-
ritation, as seen with sinusitis (Leung & Kellner, 2004).
“Cobblestoning” may be seen on the posterior phar-
ynx; this is a term used to describe streaks of lymphoid
tissue on the posterior pharynx, which is often seen 1+ 2+
with allergic rhinitis. Erythematous macules that evolve
into vesicles that ulcerate, leaving an erythematous
halo, are caused by herpangina. These lesions are usu-
ally less than 5 mm in diameter and are found on the
posterior pharynx, soft palate, tonsils, and occasion-
ally the tongue and posterior buccal mucosa. Herpan-
gina also causes mild-to-severe pharyngeal erythema
(Gompf, Casanas, & Cunha, 2008). Pharyngeal edema
may result from streptococcal pharyngitis, diphtheria,
peritonsillar or retropharyngeal abscess, cervical adeni-
tis, food allergy, foreign body in the throat, or chemi- 3+ 4+
cal ingestion. FIGURE 16-18. Grading of tonsillar size in children.
allergic rhinitis or a submucosal cleft palate. Transitional

dentition (when both primary and permanent teeth are
present), cleft lip and palate, dental injuries, neurologic
injury (i.e., cranial nerve X), and tooth decay can lead
to speech articulation difficulties. Some of these prob-
lems may also lead to difficulties with feeding and swal-
lowing and may cause recurrent middle ear infections;
appropriate referrals to a speech pathologist, otolaryn-
gologist, and pediatric dentist may be necessary.
COMMON DIAGNOSTIC
STUDIES
FIGURE 16-19. Tonsillar exudate and enlargement, as seen
with streptococcal pharyngitis and infectious mononucleosis.
For a full-color example, please refer to Figure 16-19 on Various diagnostic tests may be necessary to clarify dif-
page C3. ferential diagnoses of abnormal conditions involving
the face, nose, and mouth. Some examples of these di-
agnostic studies and their indications are summarized
exudate indicate infection. White or yellowish-white in Table 16-5.
exudate on an erythematous posterior pharynx and on
the tonsillar crypts suggests streptococcal pharyngitis
or infectious mononucleosis (Fig. 16-19). Pitting or DOCUMENTING FINDINGS
enlarged tonsillar crypts occur in children who have
had recurrent respiratory infections or chronic allergies. SAMPLE WRITE-UP: WELL CHILD
Thick, gray exudate may signify diphtheria. A thin,
gray membranous covering over the tonsils that does
Subjective Data
not bleed when removed is likely a result of infectious A 10-year-old boy is seen in the clinic for a health
mononucleosis. maintenance visit.
Palpation. Structures in the oral cavity that are palpat- Objective Data
ed include the gums and palate. Gloves should be worn Face: Symmetrical features; no periorbital edema;
when palpating the inside of the mouth. The gums are paranasal sinuses nontender on palpation.
palpated for tenderness and bleeding. Normal, healthy Nose: Nose smooth, symmetrical alignment; no de-
gum tissue is not tender and does not bleed with pal- viation or lesions. Septum midline without deviation.
pation. Findings of gum tenderness, pain, or friability Nares patent bilaterally. Turbinates pink, nonedema-
with palpation suggest infection and require a dental tous; no polyps, lesions, or drainage seen. CN I intact.
referral. In the neonate, the hard and soft palates are Oral cavity: Lips pink; no lesions. Buccal mucosa
palpated to assess for a cleft that is not easily visible on pink without lesions. Has four upper and four lower
inspection (see Chapter 11). A submucosal cleft pal- permanent teeth (lateral and central incisors); first
ate can be palpated; it also may be thin and slightly mandibular premolar loose. Teeth without plaque or
arched; this occurs when a cleft is in the hard or soft visible caries. No malocclusion. Gingival tissue pink
palate but is covered by mucous membrane and is not without bleeding. Tongue midline, pink; free of le-
easily visible on inspection. A submucosal cleft palate sions; protrudes strongly at midline (CN XII). Soft
is often associated with a bifid uvula. The strength of palate rises symmetrically. Tonsils 21 bilaterally with-
the neonate’s suck reflex is also evaluated at this time. out injection or exudate. Uvula midline. Pharynx
Once the intactness of the palate is established, it is pink; no injection, exudates, or drainage. Gag reflex
not routinely palpated in subsequent physical exami- (CN IX 1 X) intact. CN VII and IX intact for taste.
nations unless lesions, edema, or erythema are noted. Assessment: Healthy 10-year-old boy
SAMPLE WRITE-UP: 8-YEAR-OLD WITH

EVALUATION OF SPEECH SORE THROAT
As part of the assessment of the face, nose, and mouth, Subjective Data
the quality of the child’s speech is also evaluated. For An 8-year-old girl is brought to clinic by her mother
example, a nasal quality to the voice often indicates with complaints of a severe sore throat and fever.
TABLE 16-5
Diagnostic Studies Used to Evaluate Conditions of the Face,
Nose, and Mouth
DIAGNOSTIC
STUDY INDICATION COMMENTS
Computed Injuries to face that involve loss of CT scanning necessary to obtain accurate
tomography (CT) scan consciousness (⬎1 min), amnesia, lethargy, diagnosis in maxillofacial fractures; radiographs
focal neurologic deficits, skull fracture, difficult to interpret in children (Alcala-
seizures, or persistent vomiting (Rosman, Galiano, Aribas-Garcia, Martin-Perez, Romance,
2006); acute or chronic sinusitis Montalvo-Moreno, et al., 2008); also used as
adjunct in diagnosing sinusitis in children older
than 6 years (AAP, 2001).
Throat culture To isolate causative organism of infection Streptococcal infections must be treated with
antibiotics to avoid long-term complications.
Radiographs Chronic or recurrent sinusitis Waters’ view needed to demonstrate sinusitis on

radiograph.
Rapid streptococcal To diagnose pharyngeal streptococcal Findings must be confirmed with culture.
antigen test infections
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Assessment of the
17 Thorax, Lungs,
and Regional
Lymphatics ELLEN M. CHIOCCA
Respiratory infections and disorders are common or angle of Louis, a palpable bony prominence where
in infants and children. Anatomic and physiologic the manubrium meets the body of the sternum. The
immaturity of the respiratory system, increased expo- angle of Louis also marks the place at which the
sure to respiratory viruses in school or day care, the second pair of ribs articulates with the sternum; this
incidence of asthma and allergies, and infection with is a clinical reference point for counting ribs and in-
communicable respiratory diseases such as pertussis, tercostal spaces.
are all factors that make the pediatric respiratory Twelve pairs of ribs comprise the thoracic cage, ar-
assessment so important. Because of the frequency and ticulating with the thoracic vertebrae posteriorly. Only
potential severity of respiratory disorders in children, the top seven pairs of ribs articulate directly with the
excellent respiratory assessment skills are vital for the sternum. Costal cartilage, which connects these seven
pediatric health care provider. ribs to the sternum, allows for expansion and contrac-
tion of the thoracic cage with respiration. Beneath the
sternum, ribs 7 through 10 connect to the costal carti-
lage of the pair of ribs lying superior to them, forming
ANATOMY AND PHYSIOLOGY the costal angle, a frequently used assessment landmark
(see Fig. 17-1). The remaining two pairs of ribs are con-
THORAX nected only to the vertebrae.
Thoracic Cage There are eleven pairs of intercostal and eight pairs
The thoracic cage includes the sternum, twelve of thoracic muscles that work with the diaphragm to
thoracic vertebrae, twelve pairs of ribs, and costal move the thoracic cage during inspiration and expira-
cartilage intercostal and thoracic muscles (Fig. 17-1). tion. During periods of respiratory distress, intercos-
The purpose of the thoracic cage is to support and tal muscles become more visible as infants and young
protect the structures within the thoracic cavity. For children use these muscles to assist respiration. When
simplification, the thoracic cage can be divided into assessing the chest, imaginary vertical reference lines
three main sections: the sternum anteriorly, the ribs are used to describe the location of physical findings.
laterally, and the vertebrae posteriorly. The sternum, These lines are illustrated in Figure 17-2 and are sum-
which lies in the center of the chest, can be divided marized in Table 17-1.
into three parts: the manubrium (top portion), gladi-
olus (body), and the xiphoid process (the tip) (see Fig. Thoracic Cavity
17-1). The manubrium, a triangular bone, attaches to The thoracic cavity is the chamber that contains mul-
the clavicles and the first and second ribs on either tiple structures and organs of the cardiovascular, respi-
side (see Fig. 17-1). The manubrium also is the point ratory, gastrointestinal, and endocrine systems. The
at which the sternocleidomastoid and pectoralis major thoracic cage protects these structures. The mediasti-
muscles attach; both of these muscles are accessory num, or center portion of the thoracic cavity, contains
muscles of inspiration. the trachea, esophagus, heart and great vessels, thymus
Two important anatomic landmarks are located on gland, and lymph nodes of the chest. The lungs are po-
the manubrium. The suprasternal notch is located at sitioned on either side of the mediastinum. The dia-
the superior border of the manubrium (see Fig. 17-1). phragm, the main muscle of respiration, separates the
Just below the suprasternal notch is the sternal angle, thoracic cavity from the abdominal cavity.
348
C HA P T E R 17 A s s e s s m e n t o f th e Th o rax , Lun gs , an d Re gio n a l Lymphatic s • 349
Suprasternal
notch
Clavicle
Manubrium of
1 sternum
2
Cartilage
3 Manubriosternal
Intercostal 4
angle Midsternal
space 5 (angle of Louis) line
Dome of 6 Body of sternum
the diaphragm 7
8
Xiphoid process
Costal angle Costochondral
Right
9 midclavicular
10
junction
Costal margin line
FIGURE 17-1. Anterior thoracic cage. Left

midclavicular
line
Pleural Cavity
The thoracic cavity is surrounded by a thin, serous
membrane called the pleura that is divided into two
layers: the parietal pleura, which lines the chest wall,
and the visceral pleura, which lines the lungs, blood
Vertebral
vessels, and bronchi. The pleural space is the thin space
line
between these two layers. Within the pleural space is
pleural fluid, which lubricates the pleural membranes
and permits the pleural layers to move smoothly Left
against each other during respiration. scapular
line
Lungs
The lungs are two paired, conical structures within the
Right
thoracic cavity that serve as a medium for the exchange scapular
of gases (Fig. 17-3). The apex is the pointed portion that line
reaches slightly above the clavicle. The base is the wide
portion at the bottom that extends to the diaphragm.
The right lung consists of three lobes; the left lung
has two lobes. Within the lungs are the trachea and
bronchi (see Fig. 17-3). The trachea bridges the upper
and lower respiratory tracts; it extends from the larynx
to the bronchi in the upper thorax to below the ster-
num. The lower portion of the trachea bifurcates into
the left and right main stem bronchi (see Fig. 17-3).
Midaxillary
Both of these structures function as passageways for air line
moving to the lower respiratory tract for gas exchange.
The right main bronchus is shorter and lies in a more
vertical plane than the left bronchus; this explains Anterior
why aspirated objects are more likely to enter the right axillary
bronchus. The bronchi then further branch into the line
bronchioles, which become even smaller and terminate
into the alveolar ducts, alveolar sacs, and alveoli, where
Posterior
gas exchange occurs (see Fig. 17-3). axillary
line
RESPIRATORY MECHANICS
During the respiratory cycle, the lungs transport oxy-
gen from the atmosphere to the tissues and cells
and carbon dioxide from the tissue and cells to the FIGURE 17-2. Vertical reference landmarks of the chest.
atmosphere. One respiratory cycle involves an inspi-
ratory and expiratory phase. During inspiration, the
alveoli, which forces air out of the lungs. At the end

TABLE 17-1
of each expiration, some air remains in the alveoli be-
Vertical Reference cause of surfactant, a lipoprotein that is secreted by
Landmarks of the Chest type II alveolar cells to reduce the surface tension of
ANTERIOR POSTERIOR LATERAL pulmonary fluids and to prevent alveolar collapse.
CHEST CHEST CHEST Respiration is involuntary, and the rate of respiration
is controlled by age, metabolic rate, fever, and cardio-
Right Left scapular Anterior axillary vascular and neurologic function.
midclavicular line line line
Midsternal line Vertebral line Midaxillary line
Left midclavicular Right scapular Posterior DEVELOPMENTAL

line line axillary line
CONSIDERATIONS
EMBRYONIC DEVELOPMENT
diaphragm contracts and flattens to enlarge the tho- In the early embryonic period (weeks 1 to 5), lung buds
racic cavity, and the intercostal muscles lift the ster- appear, and the pulmonary vein develops to join the
num and elevate the rib cage. This creates negative lung bud. By the end of week 5, the trachea begins to
pressure, which draws air into the lungs, enhancing develop. Between weeks 5 and 17, the major lobes of
venous blood return to the heart. During expiration, the lungs begin to develop, and the main bronchi are
the diaphragm and intercostal muscles relax and the formed. The pulmonary capillary bed also develops,
lungs compress, creating positive pressure within the which connects the bronchial blood supply. Between
Frontal sinus Sphenoidal sinus
Nasopharynx
Nasal cavity
Oropharynx
Laryngeal pharynx
Epiglottis Larynx and vocal cords

Esophagus
Trachea
Right lung Left lung
Right Mediastinum
bronchus
Horizontal
cross-section
of lungs
From plumonary
artery
Alveolar duct
Terminal bronchiole Diaphragm
To pulmonary Viscera
Thoracic vertebra
vein pleura
Aveoli
Parietal
Pleural space pleura
Right lung Wall of thorax

Capillaries Sternum
FIGURE 17-3. The respiratory system.

weeks 13 and 25, type II alveolar epithelial cells appear The airway and nasal passages of the infant and
and eventually become responsible for the production child are small and narrow, and the larynx is nar-
of surfactant. During this time, the airway begins to rowest at the level of the cricoid cartilage (Swamy &
increase in size and in diameter and become more tu- Mallikarjun, 2004). One millimeter of airway edema
bular in shape. At 25 weeks, alveolar sacs are formed, can narrow an infant’s airway by 60% (Macfarlane,
but the ability for gas exchange is limited by the im- 2006). Newborns produce little respiratory mucus,
maturity of type II cells and their inability to release increasing their susceptibility to respiratory infec-
adequate amounts of surfactant. After week 26, type tions (Kyle, 2008). The oropharynx is proportionately
II cells gradually become more numerous and mature, smaller and narrower and the trachea is proportion-
and more alveoli form. Near the end of the sixth gesta- ately shorter and has a smaller diameter than that of
tional month, the alveoli are capable of gas exchange. an older child or an adult; this increases the poten-
Lung size increases rapidly until week 36 of gestation, tial for obstruction (Ball & Bindler, 2006). From birth
and more surfactant is secreted. At birth, the lungs are until approximately 8–10 years, the larynx is located
filled with fluid, which is expelled as the infant moves 2–3 cervical vertebrae higher at the level of C3–C4,
through the birth canal and as the lungs fill with air which makes the child more vulnerable to aspiration
after the umbilical cord is cut. (Macfarlane, 2006; Swamy & Mallikarjun, 2004). Un-
til age 5, the tracheal cartilage is elastic and collapses
easily, leaving the young child vulnerable to airway
STRUCTURE obstruction and resistance to airflow. The trachea con-
An infant’s chest is round and barrel shaped, and the tinues to grow in diameter and triples in size between
anterior–posterior (A-P) diameter equals the trans- birth and puberty (Ball & Bindler, 2006).
verse diameter (Fig. 17-4A). The chest circumference In infants and toddlers, the mucous membranes
should closely match the head circumference from age lining the respiratory tract are more loosely attached
6 months to 2 years; chest circumference should then and very vascular, making the potential for airway
exceed head circumference at age 2 years (Hockenberry edema greater and increasing the potential for airway
& Wilson, 2007). By age 5–6, the thorax approximates obstruction. In infants and young children, the right
the adult shape; by adulthood, the A-P diameter is bronchus is significantly shorter, wider, and more
twice the transverse diameter (Fig. 17-4B). From birth vertical than the left bronchus. In this age group, the
to age 3, the ribs lie in a horizontal plane; this restricts trachea bifurcates at the level of T3, a higher level
the infant’s ability to expand his or her chest fully than the older child or adult, where bifurcation oc-
and limits tidal volume (Macfarlane, 2005). The ribs curs at T4 or T5 (Ball & Bindler, 2006). Both of these
are also flexible and provide very little support for the factors increase an infant’s or young child’s suscep-
lungs; negative intrathoracic pressure is poorly main- tibility to aspiration of foreign bodies into the right
tained, and the work of breathing is thus increased. bronchus. Also, this causes breath sounds to be loud-
This explains why children use accessory muscles dur- er and higher in pitch in infants and young children
ing times of respiratory distress. than in adolescents or adults.
A B
FIGURE 17-4. A. The round, barrel shape of the newborn’s chest. B. The chest of the adult; the A-P
diameter is twice the transverse diameter.
FUNCTION
ASSESSMENT
In neonates and infants until age 3 months, the hy-
poxic and hypercapnic drives are not fully developed
HISTORY
(Swamy & Malliakrjun, 2004). Because of the neu-
rologic immaturity of the respiratory drive, periodic Prenatal, Perinatal, and Neonatal Histories
breathing (i.e., apnea ⱕ10 seconds) without cyanosis The prenatal, perinatal, and neonatal histories are
or bradycardia is within normal limits in the neonate. crucial elements of the respiratory assessment in chil-
Apnea that lasts longer than 20 seconds (central apnea) dren. Maternal prenatal substance abuse can result in
is outside normal limits. respiratory complications in the infant. For example,
Oxygen consumption in the neonate is almost twice prenatal cocaine use causes placental vasoconstric-
that of the adult (Swamy & Mallikarjun, 2004); how- tion, resulting in fetal hypoxia, and third-trimester
ever, the alveoli are thick walled at birth, and infants cocaine use can result in uterine contractions, caus-
have only 10% of the total number of alveoli found ing premature delivery (Datta, 2004). Periodic breath-
in the adult lung, which affects gas exchange. Respira- ing, apnea, and neonatal tachypnea are common in
tory failure is common in premature infants because neonates whose mothers used cocaine while pregnant
of surfactant deficiency, causing alveolar collapse (Datta, 2004). Fetal exposure to heroin or methadone
(Macfarlane, 2006). Over the first 8 years of life, alveoli in utero can result in preterm delivery and perinatal
increase in number, and existing alveoli grow in size hypoxia and asphyxia (Fine, 2006). Maternal tobacco
(Swamy & Mallikarjun, 2004). From birth through and cocaine use can also lead to meconium aspiration
school-age, there is a large amount of anatomic dead during delivery (Clark & Clark, 2008); infants exposed
space in the tracheobronchial tree where gas exchange to cigarette smoke in utero are also at risk for lower
does not take place (Behrman, Kliegman, Jenson, & birth weight and intrauterine growth retardation (U.S.
Stanton, 2007). These factors explain why the respira- Surgeon General Report, 2002).
tory rates in infants and children are more rapid than In all infants, Apgar scores are assessed, noting any
those of the adult. score below 7; a score this low suggests respiratory dis-
From birth until age 6, infants and children breathe tress at birth with possible perinatal asphyxia. A di-
by using the diaphragm and abdominal muscles (Ball agnosis of meconium aspiration is another important
& Bindler, 2006). From birth until approximately assessment, as are histories of endotracheal intubation
age 2, the intercostal, scaleni, sternocleidomastoid, or prolonged positive pressure ventilation (PPV) with
and diaphragmatic muscles have few type I muscle supplemental oxygen; these interventions predispose
fibers, which are used in sustained respiratory activity the infant to barotrauma, a factor in the development
(Swamy & Mallikarjun, 2004). Thus, immature respi- of bronchopulmonary dysplasia (BPD) (American Tho-
ratory muscles must work hard to assist in respiratory racic Society, 2003). Any history of congenital heart
effort; nasal flaring may occur, and poorly developed defects is also important to consider, especially defects
respiratory muscles hinder the expulsion of thick that increase pulmonary blood flow. Patent ductus ar-
respiratory secretions. Respiratory muscles that are teriosus has been associated with the development of
easily fatigued can result in retention of carbon diox- BPD, especially in extremely-low-birth-weight (ELBW)
ide, apnea, and respiratory failure. Respiration may infants (American Thoracic Society, 2003).
be inefficient when the infant or young child is cry- It is important to note a history of prematurity,
ing or with anything that restricts breathing, such making sure to include the gestational age at which
as abdominal distention (Macfarlane, 2006; Swamy the child was born, birth weight, and the nature and
& Mallikarjun, 2004). Breathing becomes thoracic degree of postnatal respiratory complications, such
between 8–10 years, and the respiratory rate lowers as asphyxia, mechanical ventilation, apnea, and any
to near adult levels. oxygen requirements. Preterm infants, particularly
very-low-birth-weight and ELBW infants who have
been diagnosed with respiratory distress syndrome,
are especially vulnerable to the development of BPD
CULTURAL AND RACIAL VARIATIONS (American Thoracic Society, 2003).
Cystic fibrosis is a genetic disease that occurs in
Caucasians of northern European ancestry. Asthma
occurs in all races, but the highest prevalence oc- Review of Systems
curs among African-American boys (Centers for The past medical history is thoroughly reviewed for any
Disease Control and Prevention, 2006). Pectus de- conditions that have respiratory manifestations or atop-
formities, which may affect respiration, are more ic components. The provider should also pay special
common in Caucasian children (Cataletto, 2008; attention to a history of more than six to ten upper respi-
Hebra, 2009). ratory infections a year, frequent lower respiratory tract
infections, the number of acute otitis media episodes, which indicate a poorly controlled condition for which
chronic cough, wheezing episodes, or any chronic respi- medical management may need to be adjusted, a sign of
ratory conditions, such as asthma, BPD, or cystic fibro- difficulty accessing care, or even neglect.
sis. Children with respiratory symptoms coupled with a
failure to gain weight should be referred to a pediatric Injuries
pulmonologist; this may be a sign of cystic fibrosis. Certain injuries can potentially impact the child’s re-
A typical review of systems in an assessment of the spiratory status and function. Smoke inhalation may
thorax, lungs, and regional lymphatics includes the accompany burns the child has sustained in a fire. As-
following: piration of a caustic substance, such as acids (e.g., drain
• Skin: Atopic dermatitis cleaners, battery fluid) or alkalis (e.g., oven cleaners,
• Ear: Acute otitis media or otitis media with effusion lye), can cause severe respiratory distress; for example,
• Cardiovascular: Congenital heart defects that in- alkali aspiration causes tissue liquefaction necrosis. Re-
crease pulmonary blood flow spiratory complications of caustic substance aspiration
• Respiratory: Upper respiratory infections (also note include airway obstruction, bronchospasm, severe respi-
frequency), viral croup, epiglottitis, viral or bacterial ratory distress, and respiratory failure (Nervi, Schwartz,
pharyngitis, tonsillitis, peritonsillar abscess, retro- Desposito, & Hostetler, 2008). Benzalkonium chloride,
pharyngeal abscess, foreign body aspiration, bacterial a chemical used in items such as leave-on skin antisep-
tracheitis, asthma, chronic cough, laryngomalacia, tics and hygienic towelettes, if aspirated, causes severe
tracheomalacia, cystic fibrosis, pneumonia, bronchi- respiratory insufficiency (Okan, Coban, Ince, & Can,
olitis, tuberculosis, or pneumothorax 2007). Blunt chest trauma can cause injury to underly-
• Immunity: Allergic rhinitis or allergic angioedema ing abdominal organs or lead to a pneumothorax.
Immunizations Surgical History

Many of the communicable diseases for which chil- It is important to note all past surgeries, with particular
dren are immunized affect the respiratory tract. When attention paid to procedures such as tracheostomy, ton-
considering diagnostic possibilities in children with sillectomy or adenoidectomy, Nissen fundoplication for
respiratory complaints, it is essential to review a reflux, or chest tube placement. The dates, the reasons,
child’s immunization status. This is particularly true and the outcomes of the surgeries are important data
for infants and very young children and for children for the pediatric history.
from developing countries who may not only lack
immunizations but may also be malnourished and are Current Medications
thus more vulnerable to respiratory infections. A complete medication history is essential, focusing on
any medications that the child uses for treatment of
Allergies asthma or allergies. The dose and frequency of broncho-
All allergies must be noted in children undergoing a dilators, inhaled or oral corticosteroids, mast cell stabi-
respiratory assessment. Examples of allergies about lizers, leukotriene receptor agonists, or methylxanthines
which to inquire include those to ragweed, grass, trees, are assessed and recorded. If the child is currently taking
pet dander, feathers, dust mites, mold spores, and antibiotics prescribed by another health care provider, it
food. Depending on the individual, allergic rhinitis should be determined if the indication relates to a respi-
can have numerous triggers, but the end result will be ratory condition, such as acute otitis media or bacterial
some degree of inflammation of the nasal turbinates, pneumonia. Use of any over-the-counter decongestants,
eustachian tubes, middle ear, sinuses, and pharynx. expectorants, or antihistamines is also noted; this assess-
Because both allergic rhinitis and atopic dermatitis are ment is especially important in children younger than 2
immunoglobulin E–mediated reactions, the provider for whom these medications are dangerous and not rec-
should assess the child for both conditions. ommended (U.S. Food and Drug Administration, 2009).
Any alternative or complementary therapies should be
Hospitalizations noted. For example, echinacea is an herb that is used to
Any past hospitalizations for respiratory conditions, such prevent and treat respiratory infections but is associated
as bronchiolitis, reactive airway disease, asthma, croup with a higher incidence of allergic and sensitivity reac-
syndromes (e.g., epiglottitis, laryngotracheobronchitis), tions (Gardiner, Dvorkin, & Kemper, 2004).
pneumonia, foreign body aspiration, gastroesophageal
reflux, and cystic fibrosis, are noted. The date, child’s age, Family History
underlying medical conditions, and length of stay are The family history includes any history of atopy. Ex-
also noted. The provider should pay particular attention amples include eczema, seasonal and environmental
to repeated hospitalizations for respiratory conditions, allergies, asthma, snoring, mouth breathing, frequent
upper respiratory infections, nasal polyps, or cystic PHYSICAL EXAMINATION

fibrosis among family members. It is important to note Physical assessment of the respiratory system in chil-
the family member’s relationship to the child. dren involves inspection, auscultation, palpation, and per-
cussion. Inspection, including general observation and
Social History auscultation, are essential components of the pediatric
Multiple aspects of a child’s day-to-day life and liv- respiratory assessment. Palpation and percussion may
ing conditions can affect his or her respiratory status be difficult to perform on infants and toddlers and may
and frequency of respiratory symptoms. For example, not yield useful information. A stethoscope is the only
it is important to ask about the child’s living condi- necessary piece of equipment for respiratory assessment;
tions, assessing whether the child is exposed to high however, the following equipment may be useful:
levels of air pollution, dust mites, mold spores, or
• A pulse oximeter to measure oxygen saturation if a
secondhand smoke. School-aged children and ado-
child presents in acute respiratory distress
lescents should also be asked if they smoke tobacco
• An otoscope, if the child is febrile, has nasal symp-
or marijuana. Any exercise intolerance is noted. It is
toms and a sore throat, and is complaining of ear
also important to note whether an infant or young
pain (see Chapter 14)
child attends day care as these children have more fre-
• A tongue blade to examine the throat (see Chapter 16)
quent respiratory infections. The provider should also
• A marking pencil to measure diaphragmatic excursion
inquire about any occupation or hobbies the child or
family members may have that necessitates the use of In quiet infants and toddlers, the chest is auscul-
paint, paint thinner, or other chemicals that can trig- tated first to maximize the accuracy of assessment
ger an exacerbation of asthma. In addition, the child’s findings. Children preschool-aged and older can be
social situation is assessed to determine if tuberculosis examined in the customary head-to-toe fashion (see
screening is necessary (see Chapter 9). Chapter 8). Inspection is also done with the infant or
young child quiet or asleep, as crying can mimic or
History of Present Illness exacerbate retractions.
Because of the immaturity of the respiratory and
immune systems in infants and young children, respi- Vital Signs
ratory diagnoses are very common. The immaturity Vital sign measurements in a child reflect the child’s
of the respiratory system also poses concerns related respiratory status and vice versa. For example, a febrile
to quick respiratory deterioration in some instances. child will become tachypneic to decreased body temper-
Common respiratory complaints in children include ature. With conditions that cause hypoxia, the heart rate
nasal congestion, cough, throat or ear pain (with and increases as the body’s demands for oxygen increase. The
without fever), difficulty breathing, and wheezing. respiratory rate also increases with conditions that cause
Associated complaints may include headache, vomit- hypercarbia, in the body’s effort to rid itself of excess
ing, abdominal pain, poor feeding, or lethargy. When carbon dioxide. Therefore, a rapid respiratory rate sug-
evaluating these complaints, the provider must con- gests lower respiratory tract disease. Normal vital signs,
sider the child’s past medical history for any chronic according to age, are provided in Appendix A.
respiratory conditions, such as asthma, cystic fibrosis,
or repeated episodes of acute otitis media or strepto-
Current Growth Parameters
coccal pharyngitis.
As part of the respiratory assessment, it is important
When obtaining the history, important data to
for the health care provider to assess physical growth
gather include the onset of the respiratory symptoms
in the child; lack of physical growth may indicate
and the presence of any fever or cough. When did
chronic hypoxia. Falling off the growth curve indicates
the child get sick? For example, did the child have an
an acute problem (see Chapter 8).
upper respiratory infection before wheezing began?
Are the respiratory symptoms worsening? If the child
has a cough, when did it start? How would the child or Inspection
parent describe the cough? Is it worse at night? General Appearance. The first step in pediatric
It is also important to evaluate the child’s immu- respiratory assessment is evaluation of the child’s
nization status, assess for any sick contacts, and de- general appearance. This begins with observing respira-
termine if the child is exposed to secondhand smoke tory effort, noting any signs of dyspnea or respiratory
at home, in the car, or in the day-care setting. Chil- distress. These signs include nasal flaring (especially in
dren exposed to secondhand smoke have a higher in- infants), grunting, and a prolonged respiratory phase
cidence of upper respiratory infections, reactive airway (indicates carbon dioxide retention). Mouth breathing
disease, asthma, bronchitis, and pneumonia (Sheahan may be a sign of respiratory distress or may indicate
& Free, 2005). Table 17-2 lists some respiratory condi- simple nasal congestion or enlarged adenoids. Drooling
tions commonly seen in infants and children. that is accompanied by sitting in the tripod position
TABLE 17-2
History of Present Illness: Respiratory Complaints
CONDITION AGE CAUSE(S) SIGNS AND SYMPTOMS
Allergic rhinitis 6 months and older Indoor and outdoor allergens (pollen, mold spores); Sneezing, itching, tearing, and rhinorrhea;
cigarette smoke, dust mites, pet dander, wood smoke, allergic “shiners,” lateral nasal crease, boggy nasal
and pollution turbinates, and injection and swelling of palpebral
conjunctivae; Dennie-Morgan lines (creases below
inferior eyelid); and “cobblestoning” of pharynx
Asthma 2 years and older Numerous triggers (e.g., exercise, cigarette smoke, Cough, shortness of breath, wheezing (characteristic
mold spores, dust mites, pet dander, wood smoke, breath sound); retractions, and nasal flaring
pollution); other indoor and outdoor allergens;
respiratory infections, fear, cold air, and food (e.g.,
nuts, dairy products); food additives or reflux disease
Bacterial tracheitis 1 month–13 years, peak Staphylococcus aureus (most common) Begins as URI, then progresses to high fever,
(membranous croup) 3–10 years hoarseness, stridor, and copious purulent secretions;
child “looks toxic,” and rapid deterioration is
common.
Bronchiolitis Birth to age 2 years Viral, (e.g., RSV [50%], adenovirus, parainfluenza Begins as URI, progresses to wheezing, fever,
virus, influenza virus, rhinovirus) decreased appetite, tachypnea, and varying degrees
of respiratory distress; paroxysmal cough that may
be followed by vomiting; very young infants become
very ill and experience the most respiratory distress.
Bronchopulmonary Premature infants treated Positive pressure ventilation, oxygen therapy, Tachypnea, wheezing, crackles, nasal flaring,
dysplasia with oxygen inflammation, and persistent hypoxia retractions, grunting, irritability, pulmonary edema,
failure to thrive; barrel-chest because of air trapping.
Severity depends on gestational age at birth,
length of time of positive pressure ventilation, and
postnatal respiratory complications.
Chest pain School age–adolescent Respiratory: RAD, bronchitis, pneumonia, pleurisy, Possible pain, dyspnea, dizziness, stridor, and
and pneumothorax anxiety (Galioto, 2007)
Cardiac: Hypertrophic cardiomyopathy, anomalous
coronary artery, pericarditis, myocarditis, and
arrhythmia
Gastrointestinal: esophagitis and gastric ulcer disease
Musculoskeletal: injury, rib fracture, and
costochondritis
Psychogenic: (Galioto, 2007).
(continued)
TABLE 17-2
History of Present Illness: Respiratory Complaints (Continued)
Croup 6 months–6 years Viral (parainfluenza viruses, adenoviruses, RSV) Usually preceded by URI; slight dyspnea, fever,
(laryngotracheobronchitis) tachypnea, and retractions; harsh, barking cough
and inspiratory stridor
Cystic fibrosis Birth throughout life S. aureus, Haemophilus influenzae, Pseudomonas Clinical manifestations in respiratory system include
aeruginosa are organisms responsible for causing chronic, frequent, dry cough; repeated episodes
pulmonary infections. of bronchitis, bronchiectasis, and pneumonia;
bronchospasm often follows paroxysms of
coughing. Recurrent sinusitis, nasal polyps, and
digital clubbing also seen. Respiratory problems are
chronic, progressive, and can lead to respiratory
failure and death.
Epiglottitis 1–5 years H. influenzae type b Rapid onset, high fever, severe sore throat,
dysphagia, drooling, muffled voice, tripod breathing,

no spontaneous cough, and agitation
Foreign body aspiration 1–3 years (peak age) Object becomes lodged in some portion of the Depends on nature of object aspirated (e.g., size and
respiratory tract material of object), age, size of child, and location
of airway where object is lodged; sudden episodes of
coughing, chronic cough with fever and unilateral
wheeze, hemoptysis, and recurrent pneumonia are
all possible clinical findings.
Nasopharyngitis All ages Viral Nasal congestion, nasal drainage, and cough; may
have fever and decreased appetite; may have sore
throat
Pertussis All ages Bordetella pertussis URI precedes illness; fever and high-pitched cough,
which occurs on inspiration and makes a “whoop”
sound; cyanosis, diaphoresis, and fatigue after
paroxysms of cough; infants age 6 months and
younger become very ill, possible pneumonia and
apnea
Pneumonia All ages Viral, bacterial Fever, cough, crackles or decreased breath sounds;
dyspnea, and varying degrees of respiratory distress,
depending on child’s age and amount of lobar
infiltration or consolidation
Reactive airway disease Birth to age 2 Airway inflammation that occurs without a viral Same as asthma
trigger
Pharyngitis Viral pharyngitis seen in Viral (e.g., adenoviruses, parainfluenza viruses, Viral: gradual onset, nasal symptoms, sore throat,
all ages; strep pharyngitis enteroviruses, herpesvirus, Epstein-Barr virus) mild cough, and low-grade fever
less common in children Mycoplasma pneumoniae; bacterial (GABHS; Neisseria Bacterial: Abrupt onset, no nasal symptoms,
2 and younger; most gonorrhoeae, Corynebacterium diphtheriae (rare) marked sore throat with exudate, moderate-to-
common in children high fever, petechiae on soft palate, tender cervical
age 5–15 lymphadenopathy, and abdominal pain with nausea
and vomiting in some cases
Sinusitis 1 year and older Bacterial (e.g., Streptococcus pneumoniae, H. influenzae, Frequent complication of URI; facial pain or
(AAP, 2001) Moraxella catarrhalis, nontypeable H. influenzae, S. pressure; headache, dental pain, eye pain, purulent
aureus) rhinorrhea, and postnasal drip on oral examination
Tonsillitis Same as pharyngitis Same as pharyngitis Tonsillar enlargement, throat pain, difficulty
swallowing, and difficulty breathing because of
tonsillar enlargement (“kissing tonsils”). Mouth
breathing when adenoids enlarge with dry mouth
and throat. Nasal voice. Otitis media is a frequent
complication.
Tuberculosis (TB) Birth throughout life Mycobacterium tuberculosis Infants, children, and adolescents with latent
TB (exposed and infected but not infectious) are
asymptomatic. Children aged 4 years are more likely
to convert from TB infection to TB disease because
of their immature immune system. Young children
do not produce sputum and cannot usually generate
enough force when coughing to expel infected
sputum. Symptomatic children present later in the
course of the disease with persistent cough, weight
loss, failure to gain weight, fever, fatigue, night
sweats, chills, wheezing, crackles, and decreased
breath sounds.
GABHS, group A beta-hemolytic streptococci; RAD, reactive airway disease; RSV, respiratory syncytial virus; URI, upper respiratory infection.
Source: Brady, M. A. (2009). Respiratory disorders. In Burns, C. E., Dunn. A. M., Brady, M. A., Starr, N. B., & Blosser, C. G. Pediatric primary care. (4th ed.). (pp. 767–794). St. Louis: Saunders Elsevier;
Selekman, J. (2006). Changes in the screening for tuberculosis in children. Pediatric Nursing, 32(1), 73–75.
FIGURE 17-6. Pectus excavatum.
chest changes from birth to young adulthood (see

Developmental Considerations). Infants normally have
a round thorax, with the A-P and transverse diameters
FIGURE 17-5. Child sitting upright, leaning forward, chin
being equal. By age 6, the thorax reaches the adult ratio
thrust forward, and mouth open to breathe, demonstrating of 1:2 (A-P to transverse diameter). Alterations in chest
air hunger. shape are assessed, noting any chest wall deformities
such as pectus excavatum (“funnel chest”), a depression
of the chest wall (Fig 17-6), or pectus carinatum (“pigeon
(i.e., upright, leaning forward, chin thrust forward, chest”), a protuberance of the chest wall (Fig. 17-7). Of
mouth open) is an especially ominous sign that points all congenital anterior chest wall deformities, pectus
to epiglottitis, a medical emergency (Fig. 17-5). The excavatum occurs much more commonly (90%) than
child may also appear acutely ill or “toxic” in the case pectus carinatum (5%–7%) (Hebra, 2009). Pectus exca-
of septicemia that accompanies the respiratory condi- vatum becomes more pronounced as the child grows,
tion. In infants, fatigue and head bobbing is a sign of with the onset of symptoms occurring by about age 10.
dyspnea. The position of the trachea is also inspected; Depending on the degree of concavity in the anterior
it should be midline. With tension pneumothorax or chest wall, the child’s symptoms may range from chest
a large pleural effusion, the trachea shifts away from and back pain to cardiac and pulmonary compression,
the affected side. In the case of atelectasis, the trachea shortness of breath, diminished breath sounds at the
shifts toward the affected side. bases, and poor posture (Hebra, 2009). In adolescents,
Skin color is also inspected, noting any pallor, mot-
tling, or cyanosis. In dark-skinned children, the mucous
membranes, palms of the hands, and soles of the feet
are inspected. Pallor may indicate anemia or hypoten-
sion. Mottling and peripheral cyanosis (cyanosis seen on
the hands and feet or around the mouth) can occur
with cool ambient room temperatures; mottling can
also occur with severe hypoxemia. Acrocyanosis (cyano-
sis of the hands and feet only) is a normal finding in
the newborn (see Chapter 11). Central cyanosis (cyanosis
along the midline) is a late sign of respiratory distress
and can also indicate cardiopulmonary disease. Chil-
dren who are anemic may not become cyanotic as early
as children with normal hemoglobin levels because of
less deoxygenated hemoglobin near the skin surface.
Chest. The chest is examined with the child’s head in

the midline position. Chest size, shape, symmetry, and
movement are inspected. Scars on the chest are noted,
with inquiries about the etiology (e.g., past medical
and surgical procedures). The diameter of the child’s FIGURE 17-7. Pectus carinatum.
eases (Newth & Hammer, 2005). Asymmetrical chest

movements may be seen with pneumonia. A prolonged
Suprasternal
expiratory phase occurs in conditions that cause carbon
Clavicular
dioxide retention, such as transient tachypnea of the
newborn, or obstructive respiratory conditions such as
asthma or cystic fibrosis. Deep and labored breathing
Substernal
(Kussmaul breathing) is a form of hyperventilation that
Intercostal occurs with metabolic acidosis.
Subcostal
Signs of Chronic Respiratory Disease. Overall in-

spection continues for any signs of chronic respiratory
disease. One sign is a barrel-shaped chest (Fig. 17-9);
this may be from chronic hyperinflation, as with cys-
tic fibrosis or asthma. Finger clubbing is associated with
conditions that cause chronic hypoxia, such as cystic
FIGURE 17-8. Anatomic locations of retractions. fibrosis. This occurs when the angle between the nail
and nailbed is flattened as capillary growth increases in
an attempt to supply the peripheral tissues with oxygen.
body image is also a concern. Pectus carinatum can be Finger clubbing occurs in three stages: normal, early,
present at birth but becomes more evident between ages and late; these stages are illustrated in Figure 12-12.
11–15 years (Cataletto, 2008). This condition primarily Poor weight gain and decreased adipose tissue are
causes cosmetic concerns and does not cause respira- other signs of chronic respiratory disease, namely cys-
tory complications. Spinal deformities (e.g., scoliosis, tic fibrosis. Other signs of chronic respiratory disease
kyphosis, lordosis) can also interfere with respiration, include nasal polyps, which occur with cystic fibrosis
depending on the degree of spinal curvature. and may interfere with respirations. Any signs of atopy
The examiner inspects the child’s thorax for move- are investigated, such as persistent clear nasal discharge
ment during the respiratory cycle, noting respiratory
effort. Respirations should be smooth, symmetrical,
easy, and without the use of accessory muscles (retrac-
tions). Retractions occur when heightened respiratory
effort is necessary to inhale extra oxygen. This use of
accessory muscles of breathing is seen in infants and
young children; older children and adolescents use
the diaphragm for increased work of breathing. Any
condition that leads to hypoxia can cause retractions.
Retractions may be suprasternal, supraclavicular, inter-
costal, substernal, or subcostal (Fig. 17-8). The location
and severity of the retractions can provide clues to the
diagnosis; for example, the use of sternocleidomastoid
muscles (suprasternal or supraclavicular retractions)
suggests upper airway obstruction, such as croup or
epiglottitis, and the use of intercostal and abdominal
muscles in children younger than 6 suggests lower air-
way disease, such as pneumonia or bronchiolitis.
The child’s respiratory rate and type of breathing are
also observed. Tachypnea is seen with fever, severe ane-
mia, anxiety, pain, cardiac disorders, lower respiratory
tract disorders (e.g., pneumonia), and metabolic aci-
dosis. Periodic breathing (up to 20 seconds of apnea) is
within normal limits in neonates. Diaphragmatic breath-
ing (i.e., the abdomen rises with inspiration) is normal
in infants and children until age 7; in older children, Cross section
of thorax
breathing should be thoracic. Any paradoxical breathing Normal chest Barrel chest
should be noted (i.e., the diaphragm falls, rather than
rises, during inspiration), which is associated with FIGURE 17-9. Comparison of normal chest shape (A) and
barrel-shaped chest (B). Note that in the normal chest, the
upper airway obstruction, rib fracture, pneumonia, A-P diameter is less than the transverse diameter; in the barrel
asthma, bronchiolitis, BPD, and neuromuscular dis- chest, the transverse and A-P diameters are equal.
or signs of atopic dermatitis (see Chapter 12); these

TABLE 17-3
findings are associated with asthma.
Differential Diagnosis of
Associated Findings. Any stridor is noted; this is a Cough in Children
loud, coarse, high-pitched sound that occurs as a result TYPE OF COUGH DIFFERENTIAL DIAGNOSES
of upper airway narrowing caused by inflammation,
edema, or the presence of a foreign body. Stridor most Acute, paroxysmal Pertussis (followed by “whoop”
sound) and RSV
often occurs with inspiration and is commonly associ-
ated with viral croup or foreign body aspiration. Stridor Acute harsh, barky Viral croup (LTB), foreign body,
can be heard without a stethoscope. and tracheitis (with purulent
Cough is frequently present with respiratory condi- sputum)
tions, but may also be associated with non-respiratory
Acute, loose, URI, pneumonia, and asthma
etiologies. In very young children, cough is usually productive
nonproductive because children usually swallow
expectorated respiratory secretions. To narrow the list of Acute, dry, hacking Viral pneumonia and pertussis
differential diagnoses, it is important to determine the Chronic dry, hacking Bronchitis; smoking, conditions
onset and type of cough, noting whether it is productive causing pulmonary edema, and
or associated with fever, and what the aggravating and CHF
alleviating factors are. Care must be taken to determine
Chronic, dry, irritated Allergies
quickly if the cough is associated with any life-threat-
ening condition that requires immediate action. Table Chronic, productive Asthma, cystic fibrosis, and TB
17-3 lists common causes of cough in children. Rhinor-
rhea, sore throat, ear pain, tonsillar enlargement, and Chronic, non-specific Chronic URI, environmental
toxin exposure, allergies, postnasal
tonsillar exudate are other clinical findings associated
drip, and psychogenic (tic)
with the respiratory assessment; these complaints are
discussed in detail in Chapters 14 and 16. Disappears with sleep Psychogenic (tic)
Honking Psychogenic
Auscultation
Auscultation of the infant or toddler’s chest requires Loose, productive URI, bronchitis, and cystic fibrosis
some alteration of assessment techniques. Children this
Post-tussive emesis RSV and pertussis
age have their chest auscultated first, before palpation or
percussion, which can elicit crying in the young child Staccato Neonatal chlamydial
and cause alterations in assessment findings. Optimally, pneumonia
the examination room should be as quiet as possible.
Tight, productive Bronchiolitis and pneumonia
To maximize the child’s comfort and decrease fear and
stranger anxiety as much as possible, it is best to have the Tight, non-productive Asthma
infant or toddler remain in the parent’s lap, facing the
Wheezing cough Asthma, bronchiolitis, GER, and
parent so the child feels safe and secure. Older children
RAD
should sit upright on the examination table. Preschoolers
and school-aged children are curious about their bodies
CHF, congestive heart failure; GER, gastroesophageal reflux;
and will often ask if they can listen to what the provider LTB, laryngotracheobronchitis; RAD, reactive airway disease; RSV,
hears. This is developmentally appropriate and helps the respiratory syncytial virus; TB, tuberculosis; URI, upper respiratory
examiner gain the child’s cooperation, maximizing the infection.
Source: Allen Jackson, P., & Kelley, L. (2008). Treating cough in chil-
accuracy and thoroughness of the assessment findings. dren. Advance for Nurse Practitioners, 16(2), 61–68; Kelley, L., & Allen
For the most accurate auscultation findings, it is es- Jackson, P. (2007). Managing acute cough in children: Evidence-
sential to use a stethoscope with an infant or pediatric based guidelines. Pediatric Nursing, 33(6), 515–524.
diaphragm. An adult-sized stethoscope with a diaphragm
that is too large yields confusing and inconclusive find-
ings. For older and overweight children, using a stetho- tates the chest over all lung fields, noting air movement
scope diaphragm that is too small is not sensitive enough anteriorly, posteriorly, and laterally, following the se-
to transmit subtle auscultatory findings. For maximum quence depicted in Fig. 17-10. The examiner auscultates
comfort, the stethoscope should be warmed before use. for one full respiratory cycle at each location. Both sides
Auscultation is performed in a routine, systematic of the chest are compared. In infants and toddlers, the
fashion, with the diaphragm placed firmly against sounds may seem louder and harsher and be difficult
the skin of the child’s chest, never over the clothes to localize because of the thinness of the chest wall. In
or examination gown; this changes the auscultatory this age group, crying may be transmitted throughout
findings. Moving from side to side, the examiner auscul- all lung fields as well. Children who are old enough to
Based on these assessments, breath sounds are classi-

fied as vesicular, bronchovesicular, or bronchial. Table 17-4
1 2 explains the classification of these breath sounds. Nor-
mal breath sounds are clear throughout all lung fields.
4 3 The inspiratory and expiratory phases should be equal.
A prolonged expiratory phase indicates carbon dioxide
5 6
retention, as with asthma or bronchiolitis.
8 7
During auscultation, any abnormal or adventitious
(“extra”) breath sounds, such as consolidated or diminished
9 10 breath sounds, are noted. Adventitious breath sounds,
such as crackles or rales, rhonchi, wheezes, and pleural rub,
12 11 can be heard over normal breath sounds. Table 17-5
16 15
13 14 summarizes and describes these breath sounds.
In an uncooperative infant or crying child, assessing
17 18
voice transmission can help clarify auscultatory assess-
ment findings. These assessment techniques are used
20 19 when areas of fluid or consolidation in the lung are
suspected. Normally, voice sounds are muffled on aus-
cultation. If the infant’s cry is loud and clear or if the
child is able to say “99” several times in a normal voice,
FIGURE 17-10. Sequence of auscultation for posterior chest.
and it is loud and clear and not muffled, the finding is
termed bronchophony. The older child is then asked to
cooperate developmentally are asked to breathe in and whisper “99” several times while the examiner auscul-
out, slowly and deeply through the mouth. During this tates several areas over each lung. If the child’s words
process, the examiner evaluates the timing, pitch, am- are heard loudly and are not muffled, this is whispered
plitude, and quality of breath sounds and compares the pectoriloquy. With young children who can cooperate,
ratio of inspiration to expiration (duration). the presence of egophony is assessed by asking the child
TABLE 17-4
Normal Breath Sounds
TYPE PITCH QUALITY AMPLITUDE DURATION LOCATION ILLUSTRATION
Bronchial High Harsh or Loud Short during Trachea and
hollow inspiration; thorax
long in
expiration
Bronchovesicular Moderate Mixed Moderate Same during Over the major

inspiration and bronchi—
expiration posterior:
between the
scapulae;
anterior: around
the upper
sternum in the
first and second
intercostal
spaces
Vesicular Low Breezy Soft Long in Peripheral lung

inspiration; fields
short in
expiration
Source: Weber, J., & Kelley, J. (2007). Health assessment in nursing. (3rd ed.). (p. 315). Philadelphia: Lippincott Williams & Wilkins.
TABLE 17-5
Abnormal and Adventitious Breath Sounds in Children
BREATH SOUND DESCRIPTION ASSOCIATED CONDITION(S)
Crackles or rales High-pitched, soft, cracking, popping sound (fine Pneumonia, bronchiolitis, and
crackles) or low-pitched, gurgling (coarse crackles); atelectasis
may be localized or diffuse, heard mainly at end of
inspiration; do not clear with cough
Diminished breath sounds Breath sounds that are less audible over an area Pneumonia, pleural effusion, and
of lung field pneumothorax
Pleural friction rub Low-pitched, grating, or creaking sound; Pneumonia, tuberculosis, and pleural
loudest on inspiration; occurs when inflamed effusion
pleurae rub together
Rhonchi Low-pitched, loud, often rattling, bubbling, Asthma, pneumonia, bronchitis, and
or gurgling; heard mainly at the beginning of bronchiolitis
inspiration; caused by secretions in large airways;
often clears with coughing; low-pitched, snoring
sounds during expiration result from narrowing
of large airways, swelling, or obstruction
Wheezes High-pitched, musical, whistling or squeaky; Reactive airway disease, bronchiolitis,

may be inspiratory or expiratory (predominantly asthma, foreign body aspiration, and
expiratory); caused by airway narrowing bronchospasm
to say “ee” continuously while auscultating the child’s sound with palpation). Lymph nodes in the chest are also
lungs. The sound heard should be a muffled “ee” sound; palpated.
if it sounds like “ay,” consolidation is likely present. All Assessment of respiratory excursion is an evaluation of
of the findings that raise the suspicion for lung consoli- symmetrical chest expansion. In the neonate, chest ex-
dation should be confirmed with a chest radiograph. pansion can be observed without palpation; asymmetry
of chest expansion in this age group can be caused by dia-
Palpation phragmatic hernia or pneumothorax. In older children,
Palpation of the chest is done to evaluate respiratory both anterior and posterior expansion are assessed while
excursion and to assess for tactile fremitus. These assess- the child is sitting upright. Beginning with the posterior
ments are typically done in children 3 and older who chest, the examiner places his or her palms on the lateral
are able to cooperate with the examination. Palpation of chest and the thumbs on the child’s back at approximate-
the chest is also done to identify any tenderness, lumps, ly the level of the 10th rib, moving the thumbs together
masses, or crepitus (crackling sensation or “popping” on the chest to create a small skin fold (Fig. 17-11). The
A B
FIGURE 17-11. Assessment of respiratory excursion. A. Initial hand positioning. B. Movement of
examiner’s hands during inspiration.
child is asked to inhale deeply and then exhale as the ex-

aminer observes his or her thumbs on the child’s chest for
symmetry of movement. With normal chest expansion,
the examiner’s thumbs are equidistant from the starting 1 4 5
3 2 6
point when the child fully inhales. Respiratory excursion
is decreased with chest pain and pneumothorax. Asym- 8 7
metrical chest expansion occurs with acute pneumotho-
9 10
rax or the presence of a foreign body.
This process is repeated on the anterior chest, with 12 11
the examiner placing both hands pointing upward,
on the costal margins at the xiphoid process. The 13 14
child is again asked to inhale deeply, as the examiner 21 16 15 19
observes for asymmetry of chest movement. Chest
17 18
movement should be symmetrical and easy as the 22 20
child breathes.
Tactile fremitus, the presence of vibrations in the
chest when the child speaks or an infant cries, is also
assessed. Using the fingertips or palmar surface of the
hands, the examiner moves along the child’s chest in a
systematic pattern, while asking the child to say, “99”
or “blue moon.” Tactile fremitus is normal in the up- FIGURE 17-12. Correct hand position and sequencing for
per chest near the bronchi and clavicles and posteri- percussion of the posterior thorax.
orly between the scapulae; fremitus should be equal bi-
laterally. There should be little to no tactile fremitus in
the lower chest. Decreased fremitus in the upper portion In a healthy child, the entire anterior chest is resonant
of the chest indicates obstruction (e.g., asthma, foreign (hollow-sounding), except the cardiac region where the
body) or pneumothorax; increased fremitus indicates percussion note is dull (thud-like). Continuing down-
consolidation of lung tissue, as with pneumonia, atel- ward, resonance should continue until the area over the
ectasis, or pleural effusion. liver is percussed; this sounds dull, and the percussion
The chest and neck areas are also palpated for note over the stomach should be tympanic (musical;
crepitus. In the newborn, the clavicle is palpated for drum-like). Next, the posterior chest is percussed, fol-
crepitus, which is heard with a fractured clavicle. Crep- lowing the sequence shown in Figure 17-12. When per-
itus is also present when air is between the lungs and cussing the posterior chest, resonance should be heard
subcutaneous tissue, which occurs in chest trauma or throughout. Hyperresonance (a booming sound) may be
alveolar rupture. normal in small children and in children or adolescents
The supraclavicular and axillary lymph nodes are pal- who have thin chest walls; on the left side of the child’s
pated for size, mobility, warmth, tenderness, consistency, chest, hyperresonance may result from air in the stom-
and degree of fixation, using both superficial and deep ach. Hyperresonance also occurs over areas of hyperin-
palpation techniques while the child holds his or her flation, as with asthma, bronchiolitis, pneumothorax or
arms at the side in a relaxed position (see Chapter 13 foreign body obstruction. Dullness is heard over fluid-
for details on lymph node assessment). filled areas or solid tissue and is present in pneumonia,
pleural effusion, and pneumothorax. Extreme dullness
Percussion is described as flat when percussed; this percussion note
Percussion of the chest is done to locate any air, fluid, or is heard over the sternum and atelectatic lung.
masses in a child’s lungs and to locate organ boundaries. Percussion is also done to assess diaphragmatic ex-
This examination technique is typically done in children cursion. This assessment technique is done when the
2 and older who are able to cooperate. Also, in younger provider observes shallow respirations or the child
children, percussion of the chest may not be accurate be- reports painful breathing. To perform diaphragmatic
cause of the size of the examiner’s fingers. Percussion can excursion, the posterior chest is percussed along the
be done directly or indirectly (see Chapter 8 for a descrip- scapular line, beginning at the apex to the lower edge
tion of these techniques). Indirect percussion is most often of the right lung. The percussion note should start as
used when assessing the chest. Figure 17-12 depicts the resonant over the apex and end as dull over the dia-
correct hand position necessary for indirect percussion. phragm. Once these percussion notes are identified,
For best results, the child should be sitting upright. The the examiner then marks the spots on the child’s chest
examiner should always percuss between the child’s ribs where the sounds changed from resonant to dull,
rather than directly over them. both on deep inspiration and expiration. The distance
The examiner begins with light percussion of the between these marks constitutes the diaphragmatic
child’s anterior chest, then moves to the posterior chest. excursion. This measurement is normally 3–5 cm in
children, with the diaphragm on the right side slightly

higher because of the presence of the liver. Diaphrag- COMMON DIAGNOSTIC STUDIES
matic excursion is limited in children with surgical
conditions such as abdominal trauma or repaired dia- Various diagnostic tests may be necessary to clarify dif-
phragmatic hernia. Auscultation may need to be re- ferential diagnoses of respiratory complaints in chil-
peated to confirm findings obtained during percussion dren. Some examples of these diagnostic studies and
and palpation. their indications are summarized in Table 17-6.
TABLE 17-6
Diagnostic Studies Used to Evaluate Respiratory Conditions
DIAGNOSTIC STUDY INDICATION COMMENTS
Allergy skin testing To identify allergies in children with Child must be observed for anaphylaxis
allergic rhinitis or asthma after test.
Arterial blood gases (ABGs) Acute respiratory distress ABGs can be very painful and are most
commonly done in acute care setting.
Chest radiograph Evidence of lower respiratory tract infection: Radiographs confirm a diagnosis of
child appears acutely ill, febrile, tachypneic, pneumonia, pneumothorax, tuberculosis,
crackles auscultated; also used when or foreign body.
tachypneic after injury and with suspected
foreign body aspiration
Complete blood count Persistent fever with respiratory Leukocytosis may occur with tracheitis,
symptoms pertussis, or pneumonia; leukopenia
occurs with pneumonia.
Computed tomography (CT) Intractable sinusitis CTs are more sensitive than radiographs
scan and can demonstrate pneumonia,
tuberculosis, or bronchiectasis.
Pulmonary function test To measure lung function and diagnose Child needs to be developmentally able
lung conditions associated with dyspnea to cooperate with testing.
Pulse oximetry To monitor oxygen saturation of This is noninvasive; false readings may
hemoglobin during respiratory distress occur with movement or hypoperfusion,
and it is not a substitute for ABGs.
Rapid streptococcal antigen To diagnose pharyngeal streptococcal Findings must be confirmed with culture.
test infections
Radioallergosorbent test To detect allergies by assessing for the RAST is often done on children with
(RAST) presence of immunoglobulin E antibodies atopic dermatitis, psoriasis, or food
in the blood allergies; blood sample may need to be
sent to referral lab.
Sinus radiographs Recurrent upper respiratory infections; to Results are more timely than CT scan or
diagnose sinusitis MRI.
Sputum culture To identify specific pathogens in the This is cultured from sputum, not
respiratory tract saliva, so it is difficult to obtain in
young children who may not be
developmentally able to cooperate.
Sweat chloride test Family history of cystic fibrosis; frequent It diagnoses cystic fibrosis.
respiratory infection in first 6 months of life
Throat culture To isolate causative organism of infection Streptococcal infections must be treated
of pharyngitis or tonsillitis with antibiotics to avoid long-term
complications.
Tuberculin (Mantoux) skin test Chronic/productive cough and fever This is used for screening for tuberculosis;
it must be administered correctly to be
accurate; an intradermal injection is
necessary.
Behrman, R. E., Kliegman, R. M., Jenson, H. B., & Stanton,

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108(3), 798–808. U.S. Food and Drug Administration. (2009). Public health advi-
American Thoracic Society. (2003). Statement on the care of the sory: Nonprescription cough and cold medication use in chil-
child with chronic lung disease of infancy and childhood. dren, January 17, 2008. Retrieved November 14, 2009, from
American Journal of Respiratory and Critical Care Medicine, 168, http://www.fda.gov/Drugs/DrugSafety/PublicHealthAdvisories/
356–396. ucm051137.html.
Ball, J. W., & Bindler, R. C. (2006). Child health nursing: Partner- U.S. Surgeon General Report. (2002). Women and smoking. Re-
ing with children & families. Upper Saddle River, NJ: Pearson trieved November 14, 2009, from http://www.cdc.gov/mmwr/
Prentice Hall. preview/mmwrhtml/rr5112a4.htm.
CHAPTER
Assessment of the
18 Cardiovascular
System LISA M. KOHR
known as dextrocardia. With dextrocardia, the heart

INTRODUCTION may be rotated or the mirror image of a normally
positioned heart. It can be associated with asplenia,
The cardiovascular evaluation of a child includes taking polysplenia, and situs inversus, a condition in which
a detailed history and conducting a comprehensive the stomach is located on the right and liver is on
physical examination that includes inspection, palpa- the left. Mesocardia is a condition in which the heart
tion, and auscultation. Further information may be is located in the midline of the chest (Keane, Fyler,
gained by obtaining a chest roentgenogram and elec- & Lock, 2006).
trocardiogram (ECG) if there is a suspicion of either The heart is encased in a fibrous, double-walled sac
congenital or acquired heart disease. It is estimated called the pericardium, which acts as a protective cover-
that 32% to 80% of children have a heart murmur ing. Serous fluid is contained between the two layers
detected during childhood, especially during a febrile of the pericardium, allowing for frictionless movement
illness (Park, 2008). In most instances, the murmur is of the heart. The thin, outer, muscular layer covering
innocent. In contrast, structural heart disease affects the heart is called the epicardium; the thick, muscular,
only 1% of all children (Biancaniello, 2005). A mur- middle layer, which is responsible for contraction of
mur can be identified as either pathologic or innocent the heart, is called the myocardium; and the innermost
by conducting a comprehensive cardiac assessment. layer that lines the four heart chambers and the valves
Further evaluation is recommended if the physical exa- is called the endocardium.
mination findings and medical history are suggestive
of heart disease.
NORMAL CARDIAC ANATOMY AND
CIRCULATION
ANATOMY AND PHYSIOLOGY There are four chambers of the heart. The upper cham-
bers (atria) are separated from the lower chambers
The heart is cone shaped and located behind the ster- (ventricles) by the atrioventricular valves. The right
num in the mediastinum just to left of the midline of atrioventricular valve or tricuspid valve has three leaflets
the thorax. It lies just above the diaphragm between and lies between the right atrium and the right ven-
the medial and lower borders of the lungs. The up- tricle. The left atrioventricular valve or mitral valve has
per portion is called the base, and the narrow lower two leaflets and lies between the left atrium and the
tip is called the apex. The position of the heart can left ventricle. When the atria contract, the tricuspid
vary slightly, depending on the patient’s size, body and mitral valves open, allowing blood to enter the
type, and chest cavity. Compared to adults, the heart ventricles. When the ventricles contract, the atrio-
in infants and children lies more horizontally, with ventricular valves snap shut, preventing blood from
the apex reaching the fourth left intercostal space. re-entering the atria.
By approximately 7 years, the position of the heart The semilunar valves have three leaflets each and
is similar to that of an adult (Seidel, Ball, Dains, & separate the great arteries from the ventricles. The pul-
Benedict, 2006). In certain situations, the heart po- monary valve regulates communication between the
sition may be located on the right side or more to- right ventricle and the pulmonary artery. Likewise, the
ward the middle of the chest which is a condition aortic valve acts as a gate between the left ventricle
366
C H A P T E R 18 A s s e s s m e n t o f th e Cardio vasc ular S ystem • 367
Ascending aorta
Superior
vena cava
Sinoatrial
node
Left atrium
Internodal
pathways
Left ventricle
Right atrium
Chordae
tendineae
Atrioventricular
node
Atrioventricular
bundle (bundle
Papillary
of His)
muscle
Right and left

bundle branches
Right ventricle Purkinje fibers
FIGURE 18-1. Normal cardiac anatomy.
and the aorta. Ventricular contraction (systole) opens the valves close because of increased ventricular pressure.
semilunar valves, allowing blood to enter the great ar- This produces the first heart sound (S1), which is typi-
teries. Ventricular relaxation (diastole) causes the semi- cally described as a “lub” sound on auscultation. Dur-
lunar valves to close, preventing blood from flowing ing systole, blood is ejected from the right ventricle into
back into the ventricles. the pulmonary artery and from the left ventricle into
Normal circulation consists of desaturated blood the aorta. The pressure within the ventricles continues
flow returning to the right atrium by way of the su- to rise until it is higher than the pressure in the corre-
perior vena cava and inferior vena cava. It then flows sponding great artery. This forces the semilunar valves
through the tricuspid valve into the right ventricle and to open, ejecting blood into the great arteries. As the
then through the pulmonary valve into the main pul- ventricles eject blood out, the pressure in the ventricles
monary artery, left and right branch pulmonary arter- drops below the pressure in the great arteries, allowing
ies, and into the lungs. The lungs allow oxygenated the semilunar valves to close. This produces the second
blood flow to return to the heart by way of the four heart sound (S2), which is typically described as a “dub”
pulmonary veins, which drain into the left atrium. sound on auscultation. The S2 has two components:
Blood flow then travels through the mitral valve into A2, reflecting closure of the aortic valve, and P2, reflect-
the left ventricle and then through the aortic valve ing closure of the pulmonary valve. As the ventricular
and into the aorta. The ascending aorta supplies the pressure continues to drop below the atrial pressure, the
head and upper trunk with oxygen-rich blood, while atrioventricular valves open, allowing blood that has
the descending aorta supplies the liver, kidney, and collected in the right atrium via the superior and in-
lower trunk with oxygen-rich blood (Fig. 18-1). ferior vena cavae and left atrium from the pulmonary
veins to fill the relaxed ventricles.
During diastole, atrial contraction occurs, causing
CARDIAC CYCLE blood to enter the ventricles. It is during diastole that the
The cardiac cycle consists of two phases; systole and di- coronary arteries are perfused. When ventricular filling
astole. At the beginning of systole, the atrioventricular is altered, additional heart sounds may be detected. The
third heart sound (S3), which sounds like “Kentucky” on

auscultation, is heard in conditions where there is ven- DEVELOPMENTAL
tricular dilation or decreased ventricular compliance. A CONSIDERATIONS
fourth heart sound (S4), which sounds like “Tennessee,”
can occasionally be heard when the atria are forcing EMBRYOLOGIC DEVELOPMENT OF
blood into ventricles with decreased compliance or when THE HEART
congestive heart failure is present. Auscultation of S4 in
Knowledge of cardiac embryology can assist clinicians
children is always abnormal (Park, 2008).
in understanding the time association between tera-
The two phases of the cardiac cycle are then repeated
togenic exposures in utero and abnormal fetal heart
with ventricular contraction and atrial filling occur-
development. The heart is the first functioning organ
ring at approximately the same time. The amount of
in the embryo. Cardiogenesis starts on the 18th day of
blood returning to the heart (preload) and the amount
gestation, beginning with the formation of the cardio-
of force the ventricles must overcome to eject blood
genic crescent derived from the precardiac mesoderm
from the heart (afterload) affect the timing of the
(Keane, Fyler, & Lock, 2006). During the third week of
components of the cardiac cycle. Pressure differences
gestation, the endocardial tube is present, and it is at
caused by stenosis or valve regurgitation can lead to
this time that the heartbeat is believed to begin. By day
premature or delayed right- or left-sided atrioventricu-
21 of gestation, the endocardial tube loops either to the
lar or semilunar valve closure. This may be heard on
right, forming normally related ventricles (D-loop), or
auscultation as a split S1 or S2, resulting from the fact
to the left, creating inverted ventricles (L-loop). Embry-
that the atrioventricular or semilunar valves do not
ologic ventricular formation occurs on days 22–35 of
close simultaneously. Conditions contributing to al-
gestation. By this time, cardiac loop formation is com-
tered cardiac output can alter the timing of the two
plete. The endocardial cushion forms, right ventricular
phases of the cardiac cycle and ultimately cardiac out-
trabeculations develop, and the truncoconal portion
put (Park, 2008).
of the heart moves to lie over the atria. Circulation
also commences, and there is evolution of the aortic
ELECTRICAL CONDUCTION PATHWAY arches. From days 27–45 of gestation, the endocardial
cushion divides the atrioventricular canal into the mi-
The electrical system of the heart coordinates the se-
tral and tricuspid valves. There is further expansion of
ries of muscular contractions that occur during the
the endocardial tissue, forming the septum primum
cardiac cycle. The electrical impulse starts at the sino-
followed by the septum secundum. The conotruncal
atrial node located at the superior vena cava and right
cushions divide the main trunk or truncus arteriosus
atrial junction. Here cellular depolarization begins, ac-
into the aorta and pulmonary artery. The pulmonary
tivating adjacent atrial muscles, beginning high in the
veins are incorporated into the left atrial wall. During
atrial septum and traveling downward and laterally to
the fifth week of gestation, the right ventricle enlarges
activate the left atrium. Sinus node depolarization is
in comparison to the left ventricle. During the sixth
too small to be recorded from body surface leads. How-
and seventh weeks of life, closure of the interven-
ever, atrial muscle cell depolarization is reflected as the
tricular and membranous part of the ventricular sep-
P wave on the ECG. After the electrical impulse travels
tum occurs, and aortic arch evolution is complete. By
through the atrium, depolarization of the atrioventric-
this time, the inferior and superior vena cavae have
ular node begins. The atrioventricular node is located
formed, and the semilunar valves are created by the
within the triangle of Koch; the perimeter of the trian-
truncal cushions and the aorticopulmonary septum.
gle consists of the membranous septum, the tricuspid
Cardiogenesis is complete by the 45th day of gestation
valve, and the coronary sinus which is located in the
and continues beyond the postnatal period (Keane,
right atrium. Typically, conduction through the atrio-
Fyler, & Lock, 2006).
ventricular node is slow and varies according to the
timing of the atrial impulses. Electrical activity of the
atrioventricular node is not directly transmitted onto
the ECG recording; the P-R interval provides the best FETAL CIRCULATION
estimate of atrioventricular node conduction. Once Comprehending the role of the fetal shunts in utero
the electrical impulse passes through the atrioven- provides a foundation for understanding the patho-
tricular node, it travels down the bundle of HIS, splits physiology as well as the presenting time frame of cya-
into right and left bundle branches, and then onto the notic and acyanotic congenital heart lesions. In fetal
Purkinje fibers located in the ventricular myocardium circulation, the placenta is primarily responsible for
before activating the ventricular myocytes. Ventricular oxygenating and filtering the blood. Oxygenated blood
contraction begins at the apex and travels towards the is carried from the placenta to the fetus by the umbili-
base of the heart. The QRS complex reflects depolariza- cal vein. The fetal lungs are collapsed and receive ap-
tion of the ventricle (Seidel et al., 2006). proximately 15% of the cardiac output (Park, 2008).
Thus, pulmonary vascular resistance (i.e., the amount CLOSURE OF FETAL SHUNTS
of opposition to blood flow caused by the pulmonary
Clamping of the placenta stimulates closure of the fetal
vasculature or the force against which the right heart
shunts either because of lack of blood return from the
pumps) is nearly equal to systemic vascular resistance
placenta (as in the case of the ductus venosus) or pres-
(i.e., the amount of opposition to blood flow caused
sure changes. Interruption of the placenta results in the
by the systemic vasculature or the force against which
lungs assuming the role of oxygenation of the blood.
the left ventricle has to pump). The collapsed fetal
Lung expansion occurs because of a decrease in pulmo-
lungs result in alveolar hypoxia, which further con-
nary vascular resistance and an increase in pulmonary
tributes to increased pulmonary vascular resistance.
blood flow. With the first breath of life, the lungs fill,
Since blood flow follows the path of least resistance
and pulmonary vascular resistance drops. Right-sided
and—in the fetus—pulmonary pressures are elevated,
pressures fall, and the left atrial pressure increases as
the majority of blood flow bypasses the lungs through
a result of an increase in blood return from the pul-
the fetal shunts, preferentially shunting oxygen-rich
monary veins. Thus, there is functional closure of the
blood to the brain and myocardium. There are four
foramen ovale as a result of the increase in left-sided
fetal shunts, including the placenta, which has the
pressure or systemic vascular resistance as compared to
lowest impedance to blood flow and receives 55% of
the right-sided pressure or pulmonary vascular resistance.
the total (right and left) ventricular output. The other
Lower right-sided pressures, along with increased arte-
three fetal shunts include the ductus venosus, the fora-
rial saturations and decreased levels of prostaglandin
men ovale, and the ductus arteriosus (Park, 2008).
E1 in the body, cause the medial smooth muscle of the
In fetal circulation, oxygen-rich blood bypasses the
vessels of the ductus arteriosus to constrict, resulting
liver through the ductus venosus. Oxygenated blood
in functional closure of the ductus arteriosus within
travels from the placenta to the umbilical vein and
10–15 hours after birth. Anatomic closure typically oc-
then through the ductus venosus to the inferior vena
curs by 2–3 weeks; however, prolonged patency of the
cava, which then drains into the right atrium. The
ductus arteriosus can be seen in premature infants and
foramen ovale is an opening between the right and
in infants with ductal-dependent congenital heart dis-
left atrium that allows blood to shunt from the right
ease (CHD) with the use of an intravenous infusion of
to left side of the heart, bypassing the lungs. The duc-
prostaglandin E1 (Park, 2008).
tus arteriosus is a muscular communication between
Neonates have right ventricular dominance as a result
the pulmonary artery and the aorta. It allows blood to
of elevated right-sided pressures. Once the pulmonary
bypass the lungs by shunting blood directly from the
circulation is established and the fetal shunts close, the
pulmonary artery to the aorta, brain, and other vital
left ventricle becomes responsible for pumping blood
organs (Fig. 18-2).
to the systemic circulation, which is at a higher pres-
sure than the pulmonary circulation. This results in a
relative increase in left ventricle mass, which continues
Ductus to develop throughout infancy. By 1 year of age, the
arteriosus relative size of the left ventricle compared to the right
Descending ventricle reaches a ratio approximating 2:1, which is
Superior aorta comparable to the adult heart (Seidel et al., 2006).
vena cava Pulmonary artery
AO
Foramen
Pulmonary vein
ovale PA ASSESSMENT OF THE
LA
RA CARDIOVASCULAR SYSTEM
HISTORY
LV
Taking a comprehensive health history is one of the
RV most important steps in evaluating whether a child is
at risk for heart disease or already has heart disease.
Components of the history should include the mater-
nal health history, family health history, and the child’s
Ductus Inferior medical history, including birth and postnatal events.
venosis vena cava
Maternal Health History and

Oxygen-rich blood
Oxygen-poor blood
Prenatal History
Mixed blood The maternal health history may help identify infants
FIGURE 18-2. Fetal circulation. at risk for heart disease because of the strong association
between maternal conditions and CHD. Infants of di- diagnosed with CHD in utero, and most cyanotic
abetic mothers, for example, have a higher incidence lesions present at birth (Rychik, 2004). Common
of cardiomyopathy and congenital heart defects, such lesions detected at birth are transposition of the great
as transposition of the great arteries, ventricular septal arteries, hypoplastic left heart syndrome, tetralogy of
defects, and patent ductus arteriosus ( Jenkins, Correa, Fallot, pulmonary atresia with intact ventricular sep-
Feinstein, Botto, Britt, Daniels, et al., 2007). Likewise, tum, interrupted aortic arch, critical aortic stenosis,
infants born to mothers with systemic lupus erythe- coarctation of the aorta, truncus arteriosus, and pat-
matosus or connective tissue disorders have a higher ent ductus arteriosus. At 6 to 8 weeks of life, when
incidence of congenital heart block. Infections during the pulmonary pressures drop, lesions that cause left-
the first trimester of pregnancy can also result in con- to-right shunts are likely to present. These include
genital anomalies. Maternal rubella during the first large ventricular septal defects, atrioventricular canal
trimester has been associated with peripheral pulmo- defects, double-outlet right ventricle, and patent duc-
nary stenosis and patent ductus arteriosus, and mater- tus arteriosus. The toddler may present with either
nal infections such as cytomegalovirus, herpes virus, an atrioventricular septal defect, ventricular septal
and coxsackievirus B have been associated with the defect, or acquired heart disease such as Kawasaki
development of myocarditis. Maternal use of some or cardiomyopathy. Since children are living longer
medications during pregnancy has been identified with CHD, children with a staged palliation may be
as being teratogenic to the fetus, resulting in myriad cyanotic if they have narrowing of a shunt that pro-
congenital defects, such as tetralogy of Fallot (warfa- vides pulmonary blood flow or if complications from
rin [Coumadin]), tricuspid valve anomalies (lithium), the palliation arise. School-aged children are more
patent ductus arteriosus (phenytoin [Dilantin]), per- likely to present with acquired heart disease such
sistent pulmonary hypertension of the newborn as cardiomyopathy. However, they may be found to
(nonsteroidal anti-inflammatory agents or aspirin), have coarctation of the aorta. Adolescents are more
and ventricular septal defect (amphetamines). Fetal likely to present with acquired heart disease, such as
exposure to alcohol also results in congenital heart cardiomyopathy, hyperlipidemia, and hypertension.
defects, including atrial and ventricular septal defects, They may also present with a coarctation of the aorta
patent ductus arteriosus, and tetralogy of Fallot (Park, found on a sports physical examination. Syncope is
2008). While many medications can cause congenital reported most often in older children, and although
heart defects, the amount of exposure is an important rare, may be associated with long QT syndrome or
variable. idiopathic cardiomyopathy. In both age groups, chil-
dren with known CHD should be monitored for the
Perinatal History long-term sequelae of their disease. Primary care prac-
Gestational age and Apgar scores may be predictive of titioners should collaborate with the child’s cardiolo-
CHD (Park, 2008; Dimmick, Walker, Badawi, Halliday, gist in screening for complications and progression
Cooper, Nicholson, et al., 2007). Details of the delivery of their disease (Wernovsky, Rome, Tabbutt, Rychik,
and conditions immediately preceding and following Cohen, Paridon, et al., 2006).
the birth should be elicited. Questions that should be
asked include the following: Review of Systems
• Were there concerns about fetal distress at birth? A thorough review of systems is conducted to identify
• Was the infant cyanotic at birth? if the child has any cardiac abnormalities or condi-
• Was oxygen required at birth? tions that could lead to cardiovascular complications.
• Was oxygen required after birth? The date and length of any hospitalizations for any of
• How soon did the infant get discharged after birth? these conditions is also noted:
If the infant’s discharge was delayed, the details • General: Dysmorphic in appearance, presence of
surrounding the delay should be elicited. Red flags for other anomalies
CHD include prematurity, low Apgar scores, a history • Growth: Obesity, poor weight gain, or poor linear
of fetal distress, and cyanosis or oxygen requirement at growth
birth. Delayed discharge because of poor feeding, leth- • Integumentary: Cyanosis, pallor, impetigo (can lead
argy, or color change should also raise concern about to rheumatic heart disease), erythema marginatum,
the presence of heart disease, especially if other find- erythema chronicum migrans (Lyme disease), previ-
ings on physical examination or from the maternal ously undiagnosed maculopapular rash (streptococcal
history are suspicious for CHD. infection; Kawasaki disease), subcutaneous nodules,
clubbing, edema, ascites; petechiae, or splinter hem-
Postnatal History orrhages (indicates rheumatic heart disease)
Advanced imaging with the use of fetal ultra- • Cardiovascular: Congenital or acquired heart disease,
sound has increased the number of infants who are vasovagal syncope, subacute bacterial endocarditis,
tachycardia, bradycardia, cardiomegaly, murmurs, for rheumatic heart disease. The child may also be tak-
clicks, S3, S4, splits, gallops, hypertension, decreased ing medications prescribed for conditions that are not
lower extremity pulses, chest pain, palpitations, or cardiac in nature, but have cardiac side effects. One ex-
jugular venous distention ample is albuterol, which can cause tachycardia.
• Respiratory: Cough, tachypnea, shortness of breath,
pulmonary edema, or frequent respiratory infections Family History
• Neurologic: Dizziness or syncope Family history is an important risk factor for both
• Hematologic: Sickle cell disease (can lead to conges- acquired and CHD. Family history incorporates genetic
tive heart failure) susceptibilities as well as shared environmental, behav-
• Endocrine: Hyperthyroidism or hypothyroidism ioral, and cultural factors (Green, 2007). In the clinical
• Infectious Disease: Lyme disease, history of untreated setting, it is used predominantly for diagnostic pur-
streptococcal infection poses. The clinical utility of obtaining a detailed family
• Immunologic: Persistent low-grade fever with or history is to determine the risk of disease and promote
without rash, streptococcal infection, Kawasaki disease, prevention. Family history can also be cost-saving by
or atopic dermatitis (itching can lead to impetigo) providing guidance for referrals and diagnostic testing.
• Rheumatology: Connective tissue disorders (Marfan, Red flags for acquired heart disease include a family his-
Ehlers-Danlos), autoimmune disorders (systemic tory of the sudden, unexplained, or premature death
lupus erythematosus or Sjogren syndrome) of a first-degree relative, arrhythmias, early myocardial
• Gastrointestinal: Hepatomegaly, poor feeding (in- infarction, hyperlipidemia, hypertension, or obesity.
fant), diaphoresis with feeding (infant), vomiting, or The incidence of CHD is 8 in 1000 live births or ap-
takes frequent breaks during feeds proximately 35,000 infants a year (American Heart As-
• Genitourinary: Renal disorders (cause hypertension) sociation, 2006; Williams, Pearson, Barst, Child, del
Nido, Gersony, et al., 2006). The risk of recurrence is
Immunization Status impacted by the prevalence of the particular heart de-
It is important to review the child’s immunization sta- fect. Group and exact concordance rates for CHD dif-
tus to determine children at risk for infections which fer, depending on the type of CHD (i.e., the recurrence
can be associated with acquired heart disease such as rate of ventricular septal defect, a lesion that increases
pneumococcus. Children with congenital or acquired pulmonary blood flow, has been estimated at 15.6%,
heart disease who develop respiratory infections may whereas a right-sided obstructive lesion such as tetralogy
experience a more severe form of the illness requiring of Fallot has been estimated at 3%) ( Jenkins et al., 2007;
hospitalization. Therefore, immunization education Correa, Cragan, Kucik, Alverson, Gilboa, Balakrishnan,
should be provided to the parent/guardian. An immu- et al., 2007; Green, 2007; Wurst, Ephross, Loehr, Clark,
nization plan should be discussed with the cardiologist & Guess, 2007). More adults and children are living
for children who have undergone a heart transplant, with CHD because of the advances in neuroprotection,
those with asplenia, or children with Di George syn- surgical techniques, and medical management (Marelli,
drome since they may be immunocompromised. It is Mackie, Ionescu-Ittu, Rahme, & Pilote, 2007). In 2000, it
also essential to determine the rubella status of the preg- was estimated that 1 out of every 250 adults and 1 out
nant teenager; exposure during the first trimester is as- of every 85 children had CHD. Yet the group that has
sociated with congenital rubella syndrome of the fetus. grown at a striking rate is adults with severe forms of
CHD, nearly equaling the number of children with com-
plex CHD. It is estimated that there has been an 85%
Surgical History increase in adults with severe CHD and a 22% increase
The child’s past surgical history is an important part of in the number of children with CHD (Williams et al.,
the cardiovascular assessment. Any history of cardio- 2006). The most significant increases are in adolescents
vascular surgeries should be noted, with a record made (13 to 17 years old) and in young adults (18 to 25 years
of the type of cardiac lesion, the reason for the surgery, old). The impact of this shift has enormous implications
the timing of the surgery, and the child’s postoperative for women’s health, obstetrics, genetics, and health care
course. The provider should also inquire if the child coverage (Mackie, Pilote, Ionescu-Ittu, Rahme, & Marelli,
with a cardiac lesion has received prophylaxis for sub- 2007; Marelli et al., 2007; Davies & Herbert, 2007).
acute bacterial endocarditis before any surgery. The cause of CHD is not clear; most cases seem to oc-
cur randomly. However, there is a genetic link. In recent
Medications years, characterization of mutations affecting cardiovas-
The health care provider must note any medications cular development have been linked to Mendelian, mul-
that the child is taking for cardiovascular conditions or tifactorial, or complex (combination) traits (Mitchell,
medications that can affect the heart. Examples include Sander, Klinkner, & Tomita-Mitchell, 2007; Sharma,
digoxin, diuretics, angiotensin-converting enzyme in- Peters, Moorhouse, van der Spek, & Bogers, 2007; Weis-
hibitors, beta-blockers, antihypertensives, or antibiotics mann & Gelb, 2007). The incidence of CHD increases to
approximately 2%–5% for the next pregnancy if one sib- Growth Failure. Growth failure and developmental
ling has CHD. If two siblings are affected, the chances of delay may suggest heart disease. Poor feeding, dyspnea
the next child having CHD rise to approximately 3%–9%, during feedings, or the need to take frequent rest periods
and if the mother has a congenital heart defect, the risk during feedings are exhibited by children with conges-
is estimated to be 3%–15% (Correa et al., 2007; Green, tive heart failure. Plotting the child’s growth on the
2007; Wurst et al., 2007; Weismann, & Gelb, 2007; Che- appropriate growth chart is mandatory. If possible, the
hab, Chedid, Saliba, & Bouvagnet, 2007). Examples of child’s growth should be compared to that of siblings
major syndromes that are associated with cardiovascular and parents. Weight and height percentiles should be
disease include the following: cri du chat syndrome (ven- proportionate. Children with heart disease often show
tricular septal defect, patent ductus arteriosus, atrial sep- growth delay resulting from increased calorie expendi-
tal defect), DiGeorge syndrome (interrupted aortic arch ture without much effect on height or head circumfer-
and other aortic arch anomalies, truncus arteriosus, te- ence. Red flags for CHD include infants over 36 weeks’
tralogy of Fallot, ventricular septal defect, patent ductus gestation who are unable to gain at least 30 grams a day,
arteriosus, coarctation of the aorta), glycogen storage dis- infants who plot under the 16% percentile for weight,
ease (cardiomyopathy), Marfan syndrome (aortic aneu- or children who have fallen off their own growth curve
rysm, aortic or mitral regurgitation), Noonan syndrome (da Silva, de Oliveira Lopes, & de Araujo, 2007).
(valvular pulmonic stenosis; hypertrophic cardiomyopa-
thy), Turner syndrome (bicuspid aortic valve; coarcta- Exercise Intolerance. Limited exercise tolerance may
tion of the aorta), and Down syndrome (atrioventricular also be a sign of heart failure. Activity levels should be
canal defect, ventricular septal defect) (Park, 2008). Red elicited from the parents in measurements that are ap-
flags for CHD include parental consanguinity or a family propriate for the child’s age. When evaluating the exer-
history notable for any first-degree relative with a struc- cise tolerance of an infant, for example, parents should
tural heart abnormality or any relative with a hereditary be asked how long the infant takes to feed, whether the
disease. In addition to CHD and genetic syndromes, oth- infant requires rest periods during the feedings, and if
er red flags for a family history of cardiovascular disease the infant displays dyspnea when feeding. For older
include sudden cardiac death before age 50, hyperten- children, soliciting the child’s normal exercise capacity
sion, rheumatic fever, and hypercholesterolemia. is important. Questions should be posed to the parent
and child to determine the child’s activity level. In what
Social History after-school activities does the child participate? Does
It is important to ask if the child or adolescent is involved the child participate in sports? Is the child able to keep
in any type of sports; regular physical activity can be the up with peers? If the child leads a sedentary lifestyle,
cause of a slow resting heart rate. Likewise, any family his- does this mimic the parents’ involvement in exercise or
tory of passing out, sudden death, or arrhythmias while is it a result of other limitations? Is this a recent change
playing sports can be a clue to a family history of long in the child’s activity level or is this normal? What is the
QT syndrome or hypertrophic cardiomyopathy, which child’s exercise capacity? It is important to determine
may preclude the child from playing certain sports. the child’s ability in measurable terms such as the num-
The use of recreational drugs should be assessed; for ber of blocks the child can run or the number of stairs
example, cocaine raises the heart rate and can lead to the child can climb without stopping or becoming fa-
arrhythmias, myocarditis, and myocardial infarction tigued. Additional questions should determine whether
(Burnett & Adler, 2008). The consumption of cola, cof- the child experiences any symptoms during exercise
fee, tea, energy drinks, or other caffeinated drinks is also such as shortness of breath or palpitations. Red flags for
determined; excessive caffeine intake is also associated congenital or acquired heart disease in infants include a
with fluid loss, tachycardia, increased sympathetic ac- history of prolonged feeding time (greater than 30 min-
tivity, and decreased parasympathetic activity (Bonnet, utes) that requires several “rest” periods because of the
Tanker, Uhde, & Yeragani, 2005). Children are more sus- increased work of breathing or exhaustion. For the child
ceptible to the effects of caffeine than adults (Braganza and adolescent, concerns about heart disease should be
& Larkin, 2007). raised if the child reports an inability to keep up with
peers, chest pain during exercise, or limited or no exer-
cise tolerance (inability to climb stairs or walk multiple
History of the Present Illness street blocks without experiencing shortness of breath
When an infant, child, or adolescent presents with a car- and stopping because of fatigue).
diovascular or respiratory complaint, a careful, detailed,
focused history is essential to narrow the list of differential Respiratory Complaints. A history of frequent lower
diagnoses. Common complaints in these areas include respiratory infections may be associated with conges-
growth failure, exercise intolerance, respiratory com- tive heart failure. This is caused by large left-to-right
plaints, palpitations, chest pain, syncope, joint pain, shunts, resulting in increased pulmonary blood flow,
neurologic signs, cyanosis, and congestive heart failure. which, in turn, can predispose the child to lower
respiratory infections. Children with unrepaired CHD a detailed description of the precipitating events from
are more likely to require a hospital admission because the child and parent. Questions to ask about chest
of a respiratory syncytial virus (RSV) lower respiratory pain include:
infection. Infants with moderate-to-severe pulmonary • Is it related to exercise?
hypertension, cyanosis, or congestive heart failure are • Is it associated with syncope or palpitations?
at the highest risk for suffering RSV-induced morbid- • Does it occur at rest or when watching television?
ity and mortality. A history of frequent upper respira- • Does it wake the child up at night?
tory infections is not related to the presence of CHD • Does it occur at the same time each day?
but may indicate the presence of a vascular ring that
In addition, the duration of the pain should be es-
should be evaluated.
tablished (seconds, minutes, hours). The child should
be asked to point to the location of the pain, whether
Palpitations. Evaluating complaints of palpitations it always occurs at the same location or radiates, and
poses a challenge for practitioners. Children as young
what, if anything, relieves it. The child should also
as preschoolers may complain of palpitations caused
be asked to describe the pain (sharp or dull, stabbing,
by irregular heartbeats. Children who chronically ex-
squeezing, or pressure) and to rate the intensity on a
perience tachycardia may not identify palpitations as
scale of 1 to 10. If the child specifically states that the
a symptom compared to children who notice a change
chest pain is related to his or her heart, the practitio-
in their heart rate for the first time. When soliciting a
ner should attempt to find out why. Determine if there
history from the older child, attempts should be made
is a family history of angina or sudden death in the
to differentiate between tachycardia and irregular-
family. Red flags for a cardiac origin of chest pain are
ity. Investigation into the etiology of the complaint
a family history of sudden death at a young age, chest
should focus on identifying the precipitating event, fre-
pain described as a deep, heavy pressure, or a squeez-
quency, duration, accompanying symptoms, and a de-
ing sensation that is triggered by exercise and associ-
tailed medical history, including a history of structural
ated with symptoms of pallor, dizziness, diaphoresis,
heart disease, arrhythmias, or metabolic disorders. In
or syncope.
addition, school-aged children and adolescents should
be questioned about over-the-counter and prescription
medication use, recreational drug use, and the quantity Syncope. Syncope is a transient loss of consciousness
of caffeine ingested each day (e.g., soda, power drinks, and muscle tone. It occurs in up to 15% of children
coffee). If tachycardia is suspected, attempts should be by the age of 21 years and accounts for up to 3% of
made to capture it on a 12-lead ECG, but the high- emergency room visits (Villain, 2004). Unlike adults,
est probability of documenting the tachycardia is by a most syncopal cases in children are benign and re-
24-hour Holter monitor. Red flags for heart disease or sult from a vasovagal episode, orthostatic hypoten-
arrhythmias include complaints of sudden-onset pal- sion, hyperventilation, or breath holding. However,
pitations associated with pallor, diaphoresis, dizziness, any episode of syncope warrants careful investigation
chest pain, or syncopal events (Keane, Fyler, & Lock, because of the risk of structural heart disease or ar-
2006; Park, 2008). rhythmias (Park, 2008; Allan & Gospe, 2005). Cardiac
causes of syncope are typically triggered by exercise;
Chest Pain. Chest pain is a frequent complaint of however, cardiac syncope can occur in the recumbent
children seen by pediatricians. In most instances, the position and is often associated with chest pain. Infor-
etiology of the chest pain is not cardiac in nature. mation that should be elicited includes a description
Less than 4% of children with heart disease present of the preceding events, the timing of onset (gradual
with complaints of chest pain (Geggel, 2004). The or sudden), and the progression and duration of the
most common causes of chest pain in children are syncopal event and recovery period. The frequency in
idiopathic factors (12%–45%), costochondritis (9%– which the events happen and any prodromes should
22%), musculoskeletal trauma (21%), and respiratory also be identified. Signs and symptoms accompanying
disease (15%–21%). Occasionally, the etiology is a re- the event should be determined, such as the presence
sult of cardiac conditions, including severe aortic ste- and duration of loss of consciousness, pallor, cyano-
nosis, pulmonary vascular obstructive disease, and, sis, diaphoresis, palpitations, nausea, incontinence,
less commonly, severe pulmonary stenosis, pericardi- seizure activity, and chest pain. Details regarding
tis, or Kawasaki disease. Chest pain is not affected by the child’s past and current medical history should
respiration unless the etiology is pericarditis. There- include use of over-the-counter and prescription
fore, it is important to evaluate the circumstances medications, recreational drug use, and the presence
surrounding the complaints of chest pain in detail of metabolic or neurologic disease. Patients who de-
(Park, 2008). scribe a history of syncope associated with swimming
To differentiate between pathologic and nonpatho- should be evaluated for long QT syndrome (Sovari,
logic causes of chest pain, the clinician should obtain Kocheril, Assadi, Baas, Zareba, et al., 2007). Red flags
for a cardiac cause of syncope include a past medical (e.g., feedings, exercise). Attempts should be made to
history of structural heart disease or a family history differentiate between a true cyanotic spell and a breath-
of CHD or sudden death. Syncopal events that are holding spell. A history of squatting or assuming a knee-
triggered by exercise and associated with symptoms chest position when tired in association with cyanosis
of chest pain, pallor, and diaphoresis are also suspi- is suspicious for tetralogy of Fallot and requires immedi-
cious for a cardiac origin. ate evaluation.
Joint Symptoms. Acute rheumatic fever is rare in Congestive Heart Failure. Tachycardia, dyspnea
the United States. The rate of attack after group A on exertion, and swelling, especially around the eyes,
streptococcal pharyngitis is approximately 0.3%–3% can all be signs of congestive heart failure. A history
(Olgunturk, Canter, Tunaoglu, & Kula, 2006). Rheu- of irritability, poor feeding, tachypnea that worsens
matic arthritis should be considered when the pri- with feedings, and poor weight gain are all consistent
mary complaint is pain in a large joint. To determine with congestive heart failure. Reports of diaphoresis,
whether the child has acute rheumatic fever, informa- a mottled appearance of the skin, and cool extremi-
tion about the number of joints involved, how long ties are also associated with decreased cardiac function
the symptoms have been present, and whether the and congestive heart failure. Parents of older children
pain is stationary (in one joint) or migratory must with congestive heart failure may report a history of
be gathered. A history of streptococcal pharyngitis shortness of breath with exercise, easy fatigability, and
1–5 weeks before the onset of symptoms is common. discomfort when lying flat, thus the use of multiple
Therefore, parents should be asked if the child had pillows for sleep (Table 18-1).
a throat culture done at the time of the pharyngitis.
Other symptoms associated with rheumatic fever in-
clude pallor, malaise, fatigue, abdominal pain, and
epistaxis. Information about whether the child had a
TABLE 18-1
rash, has difficulty walking, and what actions or med- Signs and Symptoms of
ications relieve the symptoms should be collected. Congestive Heart Failure
Massaging the affected joint does not relieve the pain
SYSTEM SIGNS AND SYMPTOMS
in rheumatic fever, but salicylates may suppress the
symptoms of rheumatic fever; therefore, it is impor- Cardiac Tachycardia
tant to inquire about a medication history. A family Gallop rhythm
history of rheumatic disease and crowded living con- Diaphoresis
Cool extremities
ditions along with joint symptoms should also raise Delayed capillary refill
suspicion for the disease. Cardiomegaly on chest film
Pulmonary Tachypnea
Neurologic Symptoms. Cyanotic heart disease Increased work of breathing
or infective endocarditis should be considered in a Congestion
patient presenting with a history of stroke. Polycy- Pulsus alternans
themia in the cyanotic child and thrombus on an Increased pulmonary vascular
infected valve can place the child at high risk for markings on chest film
Pleural effusion on chest film
stroke. Complaints of chronic headaches can be a (chronic congestive heart failure or
manifestation of cyanotic heart disease, cerebral hy- severe form)
poxia, polycythemia, or brain abscess. Children with
coarctation of the aorta may present with complaints Gastrointestinal Prolonged feeding time (greater
than 30 minutes)
of headaches resulting from hypertension proximal
Requires rest periods or tires during
to the coarctation site. A history of syncope or cho- feedings
reic type movements may also have a cardiac cause. Poor weight gain (infant) or
Small children with hypertension may be described excessive weight gain (older child)
as irritable by parents and exhibit head banging Vomiting
Hepatomegaly or
or head rubbing. Older children with hypertension
hepatosplenomegaly
may complain of visual disturbances, dizziness, or
headache. Neurologic Irritability
Lethargy (decreased exercise
tolerance)
Cyanosis. A history of cyanosis warrants further investi- Complaints of discomfort unless
gation into the etiology of symptoms. A detailed history sitting forward or upright at a 30°
should include age at onset of symptoms; frequency, se- angle or more (older child)
verity, and duration of episodes; and precipitating events
PHYSICAL EXAMINATION Inspection

The biggest challenge for the practitioner is trying General Appearance. The physical examination
to examine a frightened or crying child. To optimize should begin by inspecting the child for abnormali-
the yield from the examination, infants and toddlers ties. The child’s overall health status should be deter-
can be assessed while sitting in their parent’s lap to mined. Does the child appear ill or in distress? Infants
decrease separation anxiety. Methods of distraction in distress appear diaphoretic, pale, and fretful. What
(e.g., playing age-appropriate movies) can be used is the child’s affect? Is the child irritable or happy?
during the examination. Privacy for the adolescent Is the child consolable? Is the older child talkative
must be maintained by pulling the shades down, or lethargic? What is the child’s nutritional status?
closing the doors, and providing gowns to wear dur- Is the child well nourished or obese? If the child
ing the examination. The provider should speak to appears dysmorphic, he or she may have a chromo-
the child individually to obtain his or her perspec- somal, hereditary, or nonhereditary syndrome that
tive on the chief complaint when developmentally could be associated with heart disease. The parents
appropriate. However, both the parent and the child must be asked if the child has ever been tested or
should be included when taking the history. Warm- seen by a geneticist. Approximately 50% of children
ing the hands and stethoscope before the exami- with Down syndrome have a congenital heart defect,
nation increases the child’s comfort and decreases primarily atrioventricular canal defect, or ventricu-
anxiety. Lastly, a systematic approach that is rou- lar septal defect. Sixty-five percent of newborns with
tinely followed should be used for the examination CHARGE association have a conotruncal abnormal-
so that no cardiovascular components are missed. A ity or aortic arch abnormality (Park, 2008). Abnormal
suggested format includes first listening to the heart findings warrant further investigation for a possible
sounds and then the lung sounds. Cardiac ausculta- cardiac origin.
tion should include identifying S1, S2, and the split-
ting of S2, and describing any murmurs, noting the Growth Pattern. Evidence of the child falling off
timing, intensity, quality, location, and transmis- their own growth curve or a trend of poor weight gain
sion. Palpation of femoral pulses, liver, and spleen may be indicative of CHD that causes a left-to-right
should be the last part of the examination because it shunt, leading to congestive heart failure or lesions
may cause discomfort. School-aged children and ad- that decrease pulmonary blood flow, resulting in cya-
olescents should be placed in a comfortable position nosis. Approximately 45% of children with congestive
during the physical examination. The child may be heart failure and up to 80% of children with cyanotic
most comfortable in a supine position with the knees heart disease plot below the 16th percentile for weight
bent and feet flat on the examination table. For the (da Silva, de Oliveira Lopes, & de Araujo, 2007). There-
school-aged child who is ticklish, the child’s hand fore, it is important to plot height, weight, and head
can be placed on top of the practitioner’s hand when circumference on the appropriate growth chart for
palpating the liver and spleen. This may decrease any comparative norms. Length and head circumference
anxiety or discomfort. are minimally affected by the presence of structural
Vital signs, including the heart rate, respiratory heart disease. Children with severe cyanotic lesions
rate, upper and lower extremity blood pressure, may have overall growth retardation (Vogt, Manlhiot,
and oxygen saturation as well as height, weight, Van Arsdell, Russell, Mital, et al., 2007). The combina-
and head circumference, should be measured on all tion of CHD and associated syndromes or extracardiac
children. Measurements outside the normal range anomalies may place these children at additional risk
for the child’s sex and age should be investigated. for growth delay.
Blood pressure measurements should be part of the
physical examination. To ensure accurate measure- Respirations. Children with left-to-right shunts that
ments, an appropriate-sized cuff should be used. The result in increased pulmonary blood flow may exhibit
width of the cuff should be 40%–50% of the circum- signs of congestive heart failure. Tachypnea, retrac-
ference of the limb on which the blood pressure is tions, nasal flaring, and grunting are indicative of
measured. The same rules apply for lower extremity right-sided heart failure. A resting respiratory rate of
blood pressure measurements. The bladder should be greater than 60 beats a minute is abnormal at any age
long enough to encircle the limb completely. For op- and should be evaluated. Tachypnea accompanied by
timal readings, the child should sit upright with the tachycardia may be an early sign of left-sided heart
arm that has the blood pressure cuff positioned at failure. Determining the type of respirations (i.e., shal-
heart level. Current recommendations are to average low and rapid or deep and rapid), and how the child
at least two blood pressure readings, which are then tolerates the type of breathing pattern may assist in
compared against normative blood pressure measure- differentiating between a cardiac versus pulmonary
ments for age. cause of the tachypnea (Park, 2008).
Cyanosis. As part of the overall assessment, infants preschool children often note that the child’s pillow is
and children should be inspected for cyanosis and pal- wet upon his or her awakening from sleep.
lor. If cyanosis is noted, the degree and distribution of
the cyanosis should be documented, noting that mild Chest Deformity. Left-sided chest prominence is a
cyanosis is difficult to detect in patients with normal manifestation of CHD. The deformity is the result of a
hemoglobin levels. To optimize detection, the patient significantly enlarged and active left or right ventricle
should be examined in a well-lighted room. The lips during chest wall development. It is commonly seen
and mucous membranes as well as the tongue, nail in children with left-to-right shunts. The presence of
beds, and conjunctiva should be examined, especially a precordial bulge is a hallmark of chronic cardiac en-
in children with deep pigmentation. Pulse oximetry largement. Pectus carinatum, a condition in which the
should be used when available to confirm suspicions sternum protrudes on the midline, is not typically as-
of arterial desaturation. sociated with cardiac disease. Pectus excavatum, a con-
In addition to measuring an oxygen saturation on dition in which the sternum is concave, rarely causes
the patient, obtaining a hematocrit may also be help- cardiac compromise. It may cause a pulmonary ejec-
ful in sorting out why a child looks cyanotic. Children tion murmur or the appearance of cardiomegaly on
who are polycythemic may appear cyanotic but have a the posteroanterior view of the chest radiography. The
normal arterial saturation. Evaluating the location and presence of pectus excavatum should prompt the prac-
extent of cyanosis can provide clues as to the etiol- titioner to look for signs of Marfan syndrome or other
ogy. Circumoral cyanosis can be a normal finding in connective tissue disorders such as Ehlers-Danlos syn-
fair-skinned children or a symptom of cyanotic heart drome (Alizad & Seward, 2000).
disease. Peripheral cyanosis may be caused by sluggish
peripheral blood flow or polycythemia. Acrocyanosis, Extracardiac Anomalies. The overall incidence of
a bluish discoloration of the fingers and toes, is a nor- extracardiac anomalies among children with congen-
mal finding in the newborn. ital heart defects is approximately 15%–45% (Green,
2007; Davies, Rizo, & Arroyo-Valerio, 2002). Howev-
Clubbing. Clubbing develops when chronic arterial er, the incidence varies based on the specific defect
desaturation (⬎6 months) is present. Typically, in the (Davies, Rizo, & Arroyo-Valerio, 2002). For example,
early stages of clubbing, the phalanges begin to turn the incidence of associated anomalies with transpo-
red. It is first noted in the thumb. As clubbing becomes sition of the great arteries is quite low, but anomalies
more severe, the ends of the fingers and toes become are seen in up to 50% of patients with truncus arte-
wider and thicker, the shape of the fingernails changes riosus (Park, 2008). A good rule of thumb is to inves-
to become more convex, and angle between the nail tigate for other defects if the infant is found to have
and the thumb becomes blunted (see Fig. 12-12). other anomalies in addition to a congenital heart
Clubbing is seen in both pulmonary and cardiac dis- lesion. This is especially true for midline defects.
ease states that cause arterial desaturation, cirrhosis of Certainly if the child is diagnosed with a syndrome,
the liver, and subacute bacterial endocarditis. Familial a full evaluation for associated health problems is
clubbing is a rare condition in which clubbing is noted necessary. For example, Gonzalez et al. (2009) found
in patients without a chronic health condition. that at least 50% of neonates with a congenital heart
lesion had an extracardiac comorbidity.
Edema. Eyelid swelling and a rounded face are often
seen in children with congestive heart failure. Unlike Palpation
the adult patient with congestive heart failure, lower Precordial Activity. The cardiac examination should
extremity pitting edema is rare in children. Similarly, begin with inspection and palpation of the chest. To
it is difficult to assess jugular vein distention in infants determine precordial activity, apical impulse, point
because of their short necks, and thus it is not typically of maximal impulse, and the presence of thrills and
found. Abdominal ascites is a manifestation of long- heaves, the clinician should palpate the supraclavicu-
standing disease and requires immediate evaluation. lar region and four areas on the chest while the patient
is in the supine position. These include the left ven-
Diaphoresis. Infants with CHD often experience dia- tricular area located at the apex of the heart (fourth
phoresis, especially during feedings. Diaphoresis is a or fifth intercostal space along the midclavicular line),
manifestation of decreased cardiac output caused by the right ventricular area located in the region of the
an increased sympathetic response to the demands third to fifth intercostal space along the left sternal
placed on the heart in the setting of decreased ven- border, the pulmonic area located at the second in-
tricular function or an increased volume or pressure tercostal space along the left sternal border, and the
load on the heart. Parents also report the infant to be aortic area. A hyperactive precordium characterized by
sweaty when they fall asleep in their arms. Parents of the presence of a lift, heave, or thrill, is indicative of
CHD, which results in a volume overload on the heart. Left midclavicular

Lesions causing right ventricular volume overload in- line
clude defects with large left-to-right shunts (e.g., ven-
tricular septal defect, patent ductus arteriosus) (Park,
2008). Lesions that cause left ventricular volume over-
load include defects with severe left-sided valvular
regurgitation such as mitral regurgitation and aortic
regurgitation. The presence of increased precordial
activity should heighten concerns about a patholog-
ic finding when abnormal heart sounds are detected
on auscultatory examination. However, a hyperactive
precordium may also be associated with fever, anemia,
stress, and anxiety.
Apical Impulse. The provider should use the fingertips

FIGURE 18-3. The point of maximal impulse.
to palpate for the apical impulse to identify the loca-
tion, duration, and amplitude. This can be challenging
in young children. For optimal assessment, older chil- Thrills. Thrills are vibratory sensations felt on the chest
dren can be instructed to exhale or hold their breath caused by turbulent blood flow going rapidly from a
for a few seconds during palpation. The location of the high-pressure area to a low-pressure area within the
apical impulse varies according to the child’s age; for heart or blood vessels. They are best palpated with the
instance, in children 7 or younger, the apical impulse palm of the hand to maximize detection. The palmar
is normally palpated at the fourth intercostal space just surface of the metacarpals is more apt to pick up low-
left of the midclavicular line, and for older children, frequency vibrations, whereas the fingertips are best
the apical impulse is normally palpated at the fifth in- able to localize a thrill or a tap (Park, 2008). Findings
tercostal space along the midclavicular line. If the api- of a thrill are always pathologic.
cal impulse is palpated either laterally or inferiorly to The location of the thrill can provide clues as to
the fourth or fifth intercostal space, the provider should the origin of the pressure gradient. Thrills in the up-
suspect cardiomegaly. If the duration of the apical imper right sternal border indicate aortic stenosis, but
pulse lasts longer than half of systole or if the ampli- those in the upper left sternal border indicate pul-
tude is increased, a hyperkinetic state may be present. monary stenosis, pulmonary atresia, or patent duc-
tus arteriosus (rarely). Thrills in the lower left sternal
Point of Maximal Impulse. The point of maximal border indicate ventricular septal defect, while thrills
impulse (PMI) is the farthest point from the sternum located in the suprasternal notch indicate atrial ste-
where the cardiac impulse can be palpated. The nor- nosis, pulmonary stenosis, patent ductus arteriosus,
mal location of the PMI in an adult is felt at the inter- or coarctation of the aorta. Thrills over the carotid
section of the fifth intercostal space and the left mid- arteries represent a carotid bruit, but a bruit felt along
clavicular line. In children, it is located at the fourth with a thrill in the suprasternal notch indicates aor-
intercostal space just medial to the left nipple (Fig. tic valve disease, such as atrial stenosis or coarctation
18-3). Determining the location of the PMI can dif- of the aorta; thrills associated with coarctation of the
ferentiate ventricular dominance. The correct tech- aorta are found in the intercostal spaces in older chil-
nique for determining the right ventricular activity dren as a result of the presence of extensive intercos-
is to apply firm pressure over the parasternal region. tal collaterals.
The PMI can be felt at the lower left sternal border
or over the xyphoid process when right-ventricular
dominance is present and at the apex when left- Auscultation
ventricular dominance is present. Right-ventricular Cardiac auscultation provides valuable information
dominance is normal in newborns and infants, but about structural abnormities and cardiac function.
right-ventricular activity is typically nondetectable in Both the bell and the diaphragm of the stethoscope are
normal adults; however, if found, it may suggest pul- used during auscultation; using one or the other may
monary hypertension. Displacement of the PMI sug- result in missing a significant auscultatory finding. The
gests abnormal left-ventricular size, function, or com- bell of the stethoscope is used to detect low-frequency
pliance. With volume overload, the PMI rises slowly sounds, while the diaphragm is used to pick up high-
and is diffuse (known as a heave), but with pressure frequency events. To ensure a comprehensive cardiac
overload, the PMI is well localized and sharp (known examination, the entire precordium as well as the su-
as a tap). praclavicular region, sides, and back are included in the
contraction
relaxation
DIASTOLE SYSTOLE DIASTOLE
Isometric
Isometric
Rapid Slow Presystole Ejection Rapid
filling filling filling
(Protodiastolic)
Heart Sounds
S3 S4 S1 S2
R
Electrocardiogram
P T
Q
S
FIGURE 18-4. Timing of heart sounds.
examination (Menashe, 2007). A systematic approach, essential to identify all components during the cardiac
including an assessment of the heart rate and regulari- examination, and this requires practice in listening to
ty, heart sounds, and murmurs, should be taken during normal children. The intensity of A2 is usually louder
auscultation to avoid missing important components than P2 in the upper left sternal border. A loud P2
of the examination. compared to A2 may indicate a pathologic condition,
such as pulmonary hypertension. A soft P2 compared
Heart Sounds. to A2 is heard in patients with severe pulmonary ste-
First Heart Sound. The S1 occurs with ventricular nosis, tetralogy of Fallot, and tricuspid atresia. Timing
systole, is generated by closure of the atrioventricular of aortic valve closure in relation to pulmonary valve
valves, and is synchronous with the apical pulse. It closure as well as the intensity of each of the S2 com-
is best heard at the apex or lower left sternal border ponents should be evaluated during auscultation.
and marks the beginning of systole (Fig. 18-4). Rarely, Physiologic splitting of S2 can occur with respiration
splitting of S1 may be detected on examination, but and is normal (Fig. 18-5). The degree of splitting var-
it can be a normal finding in children. A widely split ies, increasing with inspiration and decreasing with
S1 may be associated with right bundle branch block expiration. This variation in S2 splitting is related to
or Ebstein’s anomaly, which is an anomaly of the the vascular resistance in the systemic and pulmonary
tricuspid valve, resulting in atrialization of a portion circuits. It has also been attributed to the increased
of the right ventricle and tricuspid regurgitation. A negative thoracic pressure during inspiration result-
split S1 may be confused with a systolic ejection click, ing in an increase in systemic venous blood return
which is best heard at the upper left sternal border, to the right atrium, which, in turn, lengthens right
or an S4.
Expiration Inspiration
Second Heart Sound. The S2 is associated with S1 S2 S1 S2
closure of the semilunar valves. It is best heard at the
upper left sternal border with the diaphragm of the
stethoscope. The S2 marks the beginning of diastole.
It has two components, A2, which reflects closure
of the aortic valve, and P2, which reflects closure of
the pulmonary valve. Determining the normal inten- A 2P 2 A2 P2
sity for each of the S2 is challenging, especially in FIGURE 18-5. First and second heart sounds with splitting
younger children with faster heart rates. However, it is of S2.
ventricular ejection time and delays closure of the it is also found in patients who have Wolff-Parkinson-
pulmonary valve. White syndrome.
Findings of a widely split and fixed S2, narrowly
split S2, single S2, or paradoxically split S2 are abnor- Third Heart Sound. The S3 is associated with rapid
mal and indicate the presence of a pathologic condi- filling of the ventricle. The timing of S3 occurs in early
tion. Findings of a widely split and fixed S2 indicates diastole and is best heard at the apex or lower left
pathologic conditions that alter ventricular ejection sternal border. It is a low-frequency sound and may
time. Right ventricular ejection time is prolonged in normally be heard in thin school-aged children and
the presence of increased right ventricular volume adolescents. In adults and children, a loud S3 is abnor-
load or afterload, resulting in delayed closure of the mal and indicates pathologic conditions that cause
pulmonary valve in relation to the aortic valve. Right ventricular dilation with decreased compliance, such
ventricular volume overload can be caused by an atri- as congestive heart failure. It sounds like “Ken-tuck-y”
al septal defect (a hole between the upper chambers when tachycardia is present (see Fig. 18-4).
of the heart), resulting in left-to-right shunting and
anomalous pulmonary venous return; at least one or Fourth Heart Sound. The S4 is heard immediately
more of the four pulmonary veins drain abnormally preceding the first heart sound. It is associated with
to the right side of the heart, resulting in an increase atrial contraction and excessive flow across the atrio-
in blood return to the right atrium. Another condition ventricular valves. It is rare in children, always patho-
that causes right ventricular pressure overload is pul- logic, and suggests decreased ventricular compliance
monary stenosis, which causes prolonged right ven- or congestive heart failure. The S4 is best heard at the
tricular ejection time because of the increased pressure apex but transmits widely. It can be accentuated by
against which the right ventricle must pump to force placing the patient in a left lateral recumbent position,
blood out the small pulmonary valve. A conduction having the patient hold his or her breath, or having
abnormality that results in a prolonged right ventricu- him or her exercise. It sounds like “Ten-nes-see” when
lar ejection time is right bundle branch block, which tachycardia is present (see Fig. 18-4).
causes delayed electrical activation of the right ven-
tricle. Mitral regurgitation can shorten left ventricle Gallop Rhythm. Tachycardia in combination with a
ejection time, resulting in early closure of the aortic normal S1, S2, and audible S3 with or without an S4 is
valve, which results in the backflow of blood into the called a gallop rhythm. The presence of a gallop is typi-
left atrium through the mitral valve during ventricu- cally pathologic and caused by conditions of volume
lar contraction. Subsequently, left ventricular ejection overload such as congestive heart failure.
time is shortened, resulting in early closure of the aor-
tic valve. Occasionally, a fixed, split S2 is detected, and Pericardial Friction Rub. A pericardial friction rub
the patient is referred for an echocardiogram, but the is commonly found in the initial postoperative period
findings are normal. The etiology of the widely split following open-heart surgery and is caused by the heart
and fixed S2 in an otherwise healthy child is the re- rubbing against the pericardium. Auscultatory findings
sult of idiopathic dilatation of the pulmonary arteries reveal a harsh, to-and-fro sound often heard best at the
(Park, 2008). lower left sternal border. Pericardial friction rubs may
A narrowly split S2 reflects altered closure time of be biphasic or triphasic and the intensity of the sound
the semilunar valves. It may be a normal finding in may vary in systole and diastole. The presence of a peri-
children; however, it can be associated with pathologic cardial friction rub in an otherwise healthy child or in
conditions such as pulmonary hypertension, resulting a child being seen in clinic following cardiac surgery is
in early closure of the pulmonary valve or aortic steno- always pathologic and indicates pericarditis. The rub
sis, resulting in delayed closure of the aortic valve. A may disappear with increased accumulation of fluid in
single S2 is found in aortic atresia or pulmonary atre- the pericardial space. To differentiate a pericardial rub
sia where only one semilunar valve is present. A single from other extracardiac sounds, the patient should be
S2 is also detected in conditions where the P2 is not asked to lean forward; if the sound is caused by a peri-
audible, such as in transposition of the great arteries, cardial rub, it will become louder.
tetralogy of Fallot, or severe pulmonary stenosis. Find-
ings of a single S2 may also indicate the presence of Clicks. A systolic ejection click occurs in early systole,
pulmonary hypertension resulting from an early P2 immediately following S1, and is heard in children with
component or delayed aortic valve closure caused by lesions involving the semilunar valves. It is best heard at
aortic stenosis. A paradoxically split S2 is heard when the right or left upper sternal border. The ejection click
aortic valve closure occurs after pulmonary valve clo- associated with pulmonary stenosis is heard best at the
sure. This occurs in conditions such as severe aortic ste- second and third intercostal spaces and becomes louder
nosis and left bundle branch block where the electrical on expiration. The ejection click associated with aor-
activation of the left ventricle is delayed. Occasionally, tic stenosis is best heard at the second right intercostal
EC = Ejection click
S1 S2 S1
EC S1 A2 P2 S1
FIGURE 18-7. Timing of a systolic ejection murmur.
EMC = mid-systolic click

seen in pregnancy, fever, anemia, or thyrotoxicosis.
However, the presence of an ejection or midsystolic
murmur may also be reflective of an innocent mur-
S1 S2 S2
MC mur. Ejection murmurs have variable duration and
are best heard at the second right or left intercostal
FIGURE 18-6. Ejection and midsystolic clicks.
space. Ejection murmurs are depicted as diamond-
shaped, with the apex of the diamond occurring in
space but may be louder at the apex or mid-left sternal the early part of systole when only mild stenosis is
border. In addition, an ejection click may also be heard present (Fig. 18-7). With increasing severity of the
in children with pulmonary hypertension. A mid-sys- stenosis, the diamond shape elongates horizontally,
tolic click is typically associated with mitral valve pro- and the apex shifts toward S2 to mimic the murmur
lapse and is heard at the apex (Fig. 18-6). becoming longer in duration.
Regurgitant murmurs (holosystolic and early systolic
Systolic Murmurs. Systolic murmurs occur between murmurs) begin with S1 and typically last throughout
S1 and S2 and represent the majority of heart mur- systole. When differentiating between ejection type
murs heard in children. A comprehensive examination murmurs and regurgitant type murmurs, it is important
should include auscultation of the four classic locations to note the timing of the onset of the murmur in relation
(i.e., right upper sternal border, left upper sternal bor- to S1. In regurgitant murmurs, no gap exists between S1
der, left lower sternal border, apex), as well as the axilla, and the onset of the murmur (Fig. 18-8). In holosys-
back, carotid, and supraclavicular area. Murmurs should tolic murmurs, the intensity of the regurgitant murmur
be described according to intensity, timing, location, plateaus from S1 to S2 and is depicted as rectangular,
transmission, and quality, which can provide clues to extending from S1 to S2. Early systolic murmurs begin
the etiology. Both the bell and the diaphragm of the with the S1 and end well before S2, decreasing in de-
stethoscope should be used to assess heart sounds. crescendo typically at or before mid-systole. Regurgitant
murmurs are always pathologic and result from blood
Types. Systolic murmurs occur between S1 and flowing from a high-pressure system to a low-pressure
S2 and can be classified into two subtypes according system, usually when the semilunar valves are closed.
to onset using the Aubrey Leatham classification, or The three conditions that cause regurgitant murmurs
they can be classified into four subtypes according to (holosystolic murmurs) are ventricular septal defects,
onset and termination using the Joseph Perloff classi- mitral regurgitation, and tricuspid regurgitation. When
fication. The Leatham classification identifies systolic
murmurs as either ejection type or regurgitant type.
The Perloff classification identifies systolic murmurs as
either mid-systolic, holosystolic, early systolic, or late • Holosystolic
systolic. Perloff’s classification of mid-systolic mur-
murs are synonymous with Leatham’s classification S1 S2
of ejection type murmurs and Perloff’s classification
of holosystolic type and early systolic type murmurs
are the same as Leatham’s classification of regurgitant • Early-systolic
type murmurs. Late systolic murmurs are classified
separately based on their timing during systole. Late
S1 S2
systolic murmurs begin in middle-to-late systole and
end at S2. Late systolic murmurs are audible when
mitral valve prolapse is present (Park, 2008). • Mid-systolic
Ejection murmurs (midsystolic murmurs) are asso-
ciated with normal blood flow going through stenotic
S1 S2
or malformed semilunar valves or result from increased
blood flow going through normal semilunar valves as FIGURE 18-8. Timing of a regurgitant systolic murmur.
tricuspid regurgitation is present and right ventricular

TABLE 18-2
systolic pressure is elevated, a holosystolic murmur is
heard. However, when tricuspid regurgitation is present
Intensity of Systolic Murmurs
but right ventricular pressure is normal, an early systolic (Grades I–VI)
murmur is heard. An early systolic murmur is also de- GRADE SOUND QUALITY
tected in neonates with a large ventricular septal defect,
children and adults with a very small ventricular septal I Barely audible
defect, or children with a large ventricular septal defect II Soft, but easily heard
and pulmonary hypertension.
III Moderately loud, no thrill
Intensity. Each murmur should be evaluated in
IV Loud, accompanied by a thrill
terms of intensity from grades I to VI. The difference
between grades III and IV is the presence of a thrill. V Louder (heard with a stethoscope barely on
Differentiating between grades V and VI may be sub- the chest)
jective (Table 18-2). An increase in the intensity of the
VI Heard with a stethoscope off the chest
murmur reflects an increase in the amount of turbu-
lent flow through a valve or vessel because of progres-
sive stenosis or blockage. Conditions that increase
cardiac output, such as fever, anemia, or exercise, may findings from the physical examination, ECG, and
produce a new murmur not audible at baseline or may radiologic studies can help determine the diagnosis.
intensify a pre-existing murmur. Systolic murmurs, which are best heard at the upper
left sternal border or pulmonary area, are typically an ejec-
Location. In addition to differentiating between tion type (midsystolic) and include innocent murmurs
ejection and regurgitant murmurs, the PMI where the (e.g., pulmonary flow murmur of the newborn, pulmo-
murmur is heard the loudest should be identified (Fig. nary flow murmur of older children) and pathologic
18-9). There are four key locations where murmurs are murmurs (e.g., pulmonary stenosis, atrial septal defect,
generally detected: (a) the upper left sternal border, (b) atrial stenosis, tetralogy of Fallot, coarctation of the aor-
the upper right sternal border, (c) the lower left sternal ta, patent ductus arteriosus with pulmonary hyperten-
border, and (d) the apex. Determining the timing and sion, total anomalous pulmonary venous return, partial
location of the murmur in combination with other anomalous pulmonary venous return) (Table 18-3).
Pulmonary valve stenosis

Atrial septal defect
Pulmonary ejection murmur, innocent
Pulmonary flow murmur of newborn
Aortic valve stenosis
Pulmonary artery stenosis
Supravalvular AS
Aortic stenosis
Subvalvular AS
Coarctation of the aorta
Patent ductus arteriosus
Partial anom. plum. venous return
(PAPVR)
Total anom. plum. venous return
(TAPVR)
Ventricular septal defect Mitral regurgitation

including ECD Vibratory innocent murmur
Vibratory innocent murmur Mitral valve prolapse syndrome
(Still’s murmur) Aortic stenosis
HOCM (IHSS) HOCM (IHSS)
Tricuspid regurgitation
Tetralogy of Fallot
FIGURE 18-9. Anatomic locations of systolic murmurs.

TABLE 18-3
Systolic Murmurs
CARDIAC DEFECT QUALITIES LOCATION
Aortic stenosis • Grade II–V/VI systolic ejection murmur Upper left sternal border
• ⫹/⫺ thrill (at second right intercostal space and
supraspinal notch)
• Ejection click (at apex, second left intercostal space,
and third right intercostal space)
Aortic valve stenosis • Grade II–IV/VI systolic ejection murmur (at second Upper right sternal border;
right intercostal space but louder at third left transmits to neck
intercostal space)
• ⫹/⫺ thrill at upper right sternal border, suprasternal
notch, and carotid arteries
• Ejection click
• S2 may be single
Atrial septal defect • Grade II–III/VI systolic ejection murmur Upper left sternal border
• Widely split
• Fixed S3
Atrioventricular canal defect • Grade II–IV/VI regurgitant murmur Lower left sternal border
• Diastolic rumble
• ⫹ thrill
• Gallop rhythm (in infants)
Coarctation of the aorta • Grade I–III/VI systolic ejection murmur Upper left sternal border;
• Weak or absent femoral pulses heard in back
• Hypertension in arms
Hypertrophic obstructive • Grade II–IV/VI regurgitant murmur with a medium Lower left sternal border or
cardiomyopathy pitch apex
• ⫹/⫺ thrill
• May have mitral regurgitation murmur
Mitral regurgitation • Grade II–III/VI regurgitant murmur Apex; transmits to left axilla
• May be holosystolic in infants
• May be loud in mid-precordium
Mitral valve prolapse • Midsystolic click Apex

• ⫹/⫺ late systolic murmur
• Thoracic anomalies common
Partial anomalous pulmonary • Grade II–III/VI systolic ejection murmur Upper left sternal border
venous return • Widely split
• Fixed S3
Patent ductus arteriosus • Grade II–III/VI continuous murmur Upper left sternal border;
• ⫹/⫺ thrill left infraclavicular area
• Bounding pulses
Pulmonary valve stenosis • Grade II–IV/VI Upper left sternal border;

• ⫹/⫺ thrill transmits to back
• Ejection click at second left intercostal space
Subaortic stenosis • Grade II–IV/VI systolic ejection murmur Upper right sternal border
• High-pitched diastolic murmur of aortic regurgitation
at third left intercostal space may be present
Supravalvular stenosis • Grade II–III/VI systolic ejection murmur Upper right sternal border;
• ⫹/⫺ thrill transmits to back
Tetralogy of Fallot • Grade II–IV/VI systolic ejection murmur Mid-left sternal border
• ⫹/⫺ thrill
• Loud single S2 (no P component)
• Cyanosis with severe pulmonary stenosis
Total anomalous pulmonary • Grade II–III/VI systolic ejection murmur Upper left sternal border
venous return • Widely split
• Fixed S2
• Gallop rhythm
• Diastolic rumble at lower left sternal border
Tricuspid regurgitation • Grade II–III/VI regurgitant murmur Lower left sternal border
• Gallop rhythm
• If severe, may have enlarged liver
Ventricular septal defect • Grade II–IV/VI regurgitant murmur Lower left sternal border
• May be holosystolic
• ⫹ thrill
• P2 may be loud
Systolic murmurs best heard at the upper right ster- regurgitation or a ventricular septal defect possess
nal border or aortic area are ejection type (mid-systolic) a blowing type quality. Thus, differentiating the
caused by stenosis of the aortic valve (e.g., aortic quality or pitch of the murmur can help with the
stenosis, subvalvar aortic stenosis, supravalvar aortic diagnosis.
stenosis). The murmur is heard equally well in the up-
per left sternal border and apex, transmits to the neck Diastolic Murmurs
region, and often is associated with a thrill over the Types. Diastolic murmurs are always patho-
carotid arteries (see Table 18-3). logic, and patients with these murmurs should be
Systolic murmurs best heard at the lower left ster- referred for evaluation. Diastolic murmurs occur
nal border may be either ejection type (mid-systolic) between S2 and S1, are best heard with the dia-
or regurgitant (holosystolic or early systolic). Con- phragm of the stethoscope at the left sternal bor-
ditions that result in this type of murmur include der, and are classified into three different types:
innocent murmurs (e.g., Still’s murmur) and patho- early diastolic, middiastolic, and late diastolic or
logic murmurs (e.g., small muscular ventricular presystolic murmurs.
septal defect, hypertrophic obstructive cardiomy- Early diastolic murmurs begin immediately after the
opathy, tricuspid regurgitation, tetralogy of Fallot) S2 and are depicted as decrescendo type murmurs
(see Table 18-3). (Fig. 18-10). They are associated with regurgitation
Systolic murmurs best heard at the apex include through the semilunar valves. The murmurs of aor-
ejection (midsystolic), regurgitant (holosystolic), and tic and pulmonary regurgitation are best heard at the
late systolic murmurs. Systolic murmurs located at the third left intercostal space; however, the aortic regur-
apex can either be nonpathologic (e.g., Still’s murmur) gitation murmur is high pitched and radiates to the
or pathologic murmurs (e.g., mitral regurgitation, mi- apex, while the murmur of pulmonary regurgitation
tral valve prolapse, aortic stenosis, hypertrophic ob-
structive cardiomyopathy) (see Table 18-3).
Transmission. Determining if a systolic murmur • Early diastolic murmur

transmits to another location can assist with the
ED
identification of the murmur’s etiology. Transmission S1 S1
S2
to the neck region is typically aortic in origin, and
transmission to the back is typically pulmonary in
MD
origin. A systolic murmur that is best heard at the • Mid-diastolic murmur
apex is caused by mitral regurgitation if it transmits
to the left axilla and lower back and is aortic in ori- S3
S1 S1
S2
gin if it transmits to the upper right sternal border
and neck.
• Late diastolic murmur
Quality. The ability to accurately describe the LD
quality or pitch of the murmur takes practice. S3
S1 S1
Many cardiac lesions are associated with a classic S2
pitch or tone. For example, the murmur of mitral FIGURE 18-10. Timing of diastolic murmurs.
TABLE 18-4
Diastolic Murmurs
Aortic regurgitation • Grade II–III/IV high-pitched diastolic murmur Third left intercostal space; transmits to apex
• If severe, bounding pulses are present
Mitral stenosis • Grade II–III/IV low-pitched diastolic murmur Left lower sternal border
• Loud S1 at apex with short opening snap
Pulmonary • Grade II–III/IV diastolic murmur Third left intercostal space; radiates along
regurgitation • Occurs early in diastole left sternal border
Tricuspid stenosis • Grade II–III/IV low-pitched diastolic murmur

• Heard in middiastole
• Starts with loud S3
is medium pitched and radiates along the left sternal and arterial flow (Fig. 18-11). Continuous murmurs
border (Table 18-4) (Park, 2008). must not be confused with to-and-fro murmurs, which
Middiastolic murmurs start with a loud S3 and are are heard when a systolic murmur (e.g., aortic or pul-
heard in early or middiastole. They are low pitched, monic stenosis) coexists with a diastolic murmur (e.g.,
best heard with the bell of the stethoscope, and are aortic or pulmonic regurgitation).
caused by turbulent blood flow through stenotic atrio- Pathologic continuous murmurs include the cre-
ventricular valves. Middiastolic murmurs associated scendo–decrescendo murmur of patent ductus arteriosus.
with mitral stenosis are heard best at the apex of the Described as a machinery murmur, it increases in systole
heart, while middiastolic murmurs associated with until reaching a peak at S2 before decreasing in diastole.
tricuspid stenosis are heard best along the left sternal However, if pulmonary hypertension is present, the dia-
border. Late diastolic or presystolic murmurs are low fre- stolic component may be absent. Regardless, this mur-
quency in pitch and are associated with the atria con- mur is best auscultated in the left precordium in either
tracting against anatomically small or stenotic mitral the infraclavicular or upper left sternal regions.
or tricuspid valves (Park, 2008). A second pathologic continuous murmur arises
from severe coarctation of the aorta. Collateral flow
Intensity. Each murmur should be evaluated in allows this to be heard over the intercostals. Finally, a
terms of intensity from grades I to IV. An increase in third murmur in the class, resulting from pulmonary
grade reflects an increase in the audibility of the mur- artery stenosis, can be heard bilaterally over both the
mur, with grade IV being heard with the stethoscope anterior and posterior chest.
barely on the chest (Table 18-5). Continuous murmurs that occur in the absence of
any structural heart disease are called innocent mur-
Continuous Murmurs. Continuous murmurs may murs. They are generally high frequency in tone, and
be innocent (functional) or indicate the presence of a the location varies, depending on the cause of murmur.
pathologic condition; they begin in systole and con-
tinue into diastole. Causes include aortopulmonary or Innocent Murmurs. It has been reported that up to
arteriovenous connections as well as disturbed venous 80% of children have innocent (or functional) mur-
murs during childhood (Menashe, 2007). Many are
the result of transient high-output states such as fever
TABLE 18-5 and anemia. Therefore, the challenge is to differenti-
Intensity of Diastolic Murmur ate these murmurs from those that result from more
serious disease (Box 18-1). There are five common
GRADE PITCH
I Barely audible
II Easily audible
III Loud
S1 S1
IV Audible with a stethoscope barely on the
S2
chest
FIGURE 18-11. Timing of continuous murmurs.
arteriosus and going directly out the aorta. The pulmo-

BOX 18-1
nary flow murmur is a grade I–II/VI systolic ejection
Characteristics of Pathologic
murmur that occurs early to midsystole. Although it
Murmurs is best auscultated at the upper left parasternal area, it
• Presence of a systolic murmur more than III/IV can also be heard bilaterally in the chest, both ante-
• Presence of a thrill riorly and posteriorly. If the child has features that
are characteristic of rubella or Williams syndrome
• Presence of a loud systolic murmur, which is loud in
duration or if the murmur persists beyond 6 months of age,
structural narrowing of the pulmonary artery should
• Presence of a diastolic murmur
be suspected, and the infant should be referred to a
• Presence of a pansystolic murmur
cardiologist (Park, 2008).
Venous Hum. A venous hum is a grade I–II/VI con-

innocent heart murmurs, including the classic vibra- tinuous murmur in which the diastolic component
tory murmur or Still’s murmur, pulmonary ejection may be louder than the systolic component. It is heard
murmur, pulmonary flow murmur of the newborn, ve- bilaterally or on either side in the infra- or supracla-
nous hum, and the carotid bruit. vicular regions because of turbulent flow in the jugu-
lar veins. It can be heard in preschool children up to
Still’s Murmur. A Still’s murmur is the most common 6 years of age. The venous hum is heard only when
innocent murmur in children. It is generally detected the child is sitting upright and disappears when the
in children between 3 and 6, but it may be detected child is lying down when the head is turned to the
at any age. The cause of the murmur is thought to be left and the neck veins are compressed. The murmur
low-frequency vibrations generated by normal pul- of a venous hum may be confused with that of a pat-
monary valve leaflets during systole or periodic vibra- ent ductus arteriosus; however, the murmur of patent
tions generated by a left ventricular false tendon. This ductus arteriosus is best heard in the upper left sternal
low-frequency murmur is mid-systolic, grade II–III/VI border or left infraclavicular space, it has a louder
in intensity, and best auscultated between the lower systolic component, and it may be associated with
left sternal border and the apex. It may sound like bounding peripheral pulses and wide pulse pressure.
a twanging string or have a musical quality, but it is
not associated with a thrill. Providers should use the Carotid Bruit. A carotid bruit is a grade II–III/VI
stethoscope bell when the child is supine. The mur- early systolic ejection murmur, resulting from turbu-
mur may dissipate with the Valsalva maneuver or fade lent flow in the brachiocephalic or carotid arteries,
when the child is in the upright position. that can be heard at any age. It is best heard in the
supraclavicular space or over the carotid arteries where
Pulmonary Ejection Murmur. The pulmonary ejec- a thrill may be palpable. A carotid bruit should be dif-
tion murmur is a grade I–III/VI systolic ejection ferentiated from the murmur of aortic stenosis, which
murmur best heard at the upper left sternal border in is louder in the upper right parasternal area, where
children 8 to 14 years of age. The origin of the murmur it may be associated with a thrill and which often
is an exaggeration of normal ejection vibrations with- includes an ejection click.
in the pulmonary trunk (Park, 2008). It occurs early to
midsystole with a normal S2 and is described as grat-
ing in quality. The murmur may be increased when HELPFUL MANEUVERS:
thoracic deformities (e.g., pectus excavatum, kypho-
scoliosis) are present. Compared with the pulmonary ASSESSMENT OF PERIPHERAL
stenosis murmur, there is no ejection click, no widely PULSES, LUNGS, AND LIVER
split and fixed S2 (atrial septal defect), nor any ECG
evidence of right ventricular hypertrophy. The characteristics of pathologic murmurs are listed in
Box 18-1. Occasionally, it may be difficult to differen-
Pulmonary Flow Murmur of the Newborn. The tiate between a pathologic murmur and an innocent
pulmonary flow murmur of the newborn can be murmur. Various maneuvers can be implemented to
detected in infancy and is commonly present in low- assist with the identification of the cause of the mur-
birth-weight newborns. The etiology is turbulence cre- mur. Inspiration intensifies right-sided lesions because
ated at the bifurcation of the relatively small branch it increases venous return such as the murmur of pul-
pulmonary arteries of the newborn. The small size monary stenosis. Inspiration also accentuates the S3
of the branch pulmonary arteries occurs because of component of tricuspid regurgitation. Expiration de-
decreased use in the fetal circulation with most blood creases venous blood return and can make the ejection
(85%) bypassing the lungs through the patent ductus click of pulmonary stenosis louder. Postural changes
from a squatting position for 30 seconds to a standing unilateral weak brachial pulse in an infant with single
position decreases venous blood return to the heart and ventricular anatomy is associated with a Blalock-
the systemic blood pressure. Therefore, this maneuver Taussig shunt or a subclavian flap angioplasty for repair
can be used to intensify murmurs of left-sided obstruc- of coarctation of the aorta. If the left brachial pulse is
tive lesions and mitral valve prolapse. The murmur of found to be weaker then the right, the etiology may
hypertrophic obstructive cardiomyopathy is increased be either a coarctation of the aorta proximal to or near
upon application of this position change because of the takeoff of the left subclavian artery or supravalvar
decreased venous return to the left ventricle, which is aortic stenosis. When both upper and lower peripheral
already structurally narrow. The Valsalva maneuver, and central pulses are weak, heart failure or shock is
which decreases venous blood return, may also increase present. Bounding peripheral pulses may indicate
and prolong the murmur of hypertrophic obstructive the presence of systemic hypertension or aortic run-
cardiomyopathy. To perform this maneuver, patients off lesions, such as patent ductus arteriosus, aortic
must be old enough to hold their breath midway regurgitation, large systemic arteriovenous fistula, or
through the respiratory cycle. The Valsalva maneuver neonatal truncus arteriosus. Weak lower extremity or
can also cause the mid-to-late systolic ejection click, as- femoral pulses may also be attributable to vessel injury
sociated with mitral valve prolapse, to occur earlier in sustained as the result of repetitive, same-site cardiac
systole. This is caused by the mitral valve leaflets reach- catheterizations. Pulsus paradoxus, a marked varia-
ing their maximal distention prematurely because the tion of the arterial pulses with the respiratory cycle,
left ventricle receives less blood return. To increase may be associated with a large pericardial effusion
the murmur of aortic regurgitation, the child should with tamponade physiology, constrictive pericarditis,
squat or sit, lean forward, and hold his or her breath. or respiratory distress resulting from asthma or pneu-
Using the diaphragm of the stethoscope, the location monia. Pulsus paradoxus is confirmed by the use of a
of the murmur of aortic regurgitation can be heard in sphygmomanometer by first inflating the blood pres-
the midchest. The supine position can decrease the sure cuff 20 points higher than the patient’s baseline
intensity of innocent murmurs. Still’s murmur is the systolic pressure. The cuff pressure is slowly lowered
exception; it is heard best with the child lying down. until Korotkoff sound (A) is heard for some but not
During the Valsalva maneuver, the murmur may dis- all cardiac cycles. The cuff pressure is lowered again
appear. Supination can help to differentiate between a until the systolic sounds are heard for all cardiac cycles
patent ductus arteriosus murmur and a venous hum. (B). If the difference between A and B is greater than
The venous hum disappears when the child lies down 10 mm Hg, then pulsus paradoxus is present.
and turns his or her head to the left or when the right
jugular vein is lightly compressed. The murmur of a
patent ductus arteriosus becomes more readily heard
LUNGS AND LIVER
on supination. The left lateral decubitus position inten- The lungs and liver should be evaluated for signs of con-
sifies the murmur of mitral valve prolapse. It is heard gestion. Tachypnea and the presence of rales or wheezes
best with the diaphragm of the stethoscope at the apex may indicate pulmonary congestion. The presence of
of the heart (Evangelista, 2007). hepatomegaly is a sign of elevated central venous pres-
sure. A liver edge measuring more than 2 cm below the
right costal margin is abnormal in children and may be
PERIPHERAL PULSES consistent with congestive heart failure. Monitoring the
The strength of the peripheral pulses and the pulse rate size of the liver can assist in determining the progres-
should be evaluated to determine if abnormalities are sion of the disease and effectiveness of therapy. A palpa-
present. The pulse rate should be counted for a full ble spleen is highly suspicious of bacterial endocarditis.
minute and noted for any irregularities. The normal Splenomegaly as an isolated finding is rarely caused by
pulse rate varies with age and physical condition. Pulse congestive heart failure. The presence of abdominal si-
rate should be compared with age-appropriate norms. tus inversus with or without thoracic situs inversus war-
Nonpathologic causes of tachycardia (stress) and bra- rants further investigation for the presence of CHD.
dycardia (a physically active teen) should be differenti-
ated from a cardiac etiology such as congestive heart
failure or heart block. DIAGNOSTIC TESTS
A comprehensive cardiac examination should in-
clude an assessment of the carotid (in older children), Laboratory tests, ECG, and chest films are generally
brachial, radial, femoral, and dorsalis pedis or tibialis abnormal only when the CHD or acquired heart dis-
posterior pulses for equality in strength. Abnormal ease is significant enough to cause hemodynamic
findings of strong upper extremity pulses compared changes. However, these diagnostic tests can pro-
to diminished or absent lower extremity pulses are vide useful information about the progression of the
strongly suggestive of coarctation of the aorta. A disease as well as the health status of children living
with heart disease, especially those who have under-

gone a palliative procedure, surgical correction, or
cardiac transplant.
Routine laboratory tests such as a complete blood
cell count and blood chemistries can assist in diag-
nosing and monitoring the progression of cardiovas-
cular disease. Polycythemia is found in patients with
cyanotic heart disease; however, the degree of polycy-
themia is dependent on the patient’s arterial satura-
tion. Severe anemia can cause a murmur or congestive
heart failure; polycythemia can cause a murmur. Leu-
kocytosis may be present in congestive heart failure,
bacterial endocarditis, and acute rheumatic fever.
Thrombocytopenia is commonly found in adolescents
with long-standing cyanotic heart disease. Electrolytes
and liver function studies can provide information
about the perfusion and functional status of the liver
and kidneys in the presence of either a ductal-depen- FIGURE 18-12. Normal ECG tracing.
dent lesion with long-standing congestive heart failure
or cyanotic heart disease. It can also provide clues to • The QRS complex is the interval from the beginning
the impact of medical therapies used to manage these of the Q wave to the end of the S wave.
patients. Newer screening tools have recently become • The ST segment is the interval from the end of the S
available, such as the brain natriuretic peptide, an wave to the beginning of the T wave.
active amino acid peptide released from the cardiac • The QT interval is the interval from the beginning of
ventricles in response to stretching of the chambers, the Q wave to the end of the T wave.
which have utility as a marker for the progression of First, the heart rate is calculated to determine both
congestive heart failure. the atrial and ventricular rates. To determine the
heart rate, the speed of the recorder should be set
at 25 mm/second. Therefore, one small box equals
12-LEAD ELECTROCARDIOGRAM
1 mm or 0.04 seconds, and one large box equals
Although the patient’s history and physical examination 5 mm or 0.2 seconds. In addition, the vertical volt-
are the most important components of the cardiovascu- age measurement must be determined. Full standard
lar examination, 12-lead ECGs can aid in the diagnosis height for limb and precordial leads is two large box-
of CHD, acquired heart disease, and arrhythmias (Bush, es in height ⫽ 10 mm, and half standard is one large
2005; Giuffre, Nutting, Cohen, Crawford, & Johnson, box in height ⫽ 5 mm. When determining the heart
2005). Electrocardiograms of infants and children differ rate, the atrial and ventricular rates are compared
from adults in that there is right ventricular dominance with age-appropriate norms. There are three meth-
in infants. This is expressed on the 12-lead ECG record- ods to determine the atrial and ventricular rates, the
ing as right axis deviation and large right ventricular “rule of 300,” the “1.2-second rule,” and the “1500-
forces. It is incumbent upon the practitioner to be able to box rule.” When using the “rule of 300,” 300 is di-
conduct and interpret 12-lead ECGs accurately (Grauer, vided by the number of boxes in the RR interval. The
2007). To ensure a thorough analysis of the 12-lead ECG “rule of 300” is useful for slower rates and is only
tracing, the practitioner must perform a step-wise descrip- accurate if the rhythm is regular. When using the
tive analysis that includes calculating the rate, evaluating “1.2-second rule,” the number of RR cycles in 6 large
the ECG for sinus rhythm, measuring all intervals (PR, boxes is counted and multiplied by 5; this equals
QRS, QT), as well as determining the axis and presence of 1 minute. The “1.2-second rule” is useful for faster
chamber enlargement (hypertrophy) or infarct patterns rates. When using the “1500-box rule,” the num-
(QRST changes). The ECG findings should then be corre- ber of boxes between two RR cycles is counted and
lated with the patient’s history and physical examination divided into 1500 (Grauer, 2007).
to determine the diagnosis, hemodynamic impact, and Rules for rhythm determination include monitor-
need for a cardiology consult. ing the number of P waves and QRS complexes. If
Below is a review of the ECG rhythm components there are P waves, it must be noted whether every P
(Fig. 18-12): wave precedes a QRS complex. If P waves are present,
• The PR interval is the interval from the beginning of it must be noted whether the P waves are upright in
the P wave to the beginning of the QRS complex. lead II; if so, the rhythm is sinus. The rhythm may be
• The RR interval is the interval from the preceding R a normal sinus rhythm, sinus bradycardia, sinus tachy-
wave to the R wave of interest. cardia, or sinus arrhythmia. The QRS must be assessed
to see if it is wide or narrow. Characteristics of nor- is seen in infants with total anomalous pulmonary
mal sinus rhythm include the following: every P wave venous return.
is followed by a QRS complex, every QRS complex is Prominent cardiac chambers or great arteries can
preceded by a P wave, the P-wave axis is 0–90 degrees assist in the diagnosis of a specific lesion. In addition,
(lead I and aVF are positive), the P-wave morphology lesions that either increase or decrease pulmonary
is constant and regular, and the rate is appropriate blood can be differentiated by evaluating the size of the
for age. The rhythm is junctional if the P waves occur pulmonary arteries and the appearance of the pulmo-
during or after the QRS complex or ventricular if the P nary vasculature. For example, increased pulmonary
waves occur during or after a wide QRS complex (Park blood flow as indicated by enlarged pulmonary artery
& Guntheroth, 2006). size and increased pulmonary vascularity on chest film
in an acyanotic child may be associated with the fol-
lowing cardiac lesions: atrial septal defect, ventricular
CHEST RADIOGRAPH septal defect, patent ductus arteriosus, atrioventricular
canal defect, or partial anomalous pulmonary venous
The chest film can be a useful tool to confirm suspi- return. Decreased pulmonary blood flow represented
cions of congenital or acquired heart disease. It can as a small hilum, thin vessels, and black lung fields on
provide information about heart size, cardiac silhou- chest film in a cyanotic child is consistent with tetral-
ette, enlargement of specific cardiac chambers, pulmo- ogy of Fallot.
nary vascular markings, lung parenchyma, and thorax.
A systematic approach must be followed to avoid miss-
ing important anatomic abnormalities, which may
ECHOCARDIOGRAM
prove relevant to the cardiac diagnosis. Chest radio-
graph analysis should include not only an evaluation An echocardiogram uses ultrasound to evaluate cardiac
of the cardiac structures and silhouette but also the structures and their movement through a cardiac cycle.
location of the stomach and liver in relation to the apex Depending on the type of echocardiogram, the rate
of the heart, the pulmonary parenchyma, the presence of blood flow through the heart can also be assessed.
of vertebral anomalies, and thoracic scoliosis. Echocardiogram is often used to evaluate CHD.
Cardiomegaly is measured by calculating the
cardiothoracic ratio. The cardiothoracic ratio is ob-
tained by comparing the largest transverse diameter CARDIAC CATHETERIZATION
of the heart to the widest internal diameter of the This diagnostic study uses a flexible catheter that is
heart. This is typically done by using a posteroan- passed through the femoral artery and/or vein (de-
terior film obtained on inspiration. This may be dif- pending on the rationale for the procedure) and into
ficult to secure in an infant or toddler and should be the heart to measure the oxygen saturations and pres-
taken into consideration when interpreting the film sures in the heart, great arteries, and lungs. With the
(Park, 2008). aid of radiopaque dye injected into the heart vessels,
• A ⫽ maximal cardiac diameter on right. cardiac anatomy and stenotic vessels can be identi-
• B ⫽ maximal cardiac diameter on left. fied. Cardiac catheterization can also be used for in-
CT ratio ⫽ (A ⫹ B) ⫼ C. tervention purposes, for example, to close septal de-
• C ⫽ widest internal diameter of the chest. fects, dilate vessels, or create communications between
chambers.
A cardiothoracic ratio greater than 0.5 indicates
cardiomegaly. The structures of the cardiac borders
can be determined on chest radiograph. The right
heart border is formed by the superior vena cava and DOCUMENTING FINDINGS
right atrium, the left border by the aortic knob, the
main pulmonary artery, and the left ventricle, and SAMPLE WRITE-UP: HEALTHY CHILD
the lateral view by the right ventricle, left atrium,
Subjective Data
and left ventricle (see Fig. 18-12). If cardiac disease
is suspected, the shape of the cardiac silhouette and A 15-year-old male presents for a sports physical. Fam-
the status of pulmonary blood flow can provide clues ily history negative for cardiac disease, hypertension,
to type of heart defect. A “boot-shaped” heart in a syncope, and hypercholesterolemia
cyanotic child with decreased pulmonary vascular
markings is typical in infants with tetralogy of Fallot, Objective Data
an “egg-shaped” heart with increased pulmonary Temp: 99.6⬚ F (37.6⬚ C); P: 76; R: 24; BP: 96/72
markings in a child who is cyanotic is consistent with Well-nourished male in no distress; height and
transposition of the great arteries, and a “snowman” weight in 75th percentile; color pink, normal pre-
figure with increased pulmonary vascular markings cordial activity; no thrill or heaves; strong, equal
peripheral pulses; capillary refill ⬍2 seconds in Davies, B., Rizo, T., & Arroyo-Valerio, A. (2002). Congenital heart
disease and its association with other congenital malforma-
upper and lower extremities, S1, S2, regular rate.
tions found at autopsy. Pediatric Pathology and Molecular Medi-
No murmurs auscultated. Breath sounds clear and cine, 21, 541–549.
equal bilaterally. Davies, G. A., & Herbert, W. N. (2007). Assessment and manage-
ment of cardiac disease in pregnancy. Journal of Obstetrics &
Assessment: Normal cardiac assessment
Gynaecology Canada, 29(4), 331–336.
Dimmick, S., Walker, K., Badawi, N., Halliday, R., Cooper, S. G.,
Nicholson, I. A., et al. (2007). Neonatal Intensive Care Units
SAMPLE WRITE-UP: ILL CHILD Study (NICUS) of the New South Wales Pregnancy and New-
born Services Network. Outcomes following surgery for con-
Subjective Data genital heart disease in low-birthweight infants. Journal of
Paediatrics & Child Health, 43(5), 370–375.
An 8-month-old girl presents with history of frequent Evangelista, J. K. (2007). Assessment of pediatric heart sounds.
upper respiratory infections. Mother says child has American Journal for Nurse Practitioners, 11(3), 15–28.
difficulty finishing bottle and falls asleep after about Geggel, R. L. (2004). Conditions leading to pediatric cardiology
consultation in a tertiary academic hospital. Pediatrics, 114(4),
4 ounces, “all sweaty and tired looking.” Sweat chlo- e409–e417.
ride test negative. Does not attend day care. No sick Giuffre, R., Nutting, A., Cohen, J., Crawford, S., & Johnson, D.
contacts. (2005). Electrocardiogram interpretation and management in
a pediatric emergency department. Pediatric Emergency Care,
21(3), 143–148.
Objective Data Gonzalez, J. H., Shirali, G. S., Atz, A. M., Taylor, S. N., Forbes,
G. A., Zyblewski, S. C., et al. (2009). Universal Screening for
Temp: 98.42⬚ F (36.9⬚ C); Apical pulse: 110; R: 36; extracardiac abnormalities in neonates with congenital heart
BP: 88/60; Weight: 10th percentile; Height: 25th disease. Pediatric Cardiology, 30(3), 269–273.
percentile; color pink centrally and peripherally; Grauer, K. (2007). 12-lead ECGs: A “pocket brain” for easy interpre-
tation. (4th ed.). Gainesville, FL: KG/EKG Press.
equal peripheral pulses; capillary refill ⬍2 seconds Green, R. (2007). Summary of workgroup meeting on use of fam-
in upper and lower extremities; palpable thrill along ily history information in pediatric primary care and public
left sternal border; low-pitched, grade III holosys- health. Pediatrics, 120, S87–S100.
Jenkins, K. J., Correa, A., Feinstein, J. A., Botto, L., Britt, A. E.,
tolic murmur at LLSB. No hepatosplenomegaly. EEG Daniels, S. R., et al. (2007). Noninherited risk factors and
normal; chest radiography reveals slight right ven- congenital cardiovascular defects: Current knowledge: A
tricular enlargement, echocardiogram shows ven- scientific statement from the American Heart Association
Council on Cardiovascular Disease in the Young: Endorsed
tricular septal defect. by the American Academy of Pediatrics. Circulation, 115(23),
Assessment: Ventricular septal defect 2995–3014.
Keane, J. F., Fyler, D. C., & Lock, J. E., (Eds.). (2006). Nadas’ pedi-
atric cardiology. (2nd ed.). Philadelphia: Elsevier.
Mackie, A. S., Pilote, L., Ionescu-Ittu, R., Rahme, E., & Marelli,
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genetic diseases: Part 4. Connective tissue. Journal of the Amer- 839–843.
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Allan, W. C., & Gospe, S. M., Jr. (2005). Seizures, syncope, or L. (2007). Congenital heart disease in the general population:
breath-holding presenting to the pediatric neurologist: when changing prevalence and age distribution. Circulation, 115(2),
is the etiology a life-threatening arrhythmia? Seminars in Pedi- 163–172.
atric Neurology, 12(1), 2–9. Menashe, V. (2007). Heart murmurs. Pediatrics in Review, 28,
American Heart Association. (2006). Congenital heart defects in 19–22.
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.americanheart.org/presenter.jhtml?identifier=12012. (2007). The molecular basis of congenital heart disease. Seminars
Biancaniello, T. (2005). Innocent murmurs. Circulation, 111, in Thoracic & Cardiovascular Surgery, 19(3), 228–237.
20–22. Olgunturk, R., Canter, B., Tunaoglu, F., & Kula, S. (2006). Re-
Bonnet, M., Tanker, M., Uhde, T., & Yeragani, V. (2005). Effects of view of 609 patients with rheumatic fever in terms of revised
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Contemporary Pediatrics, 24(5), 61–73. Philadelphia: Mosby Elsevier.
Burnett, L. B., & Adler, J. (2008). Toxicity, cocaine. Retrieved Park, M., & Guntheroth, W. (2006). How to read pediatric ECGs.
November 19, 2009, from http://emedicine.medscape.com/ (5th ed.). Philadelphia: Mosby Elsevier.
article/813959-overview. Patton, C., & Hey, E. (2006). How effectively can clinical ex-
Bush, D. (2005). Evaluating cardiovascular presentations: what amination pick up congenital heart disease at birth? Archives
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Chehab, G., Chedid, P., Saliba, Z., & Bouvagnet, P. (2007). Con- Rychik, J. (2004). Frontiers in fetal cardiovascular disease. Pediat-
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heart disease. Journal of Cardiovascular Nursing, 22(5), 390–396. overview.
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CHAPTER
Assessment of the
19 Abdomen and
Regional Lymphatics
ELLEN M. CHIOCCA AND
COLLEEN ANDREONI
The abdomen contains numerous organs that are GASTROINTESTINAL SYSTEM

responsible for a broad range of vital functions. It The gastrointestinal system encompasses the mouth,
is essential that pediatric health care providers have oropharynx, esophagus, and the organs of the abdominal
a thorough knowledge of the normal anatomy and cavity. The function of the gastrointestinal tract is
physiology of the abdomen as well as the ability to threefold: (a) digest and absorb nutrients, (b) maintain
gather relevant historical data. This is especially im- fluid and electrolyte balance, and (c) protect the body
portant with infants and young children, who are from toxins and pathogens.
unable to articulate their histories or relevant data The gastrointestinal tract begins at the mouth. The
about their present illness. Excellent physical as- mouth, oropharynx, teeth, salivary glands, and tongue
sessment skills are also necessary because several are discussed in Chapter 16. The esophagus is a tube-
abdominal organs are anatomically protected, and like structure located behind the trachea and in front
young children are often unable to cooperate with of the vertebral column (Fig. 19-2) that connects the
the examination. mouth to the stomach. It secretes mucus to facilitate
swallowing and to prevent gastric acid from eroding
the esophageal wall. Peristalsis and gravity move food
ANATOMY AND PHYSIOLOGY toward the stomach.
The stomach is an elongated, hollow, pouch-like struc-
The abdomen is a large hollow cavity that lies ture located below the diaphragm in the upper abdo-
between the thorax and the pelvis and contains both men, lying primarily left of the midline (see Fig. 19-2).
solid and hollow organs, which are surrounded by The stomach is involved in the second stage of digestion
muscles, the peritoneum, and the vertebral column. after mastication (chewing). It secretes hydrochloric
The solid organs are the liver, spleen, pancreas, kidneys, acid and digestive enzymes that, when mixed with
adrenal glands, and ovaries. The hollow organs are the food, form a liquid substance known as chyme. Chyme
stomach, gallbladder, small intestines, large intestines, stimulates the release of hormones, which activate
urinary bladder, and uterus. The primary functions of enzymes from the liver, gallbladder, pancreas, and
the abdominal organs are digestion and absorption duodenal mucosa that break down fat, protein, and
of nutrients, transportation and excretion of wastes, carbohydrates. Once this process occurs, chyme passes
filtration of blood and lymph, and reproduction. through the pyloric valve into the duodenum, the first
Dividing the abdomen into four quadrants—right of three parts of the small intestine (see Fig. 19-2). The
upper and lower quadrants (RUQ, RLQ) and left duodenum is a tube-like structure that extends from
upper and lower quadrants (LUQ, LLQ)—permits the the pyloric sphincter to the ileocecal valve, filling most
examiner to assess the numerous abdominal organs of the lower abdominal cavity. The second part, the
systematically and to identify organomegaly or jejunum, which follows the duodenum, absorbs water,
abnormal masses. The four abdominal quadrants are protein, carbohydrates, and vitamins from chyme. The
illustrated in Figure 19-1; Box 19-1 lists the contents ileum, the third and final part of the small intestine,
of each quadrant. absorbs bile salts, chloride, and vitamins C and B12.
391
Liver
Spleen
Outline of
duodenum Outline of
pancreas
Fundus of Stomach
gallbladder
Transverse
Pylorus colon
Jejunum Small
Ascending colon Ileum intestine
Anterior superior
iliac spine
Cecum
Appendix Decending colon
Urinary bladder
FIGURE 19-1. Four quadrants of the abdomen.
The intestinal contents then move through the of the abdomen (see Fig. 19-2). It comprises two lobes
ileocecal valve into the cecum, the first part of the large and is an extremely vascular organ, receiving its blood
intestine (see Fig. 19-2). The large intestine completes supply from the abdominal aorta and portal vein. The
digestion by further absorbing vitamins and water and liver has numerous functions: (a) it metabolizes carbo-
forming feces for elimination as solid waste. hydrates, fats, and proteins; (b) it stores iron, glycogen,
The cecum is located in the RLQ. At the bottom of fat-soluble vitamins, and some water-soluble vitamins;
the cecum is the appendix, a vestigial structure that is (c) it metabolizes drugs and toxins; (d) it excretes waste
only clinically significant if it becomes inflamed or products; (e) it produces antibodies and prothrombin
infected (see Fig. 19-2). The colon, the next portion and fibrinogen, which are essential for coagulation;
of the large intestine, is divided into the ascending and (f ) it continuously produces bile, which is stored
colon, transverse colon, and descending colon. Begin- in the gallbladder.
ning at the iliac crest and located on the anterior sur- The gallbladder is a pear-shaped structure located
face of the sacrum, the colon becomes the S-shaped under the surface of the liver (see Fig. 19-2). It is con-
sigmoid colon. This portion of the colon ends in the nected to the upper portion of the duodenum by the
rectum, where fecal matter is stored until peristalsis common bile duct. The gallbladder concentrates and
moves it through the anal canal and anus during the stores bile then secretes it into the duodenum to aid in
process of defecation. Figure 19-2 illustrates these the digestion of fats.
structures. The pancreas is a lobulated structure, located be-
Other abdominal organs also play a role in diges- hind the stomach in the LUQ (see Fig. 19-2). The
tion and metabolism. The liver, the largest organ in wide end connects to the duodenum, and the narrow
the body, is located under the diaphragm in the RUQ end touches the spleen. The pancreatic duct opens
C H A P T E R 19 A s s e s s m e n t o f th e A bdo m e n an d Re gio n a l Lymphatic s • 393
BOX 19-1
Abdominal Organs Within
Quadrants
RUQ LUQ
Liver (right lobe) Stomach
Gallbladder Liver (left lobe)
Tongue
Duodenum Spleen
Oropharynx
Pancreas (head) Pancreas (body)
Right kidney (upper pole) Left adrenal gland Larygopharynx
Right adrenal gland Left kidney (upper pole)
Hepatic flexure of colon Splenic flexure of colon
Ascending colon (part) Transverse colon (part)
Transverse colon (part) Descending colon (part) Esophagus
Stomach (pylorus)
Liver Celiac trunk
RLQ LLQ
Right kidney (lower pole) Left kidney (lower pole)
Stomach
Cecum Descending colon (part)
Appendix Sigmoid colon Rugae
Ascending colon (part) Left ovary

Gallbladder Inferior
Right ovary Left fallopian tube Portal vein mesenteric
Right fallopian tube Uterus, if enlarged Duodenum vein
(otherwise, the uterus is Pancreas
Right ureter
midline LLQ and RLQ)
Right spermatic cord Superior
Left ureter mesenteric Transverse colon
Left spermatic cord artery and
vein
Ascending Jejunum
Source: Rhoads, J. (2006). Advanced health assessment and diagnostic colon
reasoning. (p. 270, Box 11-1). Philadelphia: Lippincott Williams &
Wilkins.
into the duodenum and secrets digestive enzymes

that help break down carbohydrates, fats, and pro- Ileum
Cecum
tein. The pancreas also produces insulin and gluca-
gon directly into the bloodstream to control blood Sigmoid
Appendix
colon
glucose levels.
The spleen is also located in the LUQ above the
stomach; it is a highly vascular organ comprising Rectum
mainly lymphoid tissue (see Fig. 19-2). The spleen Anus
stores blood, filters blood and blood cells, and plays a
FIGURE 19-2. The gastrointestinal tract.
role in immunity.
receives its blood supply through the renal arteries,

GENITOURINARY SYSTEM which arise from the abdominal aorta. The right kid-
The genitourinary system comprises both the genital ney sits slightly lower than the left, owing to the pres-
and urinary systems. The male and female genital sys- ence of the liver in the abdominal cavity (see Fig. 19-
tems are discussed in Chapter 20. The urinary system 3). On top of each kidney lies an adrenal gland, which
includes two kidneys, two ureters, the urinary bladder, secretes epinephrine and norepinephrine in response
and the urethra (Fig. 19-3). The kidneys lie between to stress, and corticosteroids that control the body’s
the thoracic and lumbar regions in the RUQ and LUQ metabolism of fat, protein, and carbohydrates. These
of the abdomen and are surrounded by two layers glands also help regulate sodium and potassium lev-
of fat, the renal fascia, and the 11th and 12th ribs, els and affect body growth and male secondary sex
which help to cushion and protect them. Each kidney characteristics.
• Excretion of excess water and nitrogenous waste,

particularly urea, uric acid, and creatinine along
with water, a process that leads to the production of
urine.
Diaphragm Ureters are long, narrow, muscular tubes that carry
urine from the kidney to the urinary bladder through
peristalsis. The left ureter is longer than the right ure-
Inferior ter because the left kidney sits higher in the abdomi-
vena cava nal cavity than the right kidney. The urinary bladder
Pancreas
is an ovoid, hollow, muscular organ that collects urine
Right (see Fig. 19-3). When it is empty, it is located under-
Aorta
kidney
neath the symphysis pubis, but when it is full, it can
be readily palpated above the symphysis pubis. Urine
Left flows from the bladder through the urethra outside the
ureter body. In females, the urethra is distinct and separate
Iliac artery from the reproductive tract; in males, the urethra also
and vein functions as a passage for semen (see Chapter 20).
Uterus Anterior
superior
Bladder iliac spine DEVELOPMENTAL
Symphysis CONSIDERATIONS
pubis
GASTROINTESTINAL SYSTEM
FIGURE 19-3. The kidneys, ureters, and urinary bladder.
The gastrointestinal system begins to form during
the third week of embryonic life. At this time, a liver
bud is present, and the mesentery begins to form. By
The kidneys are composed of three layers: the cortex, week 4, the intestines are present, and the esophagus
medulla, and renal sinus and pelvis. The cortex is the and stomach are distinct. By the seventh week of gesta-
outermost portion of the kidney that contains the tion, the intestines herniate into the umbilical cord to
glomeruli, proximal and distal convoluted tubules, begin the process of rotation and elongation. Between
and collecting ducts of the nephron. The medulla is weeks 9 and 10, the intestines re-enter the abdominal
the middle portion of the kidney that contains the cavity and continue rotation. Disruption in this process
renal pyramids, straight portions of the tubules, loops results in abdominal wall defects, such as omphalocele
of Henle, vasa recta, and terminal collecting ducts. The and gastroschisis (Fig. 19-4). Both conditions involve
renal sinus and pelvis make up the innermost part of herniation of the abdominal wall contents, usually the
the kidney. small bowel. With omphalocele, the abdominal con-
The structural and functional unit of the kidney is the tents are covered with a membrane or sac, but with
nephron. Each kidney contains approximately 1 million gastroschisis, there is no membrane or sac covering
nephrons, which are located in both the renal cortex the abdominal contents. By week 12, the muscular lay-
and medulla. The functional component of the nephron ers of the intestines are present, and active transport
is the glomerulus and glomerular (Bowman’s) capsule. of amino acids begins. The pancreatic islet cells and
The nephrons play several vital functions, including: bile also appear at this time. Between weeks 13 and 14,
• Maintenance of homeostasis, which occurs through peristalsis can be detected, and by week 16, meconium
the regulation of electrolyte concentrations, and is present. By 20 weeks, secretion of insulin begins. By
maintenance of blood volume by maintaining os- 24 weeks, ganglion cells are in the rectum. By week 34,
molality of extracellular fluid within a narrow range sucking and swallowing become coordinated, and by
necessary for optimal cellular function 36–38 weeks, the development of the gastrointestinal
• Regulation of acid–base balance, which is con- system is complete.
trolled through renal reabsorption of bicarbonate Although the gastrointestinal system is physically
and renal secretion of hydrogen ions developed at birth, it is functionally undeveloped until
• Regulation of blood pressure through the renin- age 2. Neonates have lower esophageal sphincter tone,
angiotensin-aldosterone system which increases the incidence of gastroesophageal re-
• Secretion of hormones, such as erythropoietin, flux in this age group (Ball & Bindler, 2006). The stom-
which stimulates red blood cell production, and ach capacity is approximately 60 mL for a neonate, ap-
vitamin D, which regulates blood levels of calcium proximately 500 mL for a toddler, and approximately
and phosphorus 1000–1500 mL for an adolescent (Ball & Bindler, 2006).
jaundice is so common. Decreased hepatic enzyme

function also results in long drug half-lives in children
from birth until age 3–4 (Swamy & Mallikarjun, 2004).
From birth until age 1, the liver synthesizes and stores
glycogen less effectively than it does in older children,
so these children are prone to hypoglycemia (Swamy
& Mallikarjun, 2004).
The length of the infant’s small intestine is propor-
tionately longer relative to body size, which provides
a greater surface area for absorption until toddlerhood
(Hockenberry & Wilson, 2007). Until 6–8 months of
age, infants have prolonged gastric emptying and
transit time through the small intestine, which may
A affect the absorption of nutrients and medications,
increasing the chance of adverse side effects and tox-
icities (Guthrie, 2005). The gastrocolic reflex is rapid
in infants, explaining the frequency of stools. As the
spinal cord myelinates and the musculature of the
anus develops, the child is able to control the bowel
voluntarily.
GENITOURINARY SYSTEM
Embryologic development of the genitourinary system
begins within the first weeks after conception and pro-
gresses through three stages. The first stage is the pro-
nephros, also called “fore kidneys,” which appear at 3–4
weeks’ gestation and play a role in normal organogene-
B sis. The pronephroi degenerate by the fifth week and be-
come the mesonephros, or “midkidneys,” and are fully de-
FIGURE 19-4. Abdominal wall defects in the neonate. veloped by 37 days. The mesonephros consists of 30–40
A. Omphalocele includes a membranous sac covering the
abdominal organs. B. In gastroschisis, the abdominal contents glomerulotubular units, which regress by the end of the
are not covered by a membrane or sac.
Gastric pH is alkalotic at birth, and gastric acid produc-

tion slowly increases to adult levels by 2 years of age
(Swamy & Mallikarjun, 2004).
Infants and toddlers have weak abdominal muscle
tone, which causes a protuberant abdomen in neo-
nates and a prominent abdomen in toddlers. This weak
abdominal musculature poorly protects the liver and
spleen. Infants also have a cylindrical abdomen; thus,
a distended or scaphoid abdomen indicates pathology.
The abdomen is larger than the chest in children from
birth until age 4, creating a “pot-bellied” appearance
(Fig. 19-5).
Pancreatic enzyme activity is decreased at birth
until 4–6 months (Ball & Bindler, 2006). This results
in varied bioavailability of drugs that may depend on
specific enzymes to aid in drug absorption. The liver is
functionally immature from birth until age 1 (Macfar-
lane, 2006; Swamy & Mallikarjun, 2004). The liver has
decreased hepatic enzyme function in the child until
it reaches adult size at adolescence (Swamy & Mal-
likarjun, 2004). In the neonate, liver conjugation re- FIGURE 19-5.The typical “pot-bellied” appearance of
actions are impaired, which explains why physiologic the toddler.
second month of gestation. At 8 weeks, the mesoneph- diagnosed in the prenatal, perinatal, or neonatal pe-
ros then becomes the metanephros, or “hind kidneys.” riod that involve the gastrointestinal or genitourinary
At this stage, nephrons and permanent kidneys begin tracts. The prenatal history can reveal maternal poly-
to form. The kidneys produce urine by approximately hydramnios, which is associated with intestinal atresias
3 months’ gestation. The urinary bladder develops at and tracheal esophageal fistula. Maternal oligohydram-
approximately 6 weeks’ gestation, and formation of the nios can cause urinary obstructive lesions, polycystic
urethra is completed by the end of the first trimester. kidneys, renal agenesis, and gastrointenstinal atresias
The kidneys are immature at birth with increased (Boyd & Carter, 2008). In the preterm infant, perinatal
renal vascular resistance and incomplete glomerular asphyxia and immature immune function may play a
and tubular development, which results in decreased role in developing necrotizing enterocolitis (Springer
renal blood flow, glomerular filtration rate, and tubu- & Annibale, 2009). Neonatal conditions about which
lar function. This developmental variation continues to inquire include abdominal wall defects such as
until age 2 (Swamy & Mallikarjun, 2004). This renal omphalocele, gastroschisis, diaphragmatic hernia, or
immaturity puts children in this age group at risk for prune belly syndrome; intestinal obstruction, such as
dehydration or hypovolemia. pyloric stenosis, imperforate anus, and biliary, jejunal,
Until children are preschool age, the kidneys are ileal, or duodenal atresia; or malrotation. The timing
proportionately larger than those of the adult and are of the first meconium stool is also important; delayed
surrounded by less fat (Ball & Bindler, 2006). This varia- passage of meconium (meconium ileus) may indicate
tion permits the tip of the right kidney to be palpated Hirschprung disease or cystic fibrosis. A history of hy-
because of the thin abdominal wall, especially during perbilirubinemia should be noted, and physiologic
the inspiratory phase of respiration. This also makes and nonphysiologic hyperbilirubinemia should be dif-
the child’s kidneys more susceptible to trauma because ferentiated. Myelomeningocele causes lifelong altera-
more of the kidney is exposed. From birth until age 3, tions in bowel and bladder control. A history of cleft
the urinary bladder lies between the symphysis and um- lip or palate is important, as these structural defects
bilicus, and the ureters are relatively short. The urinary can affect feeding and weight gain.
bladder then descends into the pelvis by age 3, which Any history of congenital anomalies of the geni-
affects the approach to the physical examination (Hock- tourinary tract is also investigated. Conditions about
enberry & Wilson, 2007). The urinary bladder capacity which to inquire include extrophy of the bladder, hy-
varies, according to the child’s age; a useful guideline is dronephrosis, ambiguous genitalia, hypospadias, epi-
to estimate that 1% of the child’s body weight equals spadias, hydrocele, cryptorchidism, inguinal hernia,
the child’s bladder capacity (Hjalmas & Sillen, 2004). chordee, or polycystic kidney disease. A history of low-
set or abnormally formed ears should be noted, as this
can be associated with renal disease.
CULTURAL AND RACIAL
VARIATIONS Review of Systems
The pediatric review of systems (ROS) includes any
An umbilical hernia is an abdominal wall defect that is history of conditions involving the gastrointestinal or
10 times more common among African-American chil- genitourinary tracts. Some examples follow:
dren than Caucasian children (Weik & Moores, 2005).
Lactose intolerance, the inability to digest lactose (milk • General: Growth history or unusual weight gain or
sugar), is highest in children of Hispanic, African, Asian, loss
and Mediterranean ancestry, and lowest in people of • Skin: Jaundice or diaper rash (contact dermatitis due
Northern European ancestry (Guandalini, Frye, Rivera, to frequent loose stools)
& Borowitz, 2008). Cystic fibrosis is a multisystem dis- • Cardiac: Congenital heart disease or congestive
ease among Caucasian children and has several gas- heart failure (may cause hepatomegaly)
trointestinal effects (Elias, Tsai, & Manchester, 2009). • Respiratory: Cystic fibrosis or streptococcal pharyn-
Meconium ileus and fibrocystic disease of the pancreas gitis (may cause abdominal pain)
are associated with cystic fibrosis. • Gastrointestinal: Recurrent abdominal pain, inflam-
matory bowel disease, ulcerative colitis, Crohn’s dis-
ease, celiac disease, gastroesophageal reflux disease
ASSESSMENT (GERD), pyloric stenosis, anal fissure, skin tags or
polyps, intussusception, Hirschsprung disease, um-
bilical hernia, gastroenteritis, peritonitis, hepatitis,
HISTORY or peptic ulcer disease
Prenatal, Perinatal, and Neonatal Histories • Genitourinary: Urolithiasis, urinary tract infections,
It is important for the pediatric health care provider nocturnal enuresis, pyelonephritis, diabetes insipi-
to review the past medical history for any conditions dus, nephrotic syndrome, acute glomerulonephritis,
inguinal hernia, appendicitis, patent urachus, ex- stances leading to the injury may provide clues as to
strophy of the bladder, or cryptorchidism neglect; reveal knowledge deficits about motor vehicle,
• Endocrine: Diabetes bicycle, or street safety; or indicate abuse.
• Gynecologic: Menstrual history, dysmennorhea, en-
dometriosis, pelvic inflammatory disease, or ectopic Surgical History
pregnancy Surgical procedures involving the gastrointestinal or
• Hematologic: Sickle cell disease or blood dyscrasias genitourinary tract are noted along with the date of
(may cause hepatomegaly or splenomegaly) surgery and the condition for which the surgical pro-
• Neurologic: Cerebral palsy or myelomeningocele cedure was done. The provider should also note if the
• Psychosocial: Anorexia nervosa, bulimia nervosa, condition was resolved with surgery. Examples of sur-
recurrent abdominal pain, alcoholism (vomiting), gical procedures about which to inquire include ap-
anxiety, or depression pendectomy, hernia repair, surgery for ulcerative coli-
tis or Crohn’s disease, nephrectomy, or orchiopexy for
Immunizations testicular torsion.
Immunization status is an essential component of
the pediatric health history. Some diseases for which Current Medications
children are immunized can cause medical conditions The provider must note any medications the child is
involving the gastrointestinal or genitourinary tracts. taking that impact the gastrointestinal or genitouri-
For example, both hepatitis A and B can cause an- nary tract, such as diuretics, which affect urine out-
orexia, jaundice, and hepatomegaly. Rotavirus causes put. Anemic menstruating females may be taking iron
anorexia, vomiting, abdominal pain, diarrhea, and supplements, which may cause constipation. Adoles-
dehydration. cent girls may be taking diuretics or laxatives to con-
trol their weight (Pinhas, Katzman, Dimitropoulos, &
Allergies Woodside, 2007).
Food allergies and their myriad manifestations, which
include oral, gastrointestinal, cutaneous, and respira- Family History
tory symptoms, occur in 3% of children aged 3 and Any family history of gastrointestinal disorders, such
younger (Kumar, 2008). Thus, this is an important part as irritable bowel disease, Crohn’s disease, lactose in-
of the history. Children with oral allergy syndrome de- tolerance, or sickle cell disease, is important to note.
velop signs later in infancy and into childhood. Gas- Assessment of genitourinary conditions likely to be
trointestinal manifestations that indicate a food allergy seen in pediatric patients, such as congenital anoma-
include nausea, vomiting, and abdominal pain within lies involving the renal or genitourinary system, poly-
minutes to 2 hours of ingesting the allergenic food, cystic kidney disease, testicular or renal cancer, and re-
then diarrhea 2–6 hours after the ingestion. Typical nal infections, is important. A family history of cystic
foods implicated in these reactions are milk, eggs, pea- fibrosis or diabetes must also be investigated because
nuts, soy, wheat, and seafood (Story, 2008). Anaphy- cystic fibrosis has gastrointestinal manifestations,
laxis may also occur, underscoring the importance of such as meconium ileus, steatorrhea, and poor weight
this assessment. A history of atopic dermatitis should gain, and poorly controlled diabetes can lead to renal
be noted, as children with this condition have a higher failure. Wilms’ tumor (nephroblastoma) may be asso-
risk of developing food allergies, particularly infants ciated with some genetic syndromes and can run in
and toddlers with atopic dermatitis that is resistant to families (Cendron, 2009).
therapy (Kim, 2008).
Social History
Hospitalizations Multiple aspects of a child’s social history can affect
It is important to inquire about past hospitalizations abdominal assessment findings. For example, lead
for acute or chronic illnesses or infections involving the poisoning, which can be caused by living in an old
gastrointestinal or genitourinary tracts. For example, it dwelling with peeling, lead-based paint, causes nausea,
is important to note hospitalizations for dehydration vomiting, poor appetite, weight loss, abdominal pain,
secondary to gastroenteritis or vomiting; management constipation, or diarrhea. The child’s family situation
of abdominal pain, encopresis, or surgical problems, must be assessed because exposure to parental strife
such as pyloric stenosis. and domestic violence is associated with recurrent ab-
dominal pain (RAP) in children (Berkowitz, 2005). Poor
Injuries school performance or refusal to go to school should be
A history of any abdominal injury is very important. noted as this may be caused by bullying, another cause
Blunt or penetrating abdominal trauma can lead to of RAP (Governo & Siewers, 2008). Drug use and alco-
severe splenic, hepatic, or renal injuries. The circum- hol use are assessed in older school-aged children and
adolescents; drug and alcohol withdrawal can cause accompanied by intense abdominal pain in an infant
nausea, vomiting, and acute abdominal pain; acute al- suggest intussuception. A history of diarrhea, including
cohol intoxication can cause nausea and vomiting. It is the onset, frequency of loose stools, and the parent or
important to note if the child attends day care, because child’s definition of diarrhea, must be noted; in some
these children have more episodes of gastroenteritis instances, soft stools that occur as a result of increased
(Zahn & Marshall, 2006). The type of pets in the home dietary fiber are mistaken for diarrhea. In infants and
is another important assessment, as certain pets (e.g., toddlers, a history of frequent diaper rash, which may
reptiles, birds, cats, dogs, horses, farm animals) carry result from frequent or chronic diarrhea, is also noted.
salmonellosis, a bacterial disease that causes acute di- Any urinary frequency, dribbling, or incontinence must
arrhea and abdominal pain (Centers for Disease Con- be assessed; these findings suggest enuresis or a urinary
trol and Prevention, 2008). Children who travel with tract infection. Frequent urination may suggest diabe-
their families to Mexico, Central America, or Asia are at tes. Inquiring about toilet training is also important;
risk for infection with waterborne bacteria or parasites, some toddlers are fearful during this process, especially
which is also part of the social history. with defecation, which may lead to withholding stool.
Dysuria may be a sign of a urinary tract or sexually
Nutritional History transmitted infection; an age-appropriate sexual his-
The nutritional history is an essential component of tory must also be obtained (see Chapter 20).
the abdominal assessment. Diet plays a role in weight,
hydration status, and urine and stool output, and can History of Present Illness
be related to complaints of abdominal pain. A typical When an infant, child, or adolescent presents with an
nutritional history is obtained (see Chapters 6 and 10), abdominal complaint, a careful, detailed, focused histo-
focusing on usual appetite, intake of fiber-rich foods ry is essential to narrow the list of differential diagnoses.
such as fruits and vegetables, grains, and beans; and Common abdominal complaints in children include
the amount and type of fluid intake each day. Excessive pain, vomiting, diarrhea, constipation, and change in ap-
amounts of cow’s milk can lead to constipation and petite. Less common complaints include rectal bleeding,
iron-deficiency anemia. Children who drink excessive dysphagia, and jaundice. Because abdominal complaints
amounts of juice may have delayed toilet training and are so common in children, differential diagnoses can
often have chronic diarrhea (American Academy of Pe- be formulated based on age or presenting complaint, de-
diatrics Committee on Nutrition, 2007). Excessive caf- pending on the historical data obtained. Table 19-1 cat-
feine intake associated with coffee, tea, or energy drinks egorizes these differential diagnoses, according to age;
causes diuresis (Leikin & Paloucek, 2008), nausea, and Table 19-2 presents differential diagnoses, according to
indigestion (Yeomans, Ripley, Davies, Rusted, & Rogers, symptom complex, and Table 19-3 lists differential di-
2002). A history of lactose intolerance is also assessed; agnoses, according to location. Common urinary com-
this condition causes bloating; abdominal pain; loose, plaints in children are presented in Table 19-4.
watery stool; excessive flatus; and fecal urgency when
milk products are consumed (Heyman, 2006).
Elimination Patterns Preparation for the Examination
Assessment of normal elimination patterns is an Examination of the abdomen in children may be dif-
important part of an abdominal assessment. The ficult, especially in the toddler or young child who may
details of an age-specific elimination history are given be crying or ticklish. In the young child, the abdomen
in Chapter 6. For children who present with recurrent is typically examined after the heart and lungs in the
abdominal pain, stool elimination patterns include event that the abdominal examination elicits crying.
determining the frequency and consistency of bowel When a child is experiencing abdominal pain, the
movements and the level of pain, if any, with bowel abdominal assessment is best left until the end of the
movements. A history of constipation is noted, includ- physical examination. Efforts to put the child at ease
ing treatments, especially over-the-counter laxatives. include playful examination techniques, performing
The provider must be sure to determine the parent’s first on a stuffed animal or a doll, and eliciting the
definition of constipation; for example, it is considered caregiver’s support and encouragement for the exami-
normal to have a bowel movement once every 3 days, nation. Inspection is most accurate when the child is
depending on the child’s age and diet (Dunn, 2009). relaxed and not crying, and in a supine position. For
Reports of blood in the stool or rectal bleeding must the toddler, older child, and adolescent, a comfortable
also be investigated; the color and presentation of the position on the examination table is preferred. Infants
blood can provide clues to the etiology. For example, may be laid supine in the caregiver’s lap. Older children
streaks of bright red blood on the outside of a hard, may perceive the abdominal assessment as invasive. The
formed stool suggest an anal fissure. Currant jelly stools overweight older child or adolescent may be uncomfort-
TABLE 19-1 TABLE 19-2

Differential Diagnosis of Differential Diagnosis of
Abdominal Pain Based Abdominal Pain in Children
on Age Based on History
COMMON CAUSES OF SYMPTOM
AGE GROUP ABDOMINAL PAIN COMPLEX DIFFERENTIAL DIAGNOSES
Birth to 2 years Gastroenteritis Abdominal Infectious gastroenteritis

Trauma pain with fever Appendicitis
Intussusception Pelvic inflammatory disease
Incarcerated hernia Pneumonia
Urinary tract infection Urinary tract infection
Intestinal malrotation
Abdominal pain With Diarrhea:
2–5 years Gastroenteritis with change Infectious gastroenteritis
Constipation in bowel habits Irritable bowel syndrome
Trauma Inflammatory bowel disease
Incarcerated hernia (ulcerative colitis, Crohn’s disease)
Urinary tract infection Lactose intolerance
Sickle cell disease Drug-induced diarrhea
Right lower lobe pneumonia Intusussception
Lead poisoning Henoch-Schönlein purpura
Celiac disease With Constipation:
Encopresis
5–10 years Gastroenteritis Hirschprung disease
Constipation Henoch-Schönlein purpura
Trauma
Urinary tract infection Abdominal pain Gastroesophageal reflux disease
Sickle cell disease associated with Peptic ulcer disease
Irritable bowel disease midline or Chronic hepatitis B or C
Appendicitis epigastric pain Pancreatitis
Abdominal migraine Hydronephrosis
Less common: Intestinal obstruction
Henoch-Schönlein purpura Trauma
Postsurgical adhesions
Malrotation Abdominal pain Structural/Surgical:
with vomiting Intussusception
10–18 years Gastroenteritis Volvulus/small bowel obstruction
Constipation Appendicitis
Trauma Incarcerated inguinal hernia
Urinary tract infection Testicular torsion
Sickle cell disease Fecal impaction
Irritable bowel disease Peritonitis
Abdominal migraine Infectious:
Appendicitis Gastroenteritis
Testicular torsion Pneumonia
Ovarian cyst Meningitis
Dysmenorrhea Inflammatory:
Mittelschmerz (ovulatory pain) Gastritis
Pelvic inflammatory disease Reflux esophagitis
Less common: Henoch-Schönlein purpura
Pancreatitis Endocrine:
Cholecystitis Diabetic ketoacidosis
Urolithiasis Thyrotoxicosis
Peptic ulcer disease
Toxins:
Postsurgical adhesions
Alcohol intoxication
Ectopic pregnancy
Drug withdrawal
Peritonitis
Lead poisoning
Intestinal obstruction
Mercury poisoning
Malignancy:
Neuroblastoma
Wilms’ tumor
(Cambria, 2007)
TABLE 19-3 TABLE 19-4

Differential Diagnosis of Urinary Tract Problems
Abdominal Pain in Children in Children
Based on Location
URINARY DIFFERENTIAL
DIFFERENTIAL COMPLAINT DIAGNOSES
LOCATION DIAGNOSES
Dysuria UTI, STI, urolithiasis, or
RLQ pain Acute appendicitis pyelonephritis
Constipation
Irritable bowel disease Dysfunctional voiding UTI, constipation, neurogenic
Inflammatory bowel disease (urinary frequency, bladder, or vesicoureteral
Inguinal hernia urgency, hesitancy, reflux (Tobias, Mason,
Mesenteric adenitis straining) Lutkenoff, Stoops, &
Ischemic bowel disease Ferguson, 2008)
Urolithiasis
Foul smelling urine UTI or STI
Mittelschmerz
Pelvic inflammatory disease Cloudy urine UTI, STI, urolithiasis, or
Ectopic pregnancy glomerulonephritis
Ovarian cyst/torsion
Salpingitis Enuresis UTI, neurogenic bladder,
constipation, or psychosocial
RUQ pain Hepatitis causes
Right lower lobe pneumonia
Hematuria Idiopathic hematuria,
LLQ pain Constipation UTI, glomerulonephritis,
Irritable bowel disease trauma, congenital urologic
Inflammatory bowel disease anomaly, or vesicoureteral
Inguinal hernia reflux (Greenfield, Williot, &
Ischemic bowel disease Kaplan, 2007)
Urolithiasis
Pyelonephritis
STI, sexually transmitted infection; UTI, urinary tract infection.
Mittelschmerz
Pelvic inflammatory disease
Ectopic pregnancy
Ovarian cyst/torsion Preparation for the examination includes a warm,
Salpingitis
nonthreatening environment. The child should be
LUQ pain Gastritis undressed to allow full evaluation of the entire abdo-
Splenomegaly men. Appropriate draping to ensure modesty is essen-
Left lower lobe pneumonia tial in the older child or adolescent. Adequate lighting
Epigastric pain Abdominal aortic aneurysm
is essential. The order for the abdominal assessment
Peptic ulcer disease is inspection, auscultation, percussion, and palpation.
Auscultation follows inspection because palpation
Diffuse abdominal pain Sickle cell crisis may alter bowel sounds.
Gastroenteritis
Peritonitis
Diabetic ketoacidosis Equipment Needed
Intestinal obstruction Equipment for the abdominal examination includes
Flank pain Pyelonephritis a stethoscope, a metric measuring tool, and gloves
Ovarian torsion if lesions are present. Lubricant may be needed if a
Urolithiasis rectal examination is required. Appropriate supplies
Musculoskeletal pain for point-of-care testing and specimen collection may
Periumbilical pain Acute appendicitis be necessary.
Gastroenteritis
Colitis
Bowel obstruction
Vital Signs
Urinary tract infection A complete set of vital signs is obtained prior to begin-
ning the examination. Particular attention should be
focused on abnormalities that may be important for
able, and efforts to respect modesty are an important the abdominal assessment (Box 19-2).
component of the examination. The caregiver is asked
to refrain from feeding the infant immediately before Current Growth Parameters
the abdominal examination to avoid vomiting precipi- Provision of adequate nutrition in infancy is most
tated by palpation of the full abdomen. important for growth and development. Nutrition plays
The child’s body generally slows or halts growth in

BOX 19-2
response to decreased energy and nutrition intake. If
Abnormalities That May the problem is resolved quickly, the systemic slow-
Indicate an Abdominal down of growth can be reversed. However, with
Assessment chronic disease and long-term inadequate nutritional
FEVER intake, the downregulation of growth may not be eas-
ily reversed.
• Primary abdominal infectious or inflammatory
Many therapies (e.g., potent corticosteroids) nec-
processes
essary for the treatment of chronic, life-threaten-
• Secondary to systemic infectious or inflammatory
ing diseases are unfortunately often also associated
process
with delayed or retarded growth. An emphasis on
TACHYCARDIA nutrition in these chronic diseases is sometimes
• Secondary to fever, fear, anxiety, crying, or pain able to counteract this serious side effect in some
• Consider blood loss in the peritoneal or children.
retroperitoneal or pelvic compartments Growth in chronic renal failure (CRF) is adversely
• Consider infection from disruption of hollow affected by nausea, vomiting, and acidosis, which
abdominal organs are responsible for inadequate intake and utiliza-
• Consider inflammation from diseased abdominal tion of nutrients. Children who receive transplants
organs exhibit additional delays in growth as a result of
corticosteroid therapy, which follows transplanta-
TACHYPNEA
tion. The earlier the child is diagnosed with CRF, the
• Secondary to fever, fear, anxiety, crying, or pain more severe the skeletal growth delays and the delay
• Consider blood loss in the peritoneal or of secondary sex characteristic development are apt
retroperitoneal or pelvic compartments to be. The growth spurt normally seen in puberty is
• Consider infection from disruption of hollow also retarded. Despite dialysis and therapies, these
abdominal organs children rarely catch up.
• Consider inflammation from diseased abdominal
organs
• Consider diaphragmatic irritation from inflamed INSPECTION
abdominal organs Assessment of the abdomen begins with inspection.
• Consider causes such as basilar pneumonia, which Ideally, this is performed when the child is at rest,
will result in abdominal pain; however, the primary supine, and not crying, either on the examination
etiology is pulmonary
table or in the caregiver’s lap. The abdomen is observed
HYPERTENSION from above and tangentially. The abdominal contour
• Primary hypertension due to renal disease is assessed. Normally, the protuberant abdomen in the
• Secondary hypertension due to fear, anxiety, or pain infant or toddler, which results from weak abdominal
muscles, becomes flat when lying supine. The protu-
HYPOTENSION berant abdomen, which remains convex, should be
• Most often due to shock evaluated for abdominal distention. The scaphoid
abdomen in a newborn may indicate a diaphragmatic
HYPOVOLEMIA
hernia. In the older child, a scaphoid abdomen may
• Consider blood loss in abdominal compartments, indicate malnourishment.
dehydration from fluid losses, or inadequate fluid
Skin turgor of the abdomen is also assessed. Normal
intake
abdominal skin turgor is elastic. If tenting is present,
SEPTIC dehydration is a distinct possibility.
• Consider abdominal infectious process Generally, the abdomen is assessed for symmetry
• Consider cardiogenic causes and any visible masses, pulsations, or protrusions.
• Consider anaphylactic causes Umbilical hernias are common, especially among
African-American newborns (Fig. 19-6). An umbilical
hernia may indicate hypothyroidism in a Caucasian
infant. Midline pulsations of the abdominal aorta may
a greater role during infancy than growth hormone. be seen in very thin children.
Children with chronic gastrointestinal or renal disease The newborn may also exhibit other defects in the
may require gastric tube feedings during infancy. abdominal wall, such as omphalocele, an extreme
Almost all gastrointestinal conditions are associat- umbilical hernia in which some abdominal contents
ed with anorexia as a result of chronic inflammation are located outside of the body; however, these are
of the gastrointestinal tract. It is essential to assess relatively uncommon. This is always midline, in refer-
the child’s energy intake through dietary sources. ence to the location of the umbilicus. An omphalocele
pubis is inspected for the presence of a peristaltic

wave, which is not normally visible. Pyloric ste-
nosis should be considered if a peristaltic wave
is observed moving from left to right across the ab-
domen.
The abdominal surface is inspected for lesions,
rashes, bruising, and signs of injury, particularly
pattern injuries, which may indicate abuse (see Chap-
ter 23).
The umbilicus is routinely examined in the de-
livery room for the presence of two arteries and one
vein. If there is only a single artery, further evalua-
tion for congenital defects is necessary. During the
newborn period, the umbilical stump is inspected
FIGURE 19-6. Umbilical hernia with diastasis recti. for signs of infection, including redness, odor, and
purulent drainage on the underlying skin at the base
of the stump, which indicates omphalitis. A spot
may be an isolated finding or associated with other of blood from the umbilical stump is not unusual.
defects. The second abdominal wall defect seen in Umbilical granulomas at the base of the umbilical
newborns is gastroschisis. This is similar to an ompha- stump may drain serous fluid or occasionally bleed.
locele; however, the herniation of abdominal contents Most umbilical cords detach spontaneously within
is not midline in the abdomen and is not covered with 10 days, but it is not abnormal for it to take several
a membrane. Gastroschisis is caused by an embryonic weeks.
vascular deficiency. A rectal exam on children is rarely performed;
A separation of the rectus muscles may be eas- however, inspection of the diaper area, including
ily visualized when the child is crying or struggling. the anus, is necessary. In newborns, the anus is in-
A bulge between the rectus muscles indicates a di- spected for patency. An imperforate anus may have
astasis recti, or herniation. This is most commonly a blind dimple where the anus would normally be.
found in African American children and usually Female newborns may have a rectovaginal fistula,
disappears by early childhood (see Fig. 19-6). Incar- which allows the passage of stool through the va-
ceration of an umbilical hernia is rare. Most umbili- gina. The provider should note when the newborn
cal hernias may be reduced by gentle pressure from passed meconium; it is normal within the first 24
the examiner’s fingers. Also, the inguinal area is ex- hours of life.
amined for any bulges, indicating an inguinal her- Male and female children can present with sexu-
nia (Fig. 19-7). Any other visible abdominal masses ally transmitted infections, if they have been sexually
must be noted. abused. Incongruencies in the history and physical
The abdomen from the area inferior to the xi- assessment are red flags for intentional injury. The
phoid process to the area above the symphysis undergarments of preschool and school-aged children
must be inspected for discharge or bleeding. The geni-
talia must be inspected for signs of injury, such as
bruising, abrasions, or teeth marks.
AUSCULTATION
Auscultation follows the inspection of the abdomen.
However, providers may follow the respiratory auscul-
tation with the abdominal auscultation, if the child is
quiet and cooperative at that time.
Positioning is the same as for inspection, and elic-
iting cooperation from the child aids in the differen-
tiation of audible sounds. The abdomen is auscultated
for bowel and vascular sounds. The diaphragm of the
stethoscope is used for bowel sounds, and the bell is
used for vascular sounds.
Bowel sounds are normally audible in all children.
FIGURE 19-7. Inguinal hernia. It is customary to begin at the RLQ, in proximity to
the ileocecal valve, which often allows hypoactive

bowel sounds to be heard. Bowel sounds are system-
atically auscultated in each of the four abdominal
quadrants. If a child presents with abdominal pain,
the area of pain is auscultated last, as placement
of the stethoscope over an area of tenderness may
elicit pain, after which the child may not cooper-
ate. Adequate time must be allowed for the assess-
ment. Bowel sounds are not considered absent until
the provider has listened for 2 full minutes without
audible sounds.
In the newborn, bowel sounds are audible within
the first few hours after birth. Metallic tinkling can be
heard every 15–20 seconds. In older children, bowel
sounds are audible every 10–20 seconds. Hypoactive FIGURE 19-8. Percussion of the spleen.
bowel sounds represent decreased peristalsis or intes-
tinal activity. This may indicate a paralytic ileus, often
from diffuse peritoneal irritation. Hyperactive bowel
sounds indicate rapid movement of contents through of the liver. This point is marked, and the distance
the intestine, often associated with diarrhea or an ob- between the two marks is measured. The resulting
struction. measurement is the liver span. The normal liver span
Auscultation of abdominal vascular sounds in the is dependent on the child’s age. At 2 months of age,
child is done with the diaphragm or the bell of the the liver span ranges from 3.5 to 7.2 cm, averaging
stethoscope. Vascular bruits in children are uncom- 5.5 cm. By age 5, the normal liver span ranges from
mon. However, the presence of a vascular bruit over 6.5 to 10 cm, with an average of 8.2 cm (Elridge &
the renal arteries may be associated with renovas- Newton, 2007).
cular hypertension, and further diagnostic studies Percussion is also used to assess for splenic en-
are indicated. Auscultation of the renal arteries is largement in the older child and adolescent (Fig.
performed approximately 2 cm above the umbilicus 19-8). Normally in this age group, the spleen is
and 1–2 cm to the right and left of this position. under the thoracic cage and lies posteriorly in the
The exact position depends on the size of the child’s abdominal compartment. Splenic enlargement may
abdomen. be percussed as the spleen moves downward and
toward the midline. Percussion for splenic enlarge-
ment is performed with the child lying supine. The
PERCUSSION provider must percuss from the posterior axillary
Percussion helps to determine the presence of air, line anteriorly to the anterior axillary line at the
fluid, or a mass and to delineate the size of abdom- lowest intercostal space. A dull percussion note at
inal organs or masses. Abdominal tympany is gen- or beyond the anterior axillary line indicates splen-
erally present in young children, as they swallow ic enlargement.
air with feedings and crying. Tympany is the most Assessment for renal tenderness is performed
common percussion note throughout the abdomen with the child sitting upright. The technique used
in all children because of gas in the stomach, small is fist percussion. This may be direct or indirect.
bowel, and colon. A dull sound over the suprapubic Direct fist percussion is done with the examiner
area may indicate a full bladder. Percussion of the standing behind the child. Then, the provider gen-
abdomen follows a systematic assessment of all four tly strikes the child with a closed fist in each of
quadrants. the costovertebral areas, overlying the kidneys. In-
Percussion is also used to determine the dimen- direct fist percussion is also performed from behind
sions of the liver. Providers must percuss from the the seated child; however, the examiner places an
right midthoracic area in the midclavicular line. Per- open hand against the costovertebral area and then
cussion proceeds downward until a change in tone gently strikes his or her own hand on each side.
is noted from resonance to dullness. This is the up- In the presence of renal inflammation/infection or
per border of the liver, usually at the fifth intercostal pyleonephritis, the child will have extreme pain
space. This point is marked on the child’s skin. Next, even with gentle fist percussion. This technique
the provider percusses from the RLQ upward until a is used judiciously, usually toward the end of the
change in tone is noted from tympany to dullness, assessment, especially if the provider suspects py-
in the midclavicular line. This is the inferior border leonephritis.
PALPATION
Palpation is considered the most important technique
in the assessment of the abdomen. Various methods of
gaining the child’s cooperation may be used. Distrac-
tions, allowing the infant to remain in the caregiver’s
lap, or sucking on a pacifier are a few examples. The
newborn may be assessed while supporting the hips
and legs in a flexed position, facilitating relaxation of
the abdominal wall. The older child may be instruct-
ed to lie supine with knees flexed. Palpation is used
to identify areas of tenderness or rigidity, to identify
masses, and to identify enlarged organs, specifically
the liver and the spleen. Two levels of palpation are
used, light and deep palpation.
Light palpation is used to find areas of tenderness or
rigidity; deep palpation is used to evaluate the underly-
ing structures. Light palpation requires the pads of the FIGURE 19-10. Deep palpation.
fingers to be used, not the fingertips (Fig. 19-9). Jabbing
motions must be avoided. The fingers are lifted when ing abdominal structure in mind. Enlargement of the
moving from one area to another. Involuntary rigidity abdominal organs or masses may be identified. Gentle
of the abdominal muscles indicates localized or diffuse but firm and steady pressure is applied to the abdomen
peritoneal irritation. The provider must observe the (Fig. 19-10). Infants with pyloric stenosis may have a
child during light palpation for indications of discom- firm, olive-like mass palpable in the RUQ. Children
fort or pain. When a tender area is identified during with constipation may have stool, resembling a firm
light palpation, that area is examined last with deep sausage-like mass, palpable in the LLQ.
palpation. When an area of tenderness is identified in an older
Palpation follows a systematic sequence in all four child, the provider must determine if rebound tender-
quadrants, allowing for palpation of the area of dis- ness, a sign of peritoneal irritation, is present. The abdo-
comfort last. The groin is palpated for inguinal lymph men is palpated slowly and deeply away from the area
nodes, noting the number, size, and tenderness of of tenderness, quickly removing the palpating hand. If
the nodes. Each femoral pulse is palpated, noting the the child experiences pain in the area of inflammation
characteristics of each pulse. Deep palpation is per- when the palpating hand is removed quickly, rebound
formed with one hand for a younger child or bimanu- tenderness exists. Rebound tenderness may also be dif-
ally for an older child or adolescent with the underly- fuse, as in peritonitis.
FIGURE 19-9. Light palpation.

FIGURE 19-12. Palpation of the spleen.

FIGURE 19-11. Palpation of the liver.
Palpation of the liver in infants and toddlers may anterior abdomen. While pushing upward with the
be performed with one hand by grasping the child’s posterior hand, the provider palpates the correspond-
RUQ and placing the thumb anteriorly and the rest ing upper abdominal quadrant with fingertips. In this
of the hand posteriorly. An alternative technique manner, the kidney may be trapped, and thus pal-
for this age group is similar to that for older chil- pable between the examiner’s hands. This is repeated
dren and adolescents. The examiner’s fingertips are on the other side.
placed below the costal margin in the right midcla-
vicular line, palpating toward the liver until the firm
edge of the inferior liver border is palpable upon
SPECIAL TECHNIQUES
inspiration (Fig. 19-11). This may resemble a bump
or a nudge by the liver as it is displaced downward The following techniques are best performed with an
during the child’s inspiration. It is important to note older and cooperative child when possible.
the distance between the palpable liver border and
the inferior costal margin. Infants and children may Iliopsoas Test
have a palpable liver border 1–2 cm below the cos-
The iliopsoas test is used to identify intra-abdominal
tal margin. Palpation of the inferior border of the
inflammation. This is most commonly used in the
liver 3 cm or more below the costal margin indicates
evaluation of possible appendicitis. The child is posi-
hepatomegaly.
tioned on the unaffected side and is asked to extend
Palpation of the spleen is similar to palpation of
the other leg at the hip, against resistance from the
the liver, though more difficult. A spleen must be en-
examiner. Irritation of the psoas muscle from abdomi-
larged to at least two times its normal size to be pal-
nal inflammation produces pain with this maneuver.
pable. The examiner’s dominant hand is placed flat
Pain of the right psoas muscle is a sign often seen with
beneath the left upper quadrant and below the pos-
appendicitis.
terior costal margin. This hand presses inward and
upward while the other hand palpates anteriorly for
the tip of the spleen during inspiration (Fig. 19-12). Obturator Test
Splenomegaly, an enlarged spleen, will be palpable The obturator test is similar to the iliopsoas test to
by the examiner’s hand on the anterior abdomen. identify intra-abdominal inflammation. The child is
Gentle palpation of the spleen is necessary because positioned supine while the examiner flexes each leg
of the high vascularity of this organ. In the presence at the hip and rotates the hip internally and exter-
of possible splenic trauma, caution is advised during nally. Inflammation adjacent to the obturator mus-
any splenic palpation because it is possible to dis- cle elicits pain during this maneuver. Appendicitis
lodge a clot and precipitate a hemorrhage. often presents with a positive right obturator test.
Palpation of the kidneys is most easily achieved
in the infant. Kidneys are palpable as round and
smooth. The right kidney is more inferior to the left, Rectal Exam
and thus often easier to palpate. One hand is placed A rectal examination in children is not often re-
in the child’s flank area, and the other is on the quired, but if it is necessary to perform this exam, it
is best to reserve this invasive procedure until the end palpable. No CVA tenderness. No inguinal lymph-
of the physical examination. Indications for a rectal adenopathy; bilateral femoral pulses 2⫹.
exam include evaluation of sphincter tone, constipa- Assessment: Healthy school-aged child
tion, rectal bleeding, or suspicion of sexual abuse. An
informed discussion with the parent or older child
helps to gain their assent. Positioning for an infant SAMPLE WRITE-UP: CHILD WITH
is supine with both hips and legs flexed. The older ABDOMINAL PAIN
child or adolescent is positioned on the left side with
Subjective Data
the right hip and leg flexed or both hips and legs
HPI: 10-year-old female accompanied by parents
flexed. Even young children should be positioned and
complaining of abdominal pain for 2 days. Denies
draped to maintain modesty. A lubricated finger, usu-
abdominal injury. Pain began in periumbilical
ally the examiner’s smallest finger, is gently inserted
area; has now localized to RLQ. Describes pain as
at the rectal verge. As the sphincter relaxes, the fin-
“bad hurt”; rates pain a 10 on Faces of Pain Scale.
ger is moved toward the child’s umbilicus. Sphincter
Decreased appetite; nausea but no vomiting. Fever
tone, constrictions, or masses are assessed. Stool may
(Tmax 100.8⬚ F) noted today. Loose stool last night;
be present. It should be noted if the stool is soft or
no blood in stool; color light brown.
hard. Often in the constipated child, the rectal exam
PMH: Noncontributory; previously healthy
facilitates passage of stool. Digital pressure toward the
PSH: None
child’s RLQ that elicits pain may be a sign of appendi-
citis. Any stool obtained must be tested for the pres-
Current Medications: Ibuprofen, last dose 1 hour ago
ence of occult blood.
Immunizations: Up-to-date
ROS:
Pelvic Exam GU: Denies dysuria, frequency, or change in color
A pelvic examination is often helpful to evaluate the of urine.
older child or adolescent presenting with abdominal Other ROS: Noncontributory
complaints (see Chapter 20 for a discussion of pelvic
examination in adolescents).
Objective Data
T: 101.8° F (38.8° C); P: 128 beats/min; R: 26
breaths/min; oxygen saturation on room air: 98%;
COMMON DIAGNOSTIC weight: 38 kg.
STUDIES General: Appears frightened, lying on her side; be-
havior appropriate for age and condition
Various diagnostic studies may be used to evaluate Skin: Color pale; no rashes or lesions; warm and
abdominal conditions. These diagnostic studies and dry; capillary refill ⬍2 seconds; turgor elastic
their indications are summarized in Table 19-5. Abdomen: Abdomen symmetric, nondistended. No
visible scars, abnormal lesions, or skin discoloration.
No visible peristalsis; bowel sounds hyperactive in
all quadrants. Abdomen tympanic to percussion,
DOCUMENTING FINDINGS although percussion reproduces pain in RLQ. Liver
span 5.4 cm in right midclavicular line. Tender to
SAMPLE WRITE-UP: WELL CHILD palpation RLQ and LLQ; involuntary guarding in
Subjective Data RLQ. Localized tenderness at McBurney’s point.
Minimal rebound tenderness. Obturator and psoas
Healthy 8-year-old female, PMH noncontributory, no
sign positive. Rovsing’s sign positive. No masses;
history of injuries, FH noncontributory; immuniza-
kidneys nontender to palpation. No inguinal lymph-
tions up-to-date; no meds; no allergies
adenopathy; femoral pulses 2⫹ bilaterally.
Assessment: Acute abdominal pain, R/O acute
Objective Data appendicitis
Abdomen: Abdomen symmetric, nondistended. No
No visible peristalsis; bowel sounds normoactive in SAMPLE WRITE-UP: CHILD WITH
four quadrants. Abdomen tympanic to percussion;
DYSURIA
liver span 5 cm in midclavicular line. Abdomen soft,
nontender to palpation. Liver edge smooth, palpable Subjective Data
at 1 cm below right costal margin. Spleen not palpa- HPI: 22-month-old female accompanied by mother.
ble. No masses or abnormal pulsations. Kidneys not Mother states child has been crying and not wanting
TABLE 19-5
Diagnostic Studies Used to Evaluate Abdominal Conditions
DIAGNOSTIC
TEST NORMAL VALUES INDICATION COMMENTS
Albumin ⬍5 yrs: 3.4–5 g/dL Useful in diagnosing Albumin is the main protein in human blood.
⬎5 yrs: 4–5.6 g/dL liver disease Albumin is made by the liver. Liver disease
results in decreased albumin production.
Alkaline 1–9 yrs: 145–420 U/L Useful in diagnosing ALP is an enzyme in the cells that line the
phosphatase 2–10 yrs: 100–320 U/L liver disease biliary ducts of the liver. ALP is also found
(ALP) Adolescent: 100–390 U/L in other organs, including bone, placenta,
and intestine. When ALP is elevated, gamma-
glutamyl transferase (GGT) can be ordered to
confirm that the elevated ALP is derived from
the liver or biliary tract.
Amylase Child: 35–127 U/L Indicative of Produced mainly by pancreas and salivary
pancreatic injury or glands. Metabolized in part by kidneys and
disease when lipase liver.
is also elevated
Bilirubin Total: Newborn: Useful in diagnosing Bilirubin is produced from the breakdown of
2–6 mg/dL, liver disease hemoglobin. The liver clears bilirubin from
5 days: 4–12 mg/dL, the body by excreting it through bile into the
⬎1 mo: 0.3–1.2 mg/dL intestine. Elevated bilirubin levels can indicate
Indirect: liver disorders or blockage of bile ducts.
⬎1 mo: 0.3–1.2 mg/dL Total bilirubin is a measurement of all of the
Direct: bilirubin in the blood. Direct bilirubin is a
⬎1 mo: 0.1–0.4 mg/dL measurement of a form of bilirubin made in
the liver.
Blood urea Child: 5–18 mg/dL To evaluate kidney BUN concentrations may be elevated when there
nitrogen (BUN) Adolescent: function and is excessive protein catabolism, significantly
7–18 mg/dL monitor kidney increased protein in the diet, or gastrointestinal
disease bleeding.
Complete Hematocrit: Infant: Helps to diagnose Most often correlated with the differential of
blood count 28%–42% infections and the white blood cells.
Child: 35%–45% anemia/blood loss.
Male adolescent:
37%–49%
Female adolescent:
36%–46%
Hemoglobin:
6–12 yrs: 11.5–15.5 g/dL
Male adolescent:
13–16 g/dL
Female adolescent:
12–16 g/dL
Platelet Count:
Newborn:
84,000–478,000 µL
Others:
150,000–400,000 µL
RBCs:
6 mos–2 yrs:
3.7–5.3 million/mm3
2–6 yrs:
6–12 yrs:
4–5.2 million/mm3
Adolescent:
(continued)
TABLE 19-5
Diagnostic Studies Used to Evaluate Abdominal Conditions (Continued)
DIAGNOSTIC
Creatinine Infant: 0.2–0.4 mg/dL To detect diseases A combination of blood and urine creatinine
(serum) Child: or conditions levels may be used to calculate a creatinine
0.3–0.7 mg/dL that affect kidney clearance to determine how effectively the
Adolescent: 0.5–1 mg/dL function, including kidneys are filtering small molecules like
glomerulonephritis, creatinine.
pyleonephritis, Creatinine can also increase temporarily as a
acute tubular result of muscle injury.
necrosis, urinary
tract obstruction,
or conditions that
decrease blood flow
to the kidney (shock,
dehydration)
Computed Negative for Evaluates abdominal Child must remain immobilized during
tomography scan abnormalities organs; also can imaging; may use oral, intravenous, or rectal
localize presence contrast. Consult with radiologist for specific
of intra- or recommendations.
retroperitoneal air
or fluid
Erythrocyte Child: Assists with Nonspecific test for conditions associated with
sedimentation 0–10 mm/hr diagnosis of acute and chronic inflammation, including
rate (Westergren Adult: inflammatory infections, cancers, and autoimmune diseases.
method) 0–20 mm/hr conditions (e.g.,
mesenteric adenitis)
Electrolytes, Sodium: Ions measured Potassium is the electrolyte used as a

serum Infant: 139–146 mmol/L to assess renal, hallmark of renal failure. Frequent causes of
Child: 138–145 mmol/L endocrine, and hypokalemia include alkalosis, and diarrhea
Adolescent: acid–base function and vomiting.
136–146 mmol/L Hyponatremia may result from diarrhea,
Potassium: vomiting, and cystic fibrosis.
Infant: 4.1–5.3 mEq/L Hypernatremia may also be seen with
Child: 3.4–4.7 mEq/L dehydration.
Adolescent:
3.5–5.1 mEq/L
Chloride:
98–106 mmol/L
Carbon dioxide:
Infant and child:
20–28 mmol/L
Adolescent: 23–30 mmol/L
Gamma-glutamyl 0–51 IU/L Useful in diagnosing GGT is an enzyme that is useful clinically when
transpeptidase liver disease compared to ALP. By comparing the two, it can
(GGTP) be determined if the patient has bone or liver
disease. Normal GGTP + elevated ALP suggests
bone disease. Elevated GGTP + elevated ALP
suggests liver or bile-duct disease.
Hemoccult Negative To determine the

presence of occult
blood in stool
DIAGNOSTIC
Hepatitis testing HAV Used to diagnosis Hepatitis A (HAV) infection: A positive antigen
IgM anti-HAV acute or chronic test (HAV test) and a positive antibody test
HBsAg hepatitis (IgM anti-HAV antibody test) indicate an
IgM anti-HBc acute HAV infection. Previous HAV infections
anti-HCV produce a negative antigen test, but the
(see comments) antibody test will be positive.
Hepatitis B (HBV) infection: A positive
antigen test (HBsAg or HBV surface antigen
test) and a positive antibody test (IgM anti-
HBc or IgM HBV core antibody test) indicate
an acute HBV infection. In chronic hepatitis
(6 months or more of infection), the antigen
test will be positive, but the antibody test will
be negative. If the child has had a full series
of HB immunizations, the antigen test will be
negative, and the antibody test will be positive.
Hepatitis C (HCV) infection: A positive
antibody test (anti-HCV or antibody to HCV
test) indicates a current acute HCV infection.
To determine if infection is chronic, tests are
done to measure the amounts of specific HCV
viral proteins (antigens) present in the blood. If
these tests remain positive for several months,
the disease is said to be chronic.
If the newborn is tested for antibodies to the
HCV, the test may return a positive result as
a result of detecting the maternal anti-HCV
antibodies present in the infant.
Lipase Infant: 9–105 U/L Useful in diagnosis Lipase is more specific for pancreatitis than is
Child: 20–180 U/L of pancreatitis serum amylase; it is also used in diagnosis of
peritonitis, strangulated or infarcted bowel,
and pancreatic cyst.
Liver function ALT: Useful in diagnosing ALT or SGPT

tests 5–60 IU/L liver disease. ALT is primarily found in the liver; it is a more
AST: The liver uses specific test for detecting liver abnormalities.
5–43 IU/L these enzymes to AST or SGOT
metabolize amino AST is not only found in the liver. It is also
acids and to make normally found in heart, muscle, brain, and
proteins. When liver kidney tissue. Injury to any of these tissues can
cells are damaged cause an elevated blood level.
or dying, ALT
and AST leak into
the bloodstream.
Elevations are also
seen with viral
hepatitis, liver
inflammation from
medications and
certain herbs, auto-
immune hepatitis,
steatohepatitis,
inherited liver
diseases, and liver
tumors.
Prothrombin 10–15 sec Useful in diagnosing The PT or protime is used to evaluate blood
time (PT) liver disease clotting. Prothrombin is a clotting factor from
the liver. If the liver is injured or damaged, the
clotting factors are not produced normally, and
the PT is elevated.
(continued)
TABLE 19-5
Diagnostic Studies Used to Evaluate Abdominal Conditions (Continued)
DIAGNOSTIC
Sweat ⬍60 mEq/L To diagnose cystic Cystic fibrosis includes gastrointestinal
chloride test fibrosis manifestations such as steatorrhea and poor
growth.
Ultrasonography Negative for Most commonly It is noninvasive, so it requires no sedation.

abnormalities used to evaluate
liver and gallbladder;
also used to evaluate
pelvic organs in
female child; may
include transvaginal
ultrasound in older
adolescent
Urine HCG Negative To determine

pregnancy
Urinalysis Specific gravity: Most commonly Microscopic analysis provides specific

1.003–1.035 used to identify number of WBCs and RBCs seen. Microscopic
pH: infant: 5–7 urinary tract evaluation may also identify abnormal
⬎1 yr: 4.8–7.8 infection; also findings, such as casts, trichomonads, yeast, or
Protein: neg used to detect sperm.
Blood: neg kidney disease,
Glucose: neg hyperglycosuria, and
Ketones: neg evaluate dehydration
Leuk esterase: neg
Nitrites: neg
Urine culture and No growth of pathogen To identify It is often difficult for young children to obtain
sensitivity specific bacteria a clean-catch, midstream specimen.
and susceptible
antibiotics
24-hour urine Infant: 350–550 mL/d Useful in diagnosing Urine must be kept refrigerated.
volume Child: 500–1000 mL/d renal disease
Adolescent:
700–1400 mL/d
WBC differential Neutrophils (bands): Assists in Leukocytosis with a shift to the left is seen with
3%–5% differentiating if acute bacterial infections.
(segs): 54%–62% condition may be
Eosinophils: viral or bacterial;
1%–3% may be helpful in
Basophils: identification of
0%–75% allergic conditions.
Monocytes:
3%–7%
Lymphocytes:
25%–33%
ALT, alanine aminotransferase; AST, aspartate aminotransferase; HCG, human chorionic gonadotropin; RBCs, red blood cells; SGOT, serum
glutamic oxaloacetic transaminase; SGPT, serum glutamic pyruvic transaminase; WBCs, white blood cells.
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General: Denies fever, chills, or rash. Denies recent R. M., Swift, J. D., Newton, D. A., & Anas, N. G. Pediatric hos-
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GI: Denies vomiting or diarrhea; denies constipation;
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Objective Data Guandalini, S., Frye, R. E., Rivera, D. M., & Borowitz, S. (2008).
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and adolescents. Pediatrics, 118(3), 1279–1286.
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Abdomen: Abdomen symmetric, nondistended. No infants and children. (8th ed.). St. Louis: Mosby.
Kim, J. S. (2008). Food allergy: diagnosis, treatment prognosis,
and prevention. Pediatric Annals, 37(8), 546–551.
No visible peristalsis; bowel sounds normoactive in Kumar, R. (2008).Epidemiology and risk factors for the develop-
four quadrants. Abdomen tympanic to percussion; ment of food allergy. Pediatric Annals, 37(8), 552–558.
Lab Tests Online. (2009). Creatinine. Retrieved November 20,
liver span 3.5 cm in midclavicular line. Abdomen
2009, from http://labtestsonline.org/understanding/analytes/
soft with suprapubic tenderness. Child crying; how- creatinine/multiprint.html.
ever, no involuntary guarding noted. No rebound Leikin, J. B., & Paloucek, F. P. (2008). Poisoning and toxicology
handbook. (4th ed.). New York: Lexi-Comp.
tenderness. Liver edge smooth, palpable at 2 cm
Macfarlane, F. (2006). Pediatric anatomy, physiology and the
below right costal margin. Spleen not palpable. basics of pediatric anesthesia. Retrieved October 1, 2008,
No masses or abnormal pulsations. Kidneys not from http://www.frca.co.uk/article.aspx?articleid=100544.
Matthew, A., Chiemprabha, A. F., & Donelson, S. (2009). Hy-
palpable. No inguinal lymphadenopathy, bilateral
peramylasemia. Retrieved November 20, 2009, from http://
femoral pulses, 2⫹. emedicine.medscape.com/article/186389-overview.
Urinalysis: Specific gravity ⫽ 1.016, pH ⫽ 6.0, pro- Pinhas, L., Katzman, D. K., Dimitropoulos, G., & Woodside, D. B.
(2007). Bingeing and bulimia nervosa in children and adoles-
tein ⫽ neg, blood ⫽ trace, glucose ⫽ neg, ketones ⫽
cents. In Jaffa, T., & McDermott, B. (Eds.). Eating disorders in
neg, nitrites ⫽ small, leuk esterase ⫽ large; micro: children and adolescents. (pp. 133–143). New York: Cambridge
0–5 RBCs, 25–50 WBCs University Press.
Rhee, K., & Silverstein, M. (2005). Use of serum electrolyte panels
Assessment: Acute cystitis (UTI)
in gastroenteritis. Pediatrics. Retrieved October 12, 2008, from
http://www.pediatrics.org/cgi/content/full/115/4/1108-a.
Richards, T. (2009). Hepatitis A, B, and C blood tests. Retrieved
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American Academy of Pediatrics Committee on Nutrition. (2007). library/content/print_aha_heptests_crs.htm.
The use and misuse of fruit juice in pediatrics. Pediatrics, Smith, V. (2005). Testing and diagnosis of pediatric hepatitis C.
107(5), 1210–1213. Retrieved October 12, 2008, from http://www.hepatitisneigh-
Ball, J. W., & Bindler, R. C. (2006). Child health nursing: Partnering with borhood.com/content/understanding_hepatitis/what_is_
children & families. Upper Saddle River, NJ: Pearson Prentice Hall. hepatitisc_874.aspx#.
Springer, S. C., & Annibale, D. J. (2009). Necrotizing enterocolitis. Weik, J., & Moores, D. (2005). An unusual case of umbilical rupture
Retrieved November 20, 2009, from http://www.emedicine with herniation. Journal of Pediatric Surgery, 40(4), E33–E35.
.com/ped/TOPIC2601.htm. Yeomans, M. R., Ripley, T., Davies, L. H., Rusted, J., & Rogers, P. J.
Story, R. E. (2008). Manifestations of food allergy in infants and (2002). Effects of caffeine on performance and mood de-
children. Pediatric Annals, 37(8), 530–535. pend on the level of caffeine abstinence. Psychopharmocology,
Tobias, N., Mason, D., Lutkenoff, M., Stoops, M., & Ferguson, D. 164(3), 241–249.
(2008). Management principles of organic causes of childhood Zahn, M., & Marshall, G. S. (2006). Clinical and epidemiologic
constipation. Journal of Pediatric Health Care, 22(1), 12–23. aspects of rotavirus infection. Pediatric Annals, 35(1), 23–28.
CHAPTER
Assessment of the
20 Reproductive System
ELLEN M. CHIOCCA AND DIANE B. BOYER
Assessment of the reproductive system can provoke the labia majora and are joined anteriorly at the edge
a great deal of anxiety for the child or adolescent, of the clitoris, forming a hood, and posteriorly, just
the parent, and the provider. Because of discomfort below the vaginal opening. This latter area is known
or embarrassment on the part of the child, parent, as the fourchette.
or provider, it is tempting to omit this portion of the Located just below the mons pubis is the clitoris, a
assessment. However, this is an essential portion of small structure composed of erectile tissue. Like the
the history and physical examination during health penis, the clitoris is very vascular and sensitive to
maintenance visits and when formulating differential touch and becomes engorged with blood and enlarged
diagnoses during focused visits. This can lead to criti- during sexual arousal.
cal assessments and diagnoses that can identify infec- The area covered by the labia minora is known as
tions or surgical emergencies, preserve a child’s future the vestibule. The vestibule contains the urethral meatus
fertility, or diagnose sexual abuse. and vaginal orifice. The urethral meatus is the urinary
tract’s external opening and leads into the urethra and
urinary bladder. This structure is located approximately
ANATOMY AND PHYSIOLOGY 2.5 cm posterior to the clitoris and is a small, irregu-
larly oval-shaped structure. The Skene’s glands, located
on either side of the urethral meatus, produce mucus
FEMALE GENITALIA that is secreted through ducts that are not visible to
The external structures of the female genitalia include inspection but can easily become infected. This mucus
the mons pubis, labia majora, labia minora, urethral and protects the surrounding tissue against irritation from
vaginal orifices, and clitoris. The internal structures in- urine.
clude the ovaries, fallopian tubes, uterus, cervix, and vagina. The vaginal orifice, or introitus, is the entrance to the
The female urinary tract is separate and distinct from the vagina, located posterior to the urethral meatus. The
female reproductive tract. shape of the vaginal orifice depends on the condition
of the hymen. The hymen is a fold of mucous mem-
External Genitalia brane that partially covers the vaginal orifice. The size
The female external genitalia are collectively known and shape of the hymen varies greatly among girls and
as the vulva. The most visible part is the mons pubis, women, depending on their age, whether they are pre-
an area of adipose tissue covered with skin. After a girl or postpubertal, or whether they have given birth. It
reaches puberty, the mons pubis is covered with coarse, is important for the pediatric health care provider to
curly pubic hair. The mons pubis also acts as a protec- be familiar with common, normal hymenal configura-
tive covering for the pubic bone. The labia majora are tions to be able to identify signs of trauma or evidence
two small folds of fatty tissue located on either side of of sexually transmitted infections (STIs). Examples
the vaginal opening. These folds of tissue are joined of normal hymenal configurations include annular,
at the mons pubis, just above the perineum. Once a crescentic, fimbriated, cribriform, or septate, the most
girl has reached puberty, the labia majora also become common being annular and crescentic (Giardino &
hair-covered. The labia minora are two hairless folds of Finkel, 2005).
tissue that lie between the labia majora and the urethral On either side of the vaginal orifice are the Bartholin’s
and vaginal orifices. The labia minora are smaller than glands, which produce a clear lubricating mucus during
413
The uterus is divided into three parts: the fundus,

the corpus, and the cervix. The fundus is the top section
of the uterus into which the fallopian tubes connect.
The corpus, or the body of the uterus, is the largest sec-
tion and houses the fertilized ovum, which becomes
the embryo and then the fetus. The cervix lies at the
Urethral end of the uterus and connects to the vagina. It is a
meatus long, narrow canal with openings at either end. The
opening that extends into the corpus is the internal os;
the external os opens into the vagina. In the nullipa-
rous female, the cervix’s opening, the external os, ap-
pears as a doughnut-shaped area with a small, circular
hole at the center.
gland
The vagina is a tubular structure comprised of three
layers: a muscular layer, a loose connective tissue layer,
and a layer of mucous membrane. In the prepubertal
girl, the vagina is rigid, thin-walled, and nonelastic.
After puberty, the vagina becomes very elastic to ac-
FIGURE 20-1. External female genitalia.
commodate a newborn’s head. The lower one third of
the vagina is very sensitive to touch; the upper two
intercourse. This mucus is secreted through Bartholin’s thirds have little sensation. The internal female geni-
glands ducts, located on either side of the vaginal orifice. talia are illustrated in Figure 20-2.
Like the Skene’s glands, the Bartholin’s glands can be-
come blocked, and an infection may result. The exter-
nal female genitalia are illustrated in Figure 20-1.
MALE GENITALIA
The male genital structures consist of the penis, scrotum,
Internal Genitalia testis, epididymis, vas deferens, seminal vesicles, and prostate
gland (Fig. 20-3). The urethra is located within the male
The ovaries are two almond-shaped organs located on
reproductive tract.
either side of the uterus. Each ovary is held in place
by ligaments that connect them to the abdominal and
pelvic walls. Beginning at puberty, the ovaries develop Penis
ova (eggs), normally releasing one mature ovum a The penis is comprised of the shaft, glans, corona, and
month. The ovaries also produce the female hormones, prepuce. The shaft of the penis is composed of three
estrogen and progesterone, which perform many func- columns of erectile tissue: the corpora cavernosa and
tions during menstruation and reproduction. the corpus spongiosum. The corpus spongiosum ex-
The fallopian tubes are two long, muscular tubes that pands into an area of erectile tissue called the glans.
have a funnel-shaped opening at one end that extends The corona is the prominence formed where the glans
close to or over the ovaries; this end is termed the joins the shaft. The urethra is contained within the
fimbriated end. Projections at the fimbriated end pull corpus spongiosum, with the external meatus extend-
the ovum into the fallopian tube after it is released from ing to the tip, forming an opening at the glans. Over
the ovary. The remainder of the tube curves around the the glans, the skin folds form a flap; this is the foreskin
top of the ovary and attaches to the uterus. Fertilization or prepuce. The foreskin is what is surgically removed
of the egg usually occurs inside the fallopian tube. If during circumcision.
fertilization does not occur, menstruation occurs.
The uterus is located deep within the pelvis be- Scrotum and Testicles
tween the urinary bladder and rectum. Shaped like an The scrotum is a loose cutaneous pouch that hangs
inverted pear, the uterus is a hollow, muscular organ, underneath the base of the penis and contains the
the size of a closed fist. When a girl or woman is stand- testicles (see Fig. 20-3). The main function of the scro-
ing, the top of the uterus points forward and slightly tum is temperature regulation of the testicles; the
upward. A group of eight ligaments support the uterus. testicles must be 2–3° C cooler than the peritoneal
The uterus is lined with a soft, spongy layer, known as cavity for spermatogenesis to take place. The scrotal
the endometrium. Under the influence of estrogen and wall is formed by an outer layer of thin skinfolds,
progesterone, this lining becomes thick and vascular or rugae, and an underlying cremaster muscle layer.
each month during the menstrual cycle, in preparation The cremaster muscle allows contraction of the scro-
to nourish a fertilized ovum. If the ovum is not fertil- tum in response to ambient temperature. When the
ized, the lining sheds, resulting in menstruation. ambient temperature is cold, the muscle contracts,
C H A P T E R 20 A s s e s s m e n t o f th e Re p ro du c tive S ystem • 415
Peritoneal
cavity Fimbria
Fallopian tube
Sacrum
Ovary
Uterus Rectouterine
pouch
Pubic symphysis Posterior
fornix
Urinary bladder
Cervix
Clitoris
Rectum
Labium minus
Labium majus Anterior fornix

Urethra Vagina Anus
FIGURE 20-2. Internal female genitalia.
Ureter
Urinary bladder
Peritoneum
Openings of ureter
Ampulla of
Prostate gland vas deferens
Membranous urethra
Rectovesical pouch
Vas deferens
Sphincter urethrae Rectum
muscle Seminal vesicle
Pubic symphysis
Ejaculatory
Suspensory ligament duct
of penis
Corpus cavernosum
Corpus spongiosum
Corona of
glans penis
Levator ani muscle
Glans penis
Navicular fossa Bulbourethral
of urethra gland and duct
External
urethral
opening
Epididymis
FIGURE 20-3. Male genitalia. (Source: The Anatomical Chart Company. [2001].
Atlas of human anatomy. Springhouse, PA: Springhouse.)
bringing the testes closer to the body to absorb heat, The inguinal canal lies between two layers of abdominal
thereby preserving sperm viability. The resultant muscle and superior to the inguinal ligament. The
skin then appears wrinkled with furrows and ridges. femoral canal lies inferior to the inguinal ligament.
When the ambient temperature is warm, the scrotal Incomplete closure of the process vaginalis, a dimple-
muscles relax, the scrotum lowers, and the skin ap- like structure in the peritoneum, allows abdominal
pears smooth. contents to move through the inguinal canal or scro-
Inside the scrotum, a wall separates the sac into two tum, resulting in an inguinal hernia.
halves; each half contains a testicle, its epididymis, and
part of the spermatic cord (see Fig. 20-3). The testicles,
which produce sperm and testosterone, are ovoid and THE BREAST
held by the spermatic cord. The left testicle hangs lower The breasts are specialized mammary glands that are
than the right because the left spermatic cord is longer. located on either side of the anterior chest between
The epididymis is a crescent-shaped structure that is the second and sixth ribs. They are separated from
curved over the top of the testicle. Sperm matures and underlying muscles and ribs by connective tissue.
is stored in the lower portion, or tail of the epididymis, The nipple is located at the center of the breast. It
near the vas deferens. The vas deferens begins at the tail is comprised of round, protuberant tissue with tiny
of the epididymis and joins other structures (i.e., arter- milk duct openings. The areola is a circular area of tis-
ies, veins, lymphatics, nerves and cremaster muscle) to sue surrounding the nipple. Small sebaceous glands,
form the spermatic cord. The spermatic cord moves up- called Montgomery’s glands, give the areola a bumpy
ward through the inguinal canal into the abdomen be- appearance. These glands secrete a fatty substance
hind the bladder where it merges with the duct of the that lubricates and protects the nipple during breast-
seminal vesicle. The seminal vesicles are paired glands feeding. The nipple and areola are more darkly pig-
that lie behind the urinary bladder and in front of the mented than the rest of the breast, with the color
rectum. Secretions produced by the seminal vesicles varying from pink to brown, according to skin color.
play a role in producing seminal fluid. These secretions The external landmarks of the female breast are illus-
flow through the ejaculatory duct, which empties into trated in Figure 20-5.
the urethra. The breast is composed of three types of tissue:
The walnut-shaped prostate gland lies below and be- (a) glandular tissue, (b) fibrous tissue, and (c) adipose
hind the urinary bladder, surrounding the urethra. The tissue. The glandular tissue contains approximately
prostate gland secretes a thin, white, milky, alkaline 15–20 lobes radiating from the nipple; each lobe is
ejaculation fluid that helps with sperm viability. further divided into lobules; these lobules contain
milk-producing cells that empty into the lactiferous
Inguinal Area duct. Strong, fibrous tissue and suspensory ligaments
The inguinal area, or groin, is the area in which the (Cooper’s ligaments) support the breast and attach the
lower abdominal wall and the thigh meet (Fig. 20-4). breast tissue to the chest wall muscles. The internal
anatomy of the breast is illustrated in Figure 20-6.
The male breast is similar to the female breast until
puberty, at which time the female breast develops un-
der the influence of estrogen.
Inguina Anterior
canal superior
iliac spine
Inguinal Pecto
External ligament major
inguinal r ng
Axillary
of Spen
moral canal
femoral pple
Suspe ry
y & vein
ligame Areo
mery's
Se
an
FIGURE 20-4. Inguinal area. FIGURE 20-5. External landmarks of the female breast.
Pectoralis
major
Lactiferous
duct
Fatty
tissue Lactiferous
sinus
Lobule
Glandular tissue
Lobe
Cooper's ligaments
(fibrous tissue)
FIGURE 20-6. Internal anatomy of the breast.
swollen at birth and the neonate may secrete colos-

DEVELOPMENTAL trum (“witch’s milk”) as a result of the exposure to
CONSIDERATIONS maternal estrogen. Few changes in the breast occur
before puberty.
At 5–6 weeks’ gestation, the fetal gonads have not yet
differentiated into a testicle or ovary; during week six,
differentiation begins. External genitalia differentia-
tion occurs between 8 and 12 weeks’ gestation. In the
PHYSIOLOGIC CHANGES AT
female, approximately 400,000 immature ova are pres- PUBERTY
ent in the ovaries at birth. Beginning at puberty, the
ovaries normally alternate releasing one mature ovum Puberty involves several physical and psychosocial
a month; this is a part of the menstrual cycle. Between changes in the adolescent caused by the increased se-
17 and 20 weeks’ gestation, the testicles develop in cretion of sex hormones. These changes occur at differ-
the abdominal cavity. In the later months of gesta- ent rates among adolescents, but all include a growth
tion, the testicles descend through the inguinal canal spurt, establishment of fertility, and the development
into the scrotum, completing this process before birth. of secondary sex characteristics.
Because of this timing, cryptorchidism and inguinal
hernia are more common in preterm boys. Testicles
enlarge between 9 and 13 years. FEMALES
The preterm female neonate’s labia majora may Pubertal changes in girls take place as estrogen stimu-
not cover the labia minora, resulting in a protuberant lates the development of secondary sex characteristics;
clitoris that is easily visualized. Term neonates have this process takes an average of 3 years. The first signs of
enlarged labia majora due to the effects of maternal puberty in girls are breast development and the growth
estrogen. The swelling soon recedes, and the external of pubic hair. The stages of pubic hair development in
genitalia remain small until puberty. Until approxi- girls are depicted in Figure 20-7. This usually occurs
mately 2–4 years, the hymen is comprised of redun- between ages 8 to 13.5 years. Menarche usually occurs
dant folds of epithelial tissue and is pale pink. approximately 2 years after the appearance of breast
During the fourth week of embryonic life, breast buds. Axillary hair appears approximately 2 years after
development begins with the formation of the mam- the onset of pubic hair. Menarche occurs in breast de-
mary ridge (“milk lines”), which extend from the ax- velopment Stage 3 or 4, usually around age 12.
illa to the groin bilaterally. Between 12 and 16 weeks’ Before a girl reaches puberty, her breasts will appear
gestation, the nipple and areola form. Breast devel- as only areolae and nipples. At thelarche (the begin-
opment continues in utero under the influence of ning of breast development at puberty, approximately
maternal estrogen. From 32 to 40 weeks’ gestation, age 11), the presence of the hormone estrogen stimu-
milk ducts form within the nipple. At birth, only the lates the development of breast tissue. The milk ducts
lactiferous ducts within the nipple are present. Ad- then develop inward from the nipple, and adipose tis-
ditionally, both the male and female breasts may be sue accumulates around the ducts, causing the breasts
the breast and nipple elevate as a small mound, and

Stage 1 Prepubertal the areola widens. In Stage 3, there is further en-
No pubic hair
largement of the breast and areola, and the areola
becomes darker. In Stage 4, the areola and nipple
form a secondary mound over the breast tissue. Stage
5 is the mature breast. Only the nipple protrudes; in
some healthy women, the areola continues to form a
secondary mound. The stages of breast development
in girls are shown in Figure 20-8.
Stage 2
Sparse, long, straight hair
MALES
In boys, puberty typically begins between ages 9.3 and
13.5 years, at which time the testicles begin to enlarge.
Next, pubic hair begins to grow, and lastly penis size
increases. Maturation from preadolescent boy to adult
man usually lasts approximately 2–5 years. The stages
of pubic hair and genital development in boys are
illustrated in Figure 20-9.
Stage 3
Darker, coarser, curly, sparse hair
over the mons pubis.
CULTURAL, RACIAL, AND
RELIGIOUS CONSIDERATIONS
When assessing the genitalia of a child or adolescent,
the health care provider must consider the child and
family’s cultural and religious beliefs to ensure sensi-
Stage 4 tivity and respect. For example, an adolescent girl may
Dark, curly, abundant hair not have had a pelvic examination because of modesty.
over the mons pubis. An adolescent boy may have genitourinary complaints
that remain untreated because of his reluctance to
call attention to the problem due to embarrassment.
Depending on the child or adolescent’s beliefs, he
or she must be examined by a provider of the same
gender, with great care taken to preserve modesty.
This is especially true of Mennonite, Amish (Giger, &
Stage 5
Davidhizar, 2008), Orthodox Jews (Berkowitz, 2008),
Adult triangle pattern with hair Arabic, and Muslim girls (Hammoud, White, & Fetters,
growth on medial thighs. 2005). Questions about specific sexual practices and
beliefs about monogamy, abstinence, and sexual orien-
tation must be handled with respect and sensitivity.
Some racial differences are important to consider
during assessment of the reproductive system in chil-
dren and adolescents. Black and Mexican-American
girls reach thelarche, pubarche, and menarche earlier
FIGURE 20-7. Tanner’s pubic hair and genital development
in girls. than white girls of the same age (Rosenfield, Lipton, &
Drum, 2009).
Genital circumcision is a specific example of a re-
to become larger. Breast development is usually com- ligious and cultural practice involving the genitouri-
pleted by age 16. Although the age of thelarche varies, nary tract. Circumcision of newborn males is practiced
the five stages of breast development follow Marshall as part of a ritual ceremony by the followers of Islam
and Tanner’s (1969) classic sexual maturity rating, or and Judaism (Berkowitz, 2008). Female genital mutila-
Tanner staging (Marshall & Tanner, 1969). tion (FGM) or infibulation are practiced in some parts
Tanner Stage 1 is the preadolescent breast with of the Middle East and Asia. FGM involves the partial
only a small elevated nipple with no underlying or total removal of the clitoris or labia. Infibulation in-
breast tissue. Stage 2 is the breast bud stage in which volves cutting the labia, with or without the removal
Stage 1: Prepubertal of the clitoris, then stitching the remaining tissue to-
Nipple elevation begins. gether, leaving a small opening through which urine
and menstrual blood can pass (WHO, 2008). It is cultur-
ally accepted that FGM makes a girl’s genitalia aestheti-
cally pleasing and means that she is “clean” (WHO,
2008). FGM causes many complications such as cysts,
abscesses, keloid formation, urinary incontinence, sex-
ual dysfunction, prolonged labor and delivery, anxiety,
and depression (WHO, 2008).
Stage 2: Breast budding ASSESSMENT OF THE

Breast and nipple elevation appears
as a small mound with GENITOURINARY SYSTEM IN
areolar enlargement. CHILDREN
HISTORY
Any genitourinary evaluation should begin with a thor-
ough history. Although in the pediatric setting, a his-
tory is usually obtained from both a primary caregiver
and the child, it is extremely important that the pro-
vider interview an adolescent alone for at least a brief
Stage 3: Continued enlargement period of time to obtain a sexual history. The provider
The breast and areola enlarge must make it clear to the adolescent patient that any
without distinct evidence of sexual history information is private and confidential.
separation between them.

As with all assessments, the past medical history as it
relates to the system is extremely important for the
provider. The genitourinary history gives the provider
important information about known and potential
problem areas. The reasons for any past hospitaliza-
tions are ascertained, noting whether the reason for
Stage 4: Secondary mound the hospitalization involved the genitourinary or re-
A secondary mound forms productive tracts. Some examples include vesicoure-
beyond the original breast mound teral reflux, acute pyelonephritis, and pregnancy.
as the areola and nipple project.
Prenatal, Perinatal, and Neonatal Histories. The

prenatal, perinatal, and neonatal histories are important
elements of the assessment of the genitourinary and
reproductive systems in children. Some chromosomal
defects involve the genitourinary tract, such as trisomy
13 and trisomy 18, which are both associated with hy-
dronephrosis. Girls with Turner syndrome have abnor-
Stage 5: Breast maturity mally formed ovaries (Thomas, Duffy, & Rickwood,
The nipple projects and the areola 2008). Certain congenital anomalies affect the function
becomes part of the of these systems and may cause chronic genitourinary
breast contour.
difficulties. Examples of some of these conditions are
listed in Box 20-1.
Immunizations. In all children and adolescents, im-

munization status is reviewed, with special attention
paid to whether the hepatitis B and human papilloma-
virus (HPV) vaccines have been given. A possible route
of transmission for hepatitis B includes unprotected
FIGURE 20-8. Tanner’s stages of breast development in girls. sexual contact; this virus is transmitted via blood,
Stage 1: Preadolescent Stage 2 Stage 3

No pubic hair; penis and Sparse pubic hair; slight Darker, coarser pubic hair;
testes are same size and enlargement of penis and further enlargement of penis
proportion as in childhood. testes. and testes.
Stage 4 Stage 5
Coarse and curly pubic hair Hair spread to medial surface
covering more area; further of the thighs and adult in
enlargement of penis and quality and quantity; penis and
testes. testes reach adult size and
proportion.
FIGURE 20-9. Tanner’s pubic hair and genital development in boys.
semen, vaginal secretions, and wounds. It is important that may result in straddling injuries to the external
to determine if preadolescent or adolescent girls have genitalia in girls or testicular injuries in boys. It is
received the HPV vaccine, which protects against two essential to determine the circumstances leading to
types of HPV that are most likely to lead to cervical the injury; this may provide clues as to neglect; may
cancer (Someshwar, 2008). reveal knowledge deficits about motor vehicle, bicycle,
or street safety; or may indicate abuse.
Injuries. It is important to obtain any history of ab-
dominal, perineal, or groin injuries. Blunt or penetrat- Review of Systems. The pediatric review of systems
ing abdominal trauma can lead to severe renal injuries. (ROS) that is specific to the reproductive system focuses
Injuries to the perineum or groin may be due to falls on the endocrine and genitourinary systems, male and
female genitalia, and the breasts. Specific conditions
about which to inquire include:
BOX 20-1 • Genitourinary: Dysuria, urinary frequency, or ur-
Congenital Anomalies Affecting gency; urinary tract infection, hematuria, enuresis,
the Genitourinary Tract vesicoureteral reflux, cryptorchidism, testicular tor-
sion, hydrocele, varicocele, spermatocele, chordee,
• Hypospadias hypospadias, epispadias, balanitis, epididymitis, ure-
• Epispadias thritis, STI, genital/penile lesions, or rashes
• Chordee • Gastrointestinal: Constipation, pinworms, anal fis-
• Cryptorchidism sure, anal skin tag, or inguinal hernia
• Inguinal hernia • Hematologic: Sickle cell disease (can cause priapism
• Ambiguous genitalia in males)
• Labial fusion
• Endocrine: Polycystic ovary syndrome (PCOS), dia-
betes, hypothyroidism, or hyperthyroidism
• Urogenital sinus
• Neurologic: Myelomeningocele (causes neurogenic
• Extrophy of the bladder
bladder)
• Hydrocele • Reproductive: Gynecomastia (males), dysmenor-
• Vesicoureteral reflux rhea, menorrhagia, amenorrhea, pelvic inflamma-
tory disease, or pregnancy
• Integumentary: Acne, frontal or temporal hair loss, Family History

hirsutism or acanthosis nigricans in girls (may indi- Some conditions that affect the genitourinary and re-
cate PCOS); alopecia may indicate hypothyroidism productive systems may be genetic. During the initial
• Growth: Obesity may be sign of PCOS in girls and is patient encounter, the provider should inquire about
also associated with early puberty (Rosenfield, Lipton, any family history of these conditions. Box 20-2 lists
& Drum, 2009); it may cause gynecomastia in boys questions to ask when gathering this family history.
• Psychosocial: Anorexia nervosa, bulimia nervosa, or
morbid obesity; all can result in amenorrhea; obesity Social History
can also cause gynecomastia in males
The social history is an important component of the gen-
itourinary and reproductive assessment in children. For
Medications. A medication history must include any example, family strife or sexual abuse may be the etiol-
medication the child is taking or has taken in the past.
ogy of nocturnal enuresis (Dunn, 2009; Ramakrishnan,
Both prescription and over-the-counter medications are
2008). A history of depression can lead to alcohol or
included, paying close attention to medications that
drug use, which can, in turn, result in impulsive or non-
can affect the reproductive or genitourinary system.
consensual sexual encounters. Any history of eating
The indication for the medication is also determined.
disorders in girls must be noted; excessive or low body
Examples of medications about which to inquire in-
fat can affect the menstrual cycle. Excessive stress can
clude antibiotics, which may have been prescribed for
affect school performance, relationships, and, in girls,
a urinary tract infection (UTI) or for a STI; oral contra-
menstrual cycles. Involvement in contact sports may
ceptives; and steroids. It is also important to ask about
increase the risk of injury to the genital area. Box 20-3
the use of any topical creams or medications applied to
the child’s genital or anal area.
Surgical History BOX 20-3

It is important to determine if there have been any The Genitourinary and
surgeries of the reproductive tract. If so, there should be Reproductive Social History for
documentation of what type and at what age the pro-
Preadolescents and Adolescents
cedures were performed. It is also important to ascer-
tain the reason for reproductive tract surgery. In girls, • Family members
any gynecologic surgery must be noted, such as surgery • Who lives in home and relationship to child/adolescent
for dysfunctional uterine bleeding, ectopic pregnancy, • Family problems
removal of an ovarian cyst or adnexal mass, or dilata- • History of running away from home
tion and curettage for spontaneous abortion. In boys,
• School progress, likes and dislikes, grades,
repair of hypospadias, epispadias, cryptorchidism, vari- extracurricular activities
cocele, hydrocele, testicular torsion, and hernias are
• Feelings about self
some examples of genitourinary surgeries.
• Stressors
• Drug or alcohol use
BOX 20-2 • Sleep patterns
Family History • Insomnia
• Depression
Girls:
• Support system
• Maternal age at menarche
• Thoughts of self-harm or harm to others
• Family history of dysmenorrhea, dysfunctional uterine
• Relationship with parents
bleeding, or endometriosis
• Friends, relationships, peer group
• Hypo- or hyperthyroidism
• Dating history
• Wilms’ tumor
• Typical free-time activities
• Female reproductive tract cancers
• Amount of exercise each day
• Polycystic ovary syndrome
• Involvement in sports
Boys: • Employment
• Wilms’ tumor • Episodes of nocturnal enuresis
• Cryptorchidism • Age of toilet training
• Hypospadias • Ask preschool and school-aged child directly if
• Epispadias anyone has touched their genitalia and then told
• Testicular malignancy them not to tell
lists other components of the social history as it relates

BOX 20-5
to the genitourinary and reproductive systems.
The Adolescent Sexual History
Menstrual History • Current sexual activity
Starting at approximately age 8 or 9, girls should be • Age at first intercourse
sensitively questioned about whether or not they have • Number of sexual partners (current and lifetime)
begun menstruating. Adolescent girls often have irreg- • Frequency of sexual intercourse
ular cycles; a full menstrual history must be obtained. • Type of sexual activity (oral, anal, vaginal)
Questions that can be used to elicit a menstrual history • Encounters with same sex, opposite sex, or both
are listed in Box 20-4. • Characteristics of partners (e.g., monogamous,
intravenous drug user)
Sexual History • Alcohol and drug use
The adolescent sexual history must be obtained with • Exchange of sex for food, shelter, money, or drugs
the teen fully clothed in a comfortable, nonthreaten- • Method of contraception use
ing environment. The environs must be age appropri- • History of unprotected intercourse
ate and oriented toward the developmental level of the
• Use of condoms
adolescent. To ensure privacy and confidentiality, the
• History of sexually transmitted infection
interview should take place with the parent, friend,
• Use of douches, powders, or sprays in vaginal area
or significant other out of the room. A matter-of-fact,
nonjudgmental tone is maintained so that the ado- • History of pregnancy
lescent feels comfortable giving honest and accurate • History of miscarriage or abortion
answers. It may be helpful to begin with a statement • History of sexual abuse or rape
such as, “Often boys and girls your age experience. . .,”
to convey that what the adolescent is experiencing
is normal and expected. It is important to use open-
ended questions such as, “When did you. . .?” rather
all history of present illness assessments (HPIs), it is im-
than “Did you. . .?” This is less threatening because
portant to note the onset, duration, and severity of the
it implies that the topic is normal and expected. The
problem as well as aggravating and alleviating factors.
provider should convey that questions are welcome as
Any treatment of the problem, including both prescrip-
well. Examples include: “Many times adolescents have
tions and home remedies, must be documented. Ques-
questions about sexual activity. Do you have any ques-
tions relating to the HPI as it relates to the reproductive
tions about birth control, pregnancy, or STIs such as
system can be found in Tables 20-1 and 20-2.
herpes, gonorrhea, or Chlamydia?” Box 20-5 lists the
components of an adolescent sexual history.
History of Present Illness
Physical examination of the genital area in children
A detailed, focused history of a patient’s current problem and adolescents can cause stress and anxiety; this is
is a critical piece of the provider’s assessment. As with normal. Many children have been told that it is not ap-
propriate for strangers to touch their private parts, and
they may feel that the provider fits into this category.
They may also be afraid that the exam will cause pain.
BOX 20-4 Once children are preschool-aged and older, they are
The Menstrual History often embarrassed when their genital area is examined.
• Age of menarche
The health care provider must take care to be sensitive
to this, maintaining privacy and a matter-of-fact de-
• Last menstrual period
meanor. The examination should be explained to the
• Regularity of periods
child in a developmentally appropriate way. To build
• Duration of a normal period on already established rapport, it is best to examine
• Any skipped periods the genitalia and adolescent female breasts last.
• Irregularity, dysmenorrhea, metrorrhagia, or To enhance cooperation, young children can be ex-
amenorrhea longer than 3 months amined while lying supine on the parent’s lap. Young
• Presence of premenstrual syndrome children should be allowed to keep their underpants
• Presence of other symptoms with menses, such as on until the genital exam. Older girls are positioned
headaches, migraines, cramps, bloating, tender supine on the examination table; knees slightly bent,
breasts, or mood changes feet flat on the table, and legs slightly apart. The girl’s
legs should be covered with a sheet or drape.
TABLE 20-1
History of Present Illness: Abnormalities and Complaints Related to the
Reproductive System: Boys
Dysuria Is the urine cloudy, discolored, or Cystitis, urethritis, UTI, or STI
foul-smelling? Hematuria? Burning or
discomfort with urination? Does urine
stream look straight?
Deflected urinary stream Placement of urethral meatus? Is Hypospadias, epispadias, or ambiguous genitalia
urinary stream downward or to the
side? Chordee present?
Penile pain, lesions, or Past medical history? Type of lesions? Priapism (can occur during vaso-occlusive crisis
discharge Dysuria? Is child or adolescent in sickle cell disease), STI, balanitis, or nonspecific
circumcised? urethritis
Testicular swelling or mass Associated pain? Is mass mobile? A painless mobile mass suggests spermatocele;
painless firm nodule on testicle suggests testicular
malignancy.
Testicular pain Acute onset? Intensity of pain? Testis Acute onset of excruciating testicular pain suggests
enlarged or tender? Is child or teen testicular torsion, a surgical emergency. Scrotal
anxious? Is scrotum on involved side edema, warmth, and erythema are associated with
warm to touch, edematous, or tender? testicular torsion. Cremasteric reflex is absent with
Does moving testis increase pain? Is testicular torsion. Testicular trauma, orchitis, or
cremasteric reflex present? epididymitis also cause acute pain. Dull pain with a
sensation of pulling may be a varicocele.
Scrotal bulging or swelling Pain associated with scrotal swelling? Inguinal hernia, inguinal lymphadenopathy,
Does swelling increase as the day epididymitis, orchitis, hydrocele, spermatocele,
progresses? Is swelling symmetrical? varicocele, Henoch-Schönlein purpura, testicular
Does swelling transilluminate? Are tumor, or torsion. Painless swelling occurs with
both testis descended? hydrocele.
Scrotum feels empty On palpation, one or both testes Retractile testes, cryptorchidism, or anorchia
cannot be palpated.
STI, sexually transmitted infections; UTI, urinary tract infections.
Equipment for the genitourinary examination in adrenarche (Leung & Robson, 2008). Dark, coarse, and
the prepubertal child includes gloves, lubricant, and curly pubic hair on the labia major (and base of the
a penlight. To conduct the pelvic examination in ado- penis in boys) is the first observable sign. Girls with
lescent females, additional equipment is necessary (see premature adrenarche have a higher incidence of poly-
Pelvic Examination). cystic ovary syndrome and syndrome X (i.e., obesity,
hypertension, insulin resistance, type 2 diabetes, dys-
Inspection of the Female Genitalia lipidemia) (Leung & Robson, 2008). Any infestations
The external female genitalia are inspected for color, in the pubic hair should be noted; tiny white nits at-
swelling, symmetry, lesions, and discharge. Tanner staging tached to the pubic hair shaft indicate lice infestation.
is also evaluated. To begin, the mons pubis is inspected With pubic lice, the mons pubis area is also further
for skin discoloration or lesions. The area is also in- inspected for lesions secondary to bites and scratching,
spected for pubic hair, and the stage of sexual maturity which can become secondarily infected.
is evaluated (see Developmental Considerations). In The labia are then inspected. In the newborn, the
the adolescent, pubic hair appears as an inverted tri- labia are prominent. There may also be some mucoid
angle, extending along the labia majora, and onto the or bloody discharge. This is a transient condition and is
medial surface of the thighs in Tanner Stage V. The pu- considered a normal finding that results from maternal
bic hair is inspected for distribution and infestations. estrogen, which influences a female infant for the first
Irregular or sparse pubic hair suggests hormonal abnor- 8 weeks of life (Kass-Wolff & Wilson, 2004). In prepu-
malities. Precocious development of pubic hair is the bertal girls, the labia majora are pale pink and free of
presence of pubic hair before age 8; this is more com- hair or lesions, such as warts or ulcers, signs of STIs, and
mon in females (10:1) and is often caused by premature sexual abuse. The presence of condyloma acuminatum
TABLE 20-2
History of Present Illness: Abnormalities and Complaints Related to the
Reproductive System: Girls
Vulvar itching, pain, Frequency of perineal hygiene? Any Vulvovaginitis, chemical urethritis, pinworm
or rash discharge? Type of discharge? Vulvar infestation, foreign body, labial adhesions, lichen
edema or rash? Bleeding? Visible sclerosis, urethral prolapse (Lahoti, McNeese,
lesions? Girardet, & Greeley, 2008), or HPV
Vaginal discharge Type of discharge? Odor? Color? Cervix Physiologic leukorrhea, vulvovaginitis, urethral
friable? prolapse, bacterial vaginosis, STI, or vaginal foreign
body
Vaginal bleeding Type? Amount? Frequency? Clots? Vulvovaginitis, hemangioma, trauma, menorrhagia,
menometrorrhagia, pregnancy, or spontaneous
abortion
Pelvic pain Lower abdominal pain? Cervical Dysmenorrhea, PID, disseminated gonococcal
motion tenderness? Adnexal infection, or gastrointestinal causes (see Chapter 19)
tenderness? Right upper quadrant
tenderness? Fever? Vaginal discharge?
Menorrhagia?
Breast tenderness or When does it occur, and where is it? Cyclic pain or fibrocystic breast conditions
pain Is there any relation to the menstrual
cycle?
Dysuria Is the urine cloudy, discolored, or Cystitis or urethritis, UTI, vulvovaginitis, vaginal
foul-smelling? Hematuria? Burning or foreign body, urethral prolapse, injury, trauma, or STI
discomfort with urination?
Hematuria Is the urine cloudy, discolored, or UTI, urethral injury, trauma, or renal or
foul-smelling? History of renal or genitourinary condition
genitourinary conditions?
HPV, human papillomavirus; PID, pelvic inflammatory disease; STI, sexually transmitted infection; UTI, urinary tract infection.
in children may or may not be a result of sexual abuse, The clitoris is inspected for size and position. Because
depending on the child’s age and mode of transmission. of its sensitivity, it is not palpated. An enlarged clitoris
Vertical transmission can occur from mother to infant may indicate precocious puberty, congenital adrenal hy-
during delivery. Autoinoculation can occur in children perplasia, or the use of anabolic steroids. In a newborn,
younger than 2 after contact with HPV fomites. HPV
is also transmitted through sexual contact, which must
be considered when evaluating genital lesions (Horner,
2004). Edema, tenderness, or erythema of the labia
majora suggests vulvovaginitis, which is often seen
in young girls secondary to poor perineal hygiene. In
adolescent girls, the labia majora are pink and free of
lesions with an even hair distribution.
To visualize the labia minora, the provider must
gently separate the labia with gloved fingers. The
labia minora in prepubertal girls are normally thin;
moist; without discharge, redness or lesions; and pale
pink, becoming darker after puberty. Accumulation of
a sticky, white substance is smegma, indicating poor
hygiene. In prepubertal girls, the tissue between the
labia minora may be fused as a result of being in a
hypoestrogenized state, a condition known as labial
adhesions (Fig. 20-10). This tissue needs to be separated,
as it can lead to dysuria, rash, and vulvovaginitis. FIGURE 20-10. Labial adhesions.
an enlarged clitoris may be mistaken for a penis in a to touch. After puberty, the hymen becomes pinker,
child with ambiguous genitalia. A smaller than normal thicker, and more compliant, owing to the effects of
clitoris may be a sign of hypopituitarism. estrogen. In sexually active adolescents, the hymen
The urethral meatus is inspected next. There should is not visible. Visible lacerations, bruising, or healed
be no erythema, discharge, or swelling. Signs of inflam- hymenal tissue indicate penetrating vaginal trauma,
mation indicate irritation which may be caused by which must be differentiated from sexual abuse (see
soaps, laundry detergent, or pinworms. Vulvovaginitis Chapter 23).
or urethritis may occur secondary to poor hygiene or
STI. Marked urethral erythema may be caused by pro- Palpation of the Female Genitalia
lapsed urethral mucosa, especially with a history of With a gloved hand, the provider palpates the labia ma-
hematuria or dysuria. jora and minora for edema, tenderness, or lesions. The
The vaginal orifice is also inspected; it is normally labia are normally soft, nontender, and without edema
pink, moist, and free of discharge. Erythema or excori- or lesions. Palpable masses may indicate papilloma, con-
ation in the vulvar area can indicate pediculosis pubis, dyloma, or abscess. The Bartholin and Skene glands are
vulvovaginitis, STI, or enterobiasis (pinworm infesta- not normally palpable. In prepubertal girls, edema of the
tion), especially if these signs are found in the peri- labia occurs with an infection of these glands. Enlarged,
anal area as well. A small amount of whitish odorless, palpable glands may indicate gonorrhea or cysts.
mucoid discharge in the prepubertal girl is normal;
this is physiologic leukorrhea. Girls begin to men- Adolescent Pelvic Examination
struate approximately 2 years after the appearance of The first gynecologic exam for an adolescent girl can
breast buds; at that time, the amount and type of vagi- be an important factor in the development of a healthy
nal discharge varies, according to the menstrual cycle. sexual identity. The skill and sensitivity of the provider
A thick, white discharge in an adolescent girl taking can teach the adolescent that sexuality is a healthy,
oral contraceptives is likely vaginal candidiasis. Any normal aspect of human existence and can encour-
discharge that is green, yellow, or foul-smelling may age responsible sexual behavior. To help normalize the
be caused by a foreign body in the vagina or a STI. experience for the adolescent, the provider can inform
Vaginal discharge suggests an infection and warrants her that the gynecologic exam, the questions the pro-
a pelvic exam. While continuing to separate the labia vider will ask, and the procedures that will be performed
with a gloved hand, the provider visualizes the hymen. are those that are important for all women.
The hymen is just inside the vaginal orifice. There For cervical cancer screening purposes, the American
are several variations of the hymenal configuration; Cancer Society recommends that the first Papanicolaou
these variations are listed in Box 20-6. In prepubertal (Pap) test be done within 3 years of the first vaginal
girls, the intact hymen is thin, reddish, and sensitive intercourse but no later than age 21 (ACS, 2008). The
American College of Obstetricians and Gynecologists
(ACOG) recommends that the first gynecologic visit
take place between the ages of 13 and 15 to establish
BOX 20-6 a provider–patient relationship, to answer questions,
Types of Hymenal to assess sexual development, to take menstrual and
Configurations sexual histories, and to determine the need for contra-
ception or testing for STIs (ACOG, 2006).
Type Description
Annular Round, circumferential hymenal tissue; Preparation for the Exam. The provider must have
most common at birth a thorough knowledge of the anatomy and physiology
Crescentic Hymenal tissue that forms a crescent of the female reproductive system and of appropriate
shape; this is common in girls over 3 teaching techniques for adolescents. If the adolescent
Fimbriated Hymenal tissue that has an irregular girl is more comfortable with a female provider, every
edge effort should be made to schedule one for the exam.
Redundant Hymenal tissue that protrudes and folds Ideally, the provider already has an established rela-
in on itself tionship with the adolescent as a result of taking care
Cribriform Hymenal tissue that has numerous small of her other health care needs.
openings Staff who schedule appointments for gynecologic
Septate A hymen that has a band of tissue exams should be sure to explain to patients that the
running vertically, creating two openings pelvic exam should not be scheduled during men-
to the vaginal orifice struation and that the patient should refrain from
Imperforate The hymen is not open; minor surgery is intercourse, douching, and the application of any
necessary to allow menstrual blood to flow intravaginal medications for at least 24, and preferably
48, hours before the appointment. If at all possible,
extra time should be scheduled for a first pelvic exam. warm water for lubricating the speculum. Only water
At the beginning of the visit, objectives for the visit is used as a lubricant during the speculum exam. In ad-
should be verbalized by the provider. If the adolescent dition, water-soluble lubricant (single-use packets are
girl is accompanied by her mother, she should be asked preferable to multi-use tubes to maintain asepsis); two
privately if she wants her mother to be present during pairs of clean gloves (one pair to put on before starting
the exam; her wishes should be honored. the exam, and an extra pair in case of contamination),
Preparation of the adolescent, particularly for the and pH paper are also necessary. It is also important to
first pelvic exam, is essential to the success of the exam. have a good light source, a gown and sheet for the pa-
Using charts and models, the provider must first review tient, lab requisitions as necessary, and a wastebasket
the relevant pelvic anatomy, showing the patient the for contaminated materials.
speculum and reassuring her that only the blades are
inserted into the vagina. If a Pap test is appropriate, Pelvic Exam Procedure. There are certain principles
the patient should be shown the spatula and cyto- that should be observed when doing a pelvic exami-
brush that will be used and where the specimen will nation, such as using an aseptic technique, doing the
be obtained. If a mirror and flashlight are available, the exam as efficiently and quickly as possible while still
patient can be encouraged to look at the external geni- obtaining the necessary specimens and information,
talia during the provider’s inspection and at the cervix explaining to the patient at every step what is happen-
during the speculum exam. Even if this is not the first ing, and minimizing the patient’s discomfort. At the
pelvic exam, the provider must not assume that the pa- beginning of the exam, the provider should elevate the
tient has all the information she needs about the exam. head of the exam table 45 degrees and cover the client
Previous experiences may not have been informative. from the waist down with the drape. The patient may
Relaxation techniques, such as abdominal breathing need the provider’s help to position herself on the table
(breathe in through the nose and out through the with her feet in stirrups and her buttocks just off the
mouth, with both hands on the diaphragm, focusing bottom edge. The patient should be told to feel along
on making the hands go up and down), can be useful the sides of the table until she reaches the bottom and
during the exam; the provider should explain that the move herself into position while covered by the drape.
more relaxed the patient is, the more comfortable the When the patient is in position, the drape should be
exam is. The provider should also inform the patient moved slightly between the legs so that the provider
at every step of the exam about what is happening. All can see the patient’s face during the exam.
of the interactions with the patient up to this point When the exam begins, the provider can review the
should be done with her fully clothed, making sure the relaxation techniques and remind the patient that the
bladder is empty and securing any urine specimens that exam will proceed slowly and that an explanation will
are warranted by the history. Blood should be drawn be given for each step. The light should be positioned
for serologic testing for syphilis as necessary. before beginning, and then the provider should put
Preparation of the environment includes putting a gloves on both hands. (Some providers will glove only
paper barrier on a stand or table placed on the non- their dominant hand, which means that they can only
dominant side of the examiner. On this stand, the use that hand when palpating the external genitalia.)
provider should place any equipment needed for the Lubricant is not used for the first part of the exam.
Pap test, such as one or two slides labeled in pencil, The external genitalia are examined using inspec-
fixative, wooden or plastic Ayre’s spatula, cytobrush for tion and palpation. The inguinal lymph nodes are pal-
conventional Pap, tube with solution, and cytobrush pated first, using one or both hands. (Some beginning
for liquid-based Pap; equipment needed for STI testing examiners find it easier to use just one hand palpating
(e.g., for such diseases as gonorrhea, Chlamydia) and each side separately, so they can better focus on what
herpes cultures or PCR testing; and equipment needed they are feeling.) The provider should touch the inside
for a wet mount, such as dropper bottles of normal of the patient’s thigh with the back of the dominant
saline and 10% potassium hydroxide (KOH), slides, hand before touching the pubic area. First touching
cover slips, and cotton swabs. the patient in a less sensitive area prepares her for hav-
It is important to choose the appropriate size specu- ing her genitalia touched. The provider first inspects
lum based on the patient’s history (e.g., parity); two the pubic hair, looking for hair distribution, lice, nits,
different sizes can be put on the tray so that the most and lesions, using both hands to separate hair and pal-
appropriate size can be chosen after an initial assess- pate the area. Some lesions (e.g., suspected herpes) may
ment of the vagina (see below). All plastic specula require a culture. Having a magnifying glass may be
must be inspected for cracks or rough edges, and metal useful during this exam. The Tanner stage of pubertal
specula must be inspected to be sure they are working development, according to pubic hair type, amount,
properly. and distribution, is noted.
Large swabs for clearing any excessive discharge from The examination moves posteriorly beginning with
the cervix should be available, as well as a container of inspection and palpation of the labia majora. The labia
are separated and the provider retracts the hood of the

clitoris; inspects the clitoris, urethral meatus, introitus,
and perineum; and looks for lesions, discharge, edema,
erythema, or tenderness. Using the back of the hands,
the provider separates the buttocks for inspection of
the anal region for lesions or hemorrhoids. The pro-
vider can offer the patient a mirror at this point of
the examination so that she can visualize the external
anatomy. The provider may want to say, “Everything
looks healthy on the outside,” or relate specific find-
ings if that is not the case. The provider’s index finger
is then inserted about 2 cm into the vagina and pressed
down on the perineal muscles. The provider can then
explain that these are strong muscles that the patient
needs to keep relaxed to make the exam as comfortable
as possible; however, pressing firmly with downward
pressure on the perineum should not be painful. The FIGURE 20-11. Insertion of speculum into vagina.
provider then advances the index finger further into
the vagina to locate the cervix, noting whether it is fingers of the gloved hand that are in the vagina; they
anterior, posterior, or deviated to one side; and noting are then spread apart slightly to create a small space
the length of the vagina to determine how to aim the into which the speculum is inserted at a slight angle;
speculum when it is inserted. The muscle tone of the the fingers are withdrawn slowly as the speculum is in-
vagina is evaluated to estimate the appropriate specu- serted (Fig. 20-11). At this point, the provider should
lum size to use. Experienced providers may skip this check to be sure the labia or pubic hairs are not caught
step of locating the cervix prior to speculum insertion, in the speculum. The handle of the speculum is then
but beginners may find it very helpful. transferred to the dominant hand and inserted the rest
When the index finger is withdrawn, it should be of the way, while the provider rotates it to a horizontal
pressing on the anterior vaginal wall to “milk” the position, pointing slightly downward (Fig. 20-12).
Skene’s glands; the provider should look for a discharge Next, the provider inserts the closed blades of the
from the urethra, which should be cultured if present. speculum into the posterior fornix, withdrawing slight-
The index finger can also be left just inside the vagina ly and then opening the blades (Fig. 20-13). The specu-
with the thumb on the outside to be used to palpate lum is not locked at this point, but the cervix should
the posterior labia majora on both sides, evaluating be visible. If not, the blades are closed, partially with-
for swelling or tenderness in the Bartholin’s glands. At drawn, and then re-inserted at a different angle, before
this time, the glove from the nondominant hand is re- they are opened again (Fig. 20-14). Before locking the
moved and thrown away. From now on, the ungloved blades of a plastic speculum, the provider should warn
hand is used only to manipulate equipment and not to
touch the patient.
Speculum Exam. To begin the speculum examination,

the provider should touch the inside of the thigh with
the back of the gloved dominant hand and place the
index finger into the vagina about 2 cm, pressing down
and reminding the patient to keep her muscles relaxed.
The provider then inserts his or her middle finger while
asking the patient to squeeze the examiner’s fingers
with the perineal muscles. To assess muscle tone, the
provider spreads his or her fingers apart and asks the pa-
tient to bear down. The provider looks anteriorly for a
bulge, which could indicate cystocele, and looks poste-
riorly for a bulge, which could indicate rectocele. (These
findings are not likely in an adolescent, but might be
found in a parous teenager.)
The provider should then pick up the speculum with
the nondominant, clean hand, dip it in warm water,
and hold the blades together between the index and FIGURE 20-12. Insert vaginal speculum by pointing blades
middle fingers. The provider presses down with the two downward.
FIGURE 20-13. Slowly open speculum blades.
the patient about the loud click that will be heard. The
blades are then locked into position, and the light is B
adjusted to allow good visualization of the cervix. FIGURE 20-15. Shapes of the cervical os. A. Nulliparous
When inspecting the cervix, the provider assesses cervical os. B. Parous cervical os.
for color, lesions, ectropion, discharge, scars, nodules,
bleeding, and the shape of the os (Fig. 20-15). Speci-
mens are obtained for lab tests as needed. If doing both
tions is tested to make sure it is a vaginal secretion and
gonorrhea and Chlamydia testing and a Pap test, the
not a cervical discharge.
provider performs the Pap test first so that potentially
Before unlocking the speculum, the provider should
malignant cells are not removed during other tests.
warn the patient about the click that will be heard.
Excessive discharge that obscures the cervix may need
Keeping a downward pressure, the provider rotates the
to be removed gently with large cotton swabs prior to
speculum when it is withdrawn; the provider then in-
obtaining specimens. Any purulent discharge from
spects the vaginal walls, gradually closing the blades so
the cervix should be cultured. If the history or find-
that they are completely closed by the time the end of
ings during the exam are suspicious for vaginitis, a wet
the blades reach the introitus.
mount is obtained, and the pH of the vaginal secre-
The discharge on the lower blades of the speculum
are noted for unusual odors, particularly fishy odors,
which result from amines released by bacteria that
cause bacterial vaginosis; if present, this would be con-
sidered a positive “whiff” test. Then two to three drops
of 10% KOH are inserted into the discharge (Note: only
the provider’s clean hand is used to touch the dropper
bottle). The patient should then be informed about
what was found.
Bimanual Exam. For the bimanual exam, the provider

should turn off the light and move it out of the way.
Gloves are changed as necessary, for example, if KOH
contaminated a glove. The provider should explain to
the patient what will be done in the bimanual exam.
First, the provider lubricates the index and middle fin-
gers of the gloved hand. Next, the provider touches
the inside of the thigh with the back of the hand and
FIGURE 20-14. Once the uterine cervix is visible, the specu- inserts the index finger and then the middle finger into
lum blades should be locked into place. the vagina, keeping the pressure downward to avoid
the anterior periurethral structures. The vaginal walls

are felt for nodularity or tenderness. The provider then
locates the cervix and feels for lesions, keeping in mind
what was seen during the speculum exam. The length,
position, and patency of the os are noted. The provider
then puts a finger on each side of the cervix and moves
it from side to side, while asking the patient if this
movement is painful. (“I am moving your cervix; this
may be a little uncomfortable, but is it really painful?”)
Severe pain is a sign of pelvic inflammatory disease.
The examiner leaves the fingers in place on the cer-
vix and places the other hand on the lower abdomen
to palpate for the location of the body of the uterus,
trapping the uterus between the inside and outside FIGURE 20-16. The bimanual examination.
hands. Starting about halfway between the symphysis
and the umbilicus, the provider palpates the uterine
outline, noting the shape, consistency, and any irregu-
larity and estimates the width and length. Then the in Figure 20-16. The provider should inform the pa-
provider moves the inside fingers into the anterior for- tient of any findings.
nix, using the inside hand to palpate as much of the
anterior surface as possible and using the abdominal Rectovaginal Exam. It is usually not necessary to
hand to palpate as much of the posterior surface as perform a rectovaginal exam on an adolescent girl.
possible. If the provider does not feel the uterus ante- When the exam is completed, the provider can help
riorly, the inside fingers are moved up the cervix, fol- the patient to sit up and step down from the exam
lowing the cervical outline as it merges into the body table. The patient should be given tissues with which
of the uterus. The provider’s fingers will likely end up to remove any lubricant from the perineum. If a Pap
in the posterior fornix; the provider should push up to test has been done, the provider should explain that
determine if there is a firm bulge there, which would spotting may occur after the exam. If the cervix was
indicate a retroverted uterus. This can be confirmed friable, there may be enough bleeding to warrant giv-
later on a rectovaginal exam, if indicated. ing the patient a sanitary pad. The patient should be
If the provider has trouble reaching as far as the pos- given privacy to get dressed and afterward should sit
terior fornix, he or she can rest an elbow on the pa- down with the provider to answer any questions she
tient’s knee for leverage to push harder while keeping may have.
the pressure downward as much as possible to avoid A skilled and sensitive provider, with enough time
the sensitive periurethral areas. The abdominal hand and teaching, usually will be able to perform a satis-
can also be used to push the uterus down toward the factory pelvic exam, even on a reluctant and nervous
inside fingers. adolescent. Occasionally, an adolescent, despite a pro-
The provider next examines the adnexa by placing vider’s best efforts, will not allow the examination. In
the fingers in the right lateral fornix with the palmar such cases, sexual abuse should be suspected, which will
surface of the fingers facing anterolaterally and point- require further assessment by a provider who specializes
ing almost straight up. The back of the fingers should in these examinations (see Chapter 23).
be against the cervix. The outside hand is placed just
above the inguinal area and swept down toward the Inspection of the Male Genitalia
inside hand. If nothing is felt, the fingers of both Both the penis and scrotum are inspected. Tanner staging
hands are moved medially and then another sweep is is also evaluated. The penis is inspected for size, position
attempted to bring the structures in the adnexa (fallo- of the urethral meatus, foreskin, hygiene, and lesions. The
pian tube, ovary, and any masses in the area) between glans and shaft are also examined. The newborn infant’s
the provider’s two hands. The fallopian tubes will not penis normally measures approximately 2–3 cm (1 in)
be palpable unless there is a mass there. The ovary may in length. The penis grows in length and width during
be felt as a firm, oval, 2 ⫻ 3 cm mass. If the ovary is pal- puberty. An enlarged penis in the prepubertal child can
pated, the size and contour are noted. Any tenderness indicate precocious puberty or anabolic steroid use. An
or pain on palpation of the adnexa is noted. abnormally small penis in the infant may in fact be a
The provider then moves the fingers to the left lat- clitoris in a genetically female infant. In obese boys, the
eral fornix, with the palmar surface facing anterolat- penis appears to be smaller due to the large amount of
erally. This is awkward to do if the right hand is the adipose tissue obscuring the base of the penis. An abnor-
examining hand. Repeat the maneuvers to palpate the mally small penis also occurs in boys with Prader-Willi
left adnexa. The bimanual examination is illustrated syndrome, Klinefelter syndrome, and hypopituitarism.
The penis is normally straight. Ventral curvature

may be caused by a chordee, a band of connective tis-
sue between the urethral meatus and the glans that
causes the penis to curve. This condition is associated
with hypospadias.
The glans is then inspected; it is normally pink,
smooth, and cone-shaped. Any lesions, swelling, dis-
charge, or inflammation are noted. In the circumcised
child, the glans should be smooth, pink, and free of
edema. The child in diapers may have an irritated
meatus owing to ammonia irritation. This is more com-
mon in circumcised infants. In the uncircumcised new-
born, the foreskin is usually not retracted to examine
the glans (see Chapter 11). Erythema and edema of the
glans indicate balanitis, which is often caused by poor FIGURE 20-18. Paraphimosis.
hygiene. Urethral discharge, redness, lesions, or edema
suggest urethritis. In the prepubertal child, sexual abuse
must be considered with these findings. The glans is foreskin cannot be retracted, the child has phimosis.
then inspected for placement of the urethral meatus, If the foreskin remains constricted and cannot be re-
a slit-like opening normally in the center of the glans. turned to the original position, the child has paraphi-
In hypospadias, the urethral meatus is located on the mosis. Paraphimosis is considered a urologic emergen-
ventral surface of the penis; in epispadias, the urethral cy to avoid ischemia or infarction of the glans (Ghory
meatus is located on the dorsal surface of the penis & Sharma, 2009) (Fig. 20-18). Some smegma under the
(Fig. 20-17). In both instances, it is important to note foreskin is a normal finding.
this; the infant should not be circumcised, because the Pubic hair development should be consistent with
foreskin tissue may be used for the surgical repair. If age, and Tanner staging is evaluated (see Fig. 20-9).
possible, the examiner should observe the urine stream Pubic hair should be in a diamond-shaped pattern
of the infant boy. The urine stream should be straight, at puberty, coarse, and without infestations, such as
strong, and form a slight arc. A weak urinary stream lice. Premature pubarche (the presence of pubic hair in
can indicate a neurogenic bladder. boys younger than 9) may be a sign of premature ad-
Next, the shaft of the penis is inspected in the cir- renarche, which includes other signs of early puberty,
cumcised child or adolescent. The skin covering the such as axillary hair, increased body odor, oily skin,
penis is normally smooth and pink, and the dorsal and acne (Leung & Robson, 2008).
vein may be visible. There should be no swelling, The scrotum is inspected for color, size, symmetry, lesions,
inflammation, discoloration, lesions, vesicles, ulcers, inflammation, and the presence of the testicles. In Cauca-
or papules. In the uncircumcised male, the foreskin of sian infants, the scrotum appears pink. In dark-skinned
the child older than 3 years should be gently retract- infants, the scrotum appears dark brown. After puberty,
ed; it should retract easily. Some foreskin adhesions the scrotal skin is a deeper color than surrounding skin.
are normal until approximately 4 years of age in most The scrotum should hang loosely from the perineum
boys. The foreskin must not be forcibly retracted. If the behind the penis. The left side of the scrotum normally
hangs lower than the right side. Scrotal rugae should be
prominent on inspection; well-developed scrotal rugae
indicate that the testicles have descended even if they
cannot currently be palpated in the scrotum. Although
scrotal size varies with ambient temperature, bulges or
masses are abnormal findings. Lesions on the scrotum
may be sebaceous cysts or caused by folliculitis in ado-
lescent males. Scrotal skin that is red and shiny suggests
orchitis (mumps). Scrotal bulges or masses in children
and adolescents may be caused by an inguinal hernia,
epididymitis, orchitis, spermatocele, hydrocele, varico-
cele, Henoch-Schönlein purpura, testicular tumor, or
testicular torsion. One inspection technique to help dif-
ferentiate hydrocele from incarcerated inguinal hernia is
to transilluminate the scrotum with a transilluminator
FIGURE 20-17. A. Hypospadias in which the urethral meatus
is located on the ventral surface of the penis. B. Epispadias in or bright penlight. The fluid in the hydrocele will cause
which the urethral meatus is on the dorsal surface of the penis. the scrotum to transilluminate; a hernia will not.
Palpation of the Male Genitalia

Palpation of the male genitalia includes palpating the
penis, scrotum, testes, and spermatic cord. When palpat-
ing the male genitalia, the examiner must remember to
warm his or her hands and make the child or adolescent
as comfortable as possible; this is done to minimize the
Normal
possibility of eliciting the cremasteric reflex. This nor-
mal reflex is evident when the cremaster muscle draws
descended testicles back into the abdomen; anxiety or
the touch of cold hands can elicit this reflex when the
inner thigh is stroked. If the child has an erection at
any time, the provider should react matter-of-factly, re-
assuring him that this is a normal reaction to touch.
Descent
The shaft of the penis is palpated for masses or nod- interrupted
beyond Partially
ules; they are normally absent. Next, the glans is gently external descended
inguinal ring
compressed between the examiner’s thumb and fore-
finger. There should be no discharge; a discharge sug-
gests a STI. The scrotum is palpated for the presence of
the testicles. The testicles are palpated for size, shape,
symmetry, and consistency. Helpful maneuvers may be
necessary to facilitate the stretching of the cremaster
muscle to prevent it from contracting. Positioning the
Testis
child in a squatting position, asking him to sit with his retained in
abdomen
legs crossed in front of him, or placing the infant su- Descended
but not to
pine with his legs raised and spread are maneuvers that bottom of
scrotum
help to move the testicles into the scrotum. Blocking
the inguinal canals by gently pressing upward from be-
hind the scrotum with the thumb and forefinger of the FIGURE 20-20. Types of cryptorchidism.
opposite hand also help to minimize the cremasteric
reflex (Fig. 20-19).
Normally, the testicles are palpated. They should feel
testicles (cryptorchidism) are associated with steril-
smooth, firm, almond-shaped, and of equal size bilater-
ity and testicular cancer. Therefore, documentation
ally (approximately 1.5 to 2 cm until puberty) without
of palpated testes is very important because once pal-
palpable masses. Each epididymis should be soft and
pated, they are considered descended, even if they are
nontender. The testicles are also easily moveable. The
retracted at the next visit. If the scrotal sac feels empty,
testicles should be fully within the scrotum. Retractile
the provider should search for the testicles along the
testicles are those that move between the scrotum and
inguinal canal and try to milk them down. If the scrotal
external ring; this can occur up to age 7. Undescended
sac remains empty beyond 6–12 months, a referral to
a urologist should be made since almost all boys who
experience spontaneous descent do so by 6 months
(Kelsberg, Bishop, & Morton, 2006). Figure 20-20 illus-
trates the types of cryptorchidism.
If the provider has difficulty palpating the testi-
cles, the toddler or child can be asked to squat in the
“catcher’s” position, which may force the testes down.
Alternatively, the child can be asked to sit cross-legged
to relax the cremasteric reflex. Beginning at age 15, the
health care provider should teach the adolescent male
how to perform the testicular self-examination. Masses
in the scrotum are abnormal and require investigation.
Inspection and Palpation of the

Inguinal Area
The inguinal area is inspected and palpated for masses,
lymphadenopathy, and hernias. The inguinal area is
FIGURE 20-19. Technique to minimize cremasteric reflex. normally free of visible bulges, which may indicate
may be palpated. Enlarged, tender, hard, or fixed lymph

nodes are abnormal findings and may indicate infec-
tion or malignancy.
Examination of the Anus

The anus and rectum are not routinely examined in
children and adolescents. Children who present with a
history of constipation or anal itching may have an anal
fissure, pinworms, or dermatitis caused by detergents
or poor toilet hygiene. In these instances, inspection
of the anus is necessary to make an accurate diagnosis.
Anal discharge or proctitis can also occur with Chla-
mydia trachomatis, Neisseria gonorrheae, Treponema pal-
lidum, and herpes simplex viruses (Fortenberry, 2005).
If any visible lesions suggest child abuse or STIs, a de-
tailed history is essential, accompanied by a thorough
inspection of the anal region.
Ileum Examination of the anus is best performed in the
left lateral position for older children and adolescents
Inguinal or on the hands and knees with the young child. The
canal
anus should appear moist with dark, folded skin. The
Hernia opening should be tightly closed, and there should
be no lesions. Scratch marks around the anus may
indicate pinworms. Any fresh or healed injuries are
noted, including secretions, bruising, tears, lacera-
FIGURE 20-21. Inguinal hernia.
tions, rashes, or STI lesions. Papular anal lesions may
be caused by HPV (Horner, 2004). Poor anal sphincter
tone or anal laxity may be caused by the passage of
inguinal lymphadenopathy or hernia (Fig. 20-21). In large, hard bowel movements, unintentional injury to
the adolescent, the provider should also palpate the in- the anus after impalement, or sexual abuse (Giardino
guinal canal bilaterally. For the right side, the provider & Finkel, 2005). See Chapter 23 for a complete discus-
places his or her index finger on the lower portion of sion of the assessment of child abuse.
the right scrotal half and palpates up to the external
inguinal ring, invaginating the scrotum (Fig. 20-22). Examination of the Breasts
Providers may or may not be able to insert their finger. In the young adolescent girl, the provider can assess pu-
If the provider’s finger easily inserts, the finger is gen- bertal development by inspection of the breasts, using the
tly advanced, and the patient is asked to bear down. Tanner stages of development (see Fig. 20-8). For the teen
If there is a hernia, a mass will be felt either at the tip with mature breast development and no reports of chang-
of the finger or against the side of the finger medially es or symptoms involving the breasts, there is no good
as the patient bears down. In the absence of a hernia, evidence to support performing a routine clinical breast
nothing should be felt as the patient bears down. Her- examination or for teaching breast self-examination
nias in children always require surgical correction. (BSE). In a review of the existing research, The Cochrane
The horizontal chain of inguinal lymph nodes is Collaboration concluded that there was no difference in
palpated next. Occasionally, a soft, small (⬍1 cm) node breast cancer mortality between women who performed
BSE and those who did not (n ⫽ 388,535), but that there
were almost twice as many biopsies for benign lesions
in the self-exam group. A large trial that included clini-
cal breast examinations as well as self-examination was
discontinued, so no conclusions could be drawn about
the benefits of clinical breast exams done by a trained
provider (Kosters & Gotzsche, 2007). The American Can-
cer Society (ACS) recommends that beginning in their
twenties, women should be informed of the benefits and
limitations of BSE and be taught the procedure if desired
(ACS, 2009).
In spite of the evidence that, for populations as a
whole, clinical breast exams and BSE are not effec-
FIGURE 20-22. Palpating for an inguinal hernia. tive in reducing breast cancer mortality, many breast
changes that prove to be malignant are discovered

by BSE. Therefore, it may be beneficial for the older
teen to receive a clinical breast exam and be taught
BSE. All females should become familiar with the
normal state of their breasts and changes that may
occur with the menstrual cycle. One way to accom-
plish this is by teaching BSE during the course of a
physical examination.
History Related to the Breasts. As part of a com-

plete health history, obtaining data about the breasts is
appropriate by using the following questions:
FIGURE 20-23. Palpation of the breast in circular motion.
• When did breast development begin?
• How do you feel about your developing breasts?
• What do you know about breast anatomy and
physiology? At each location where the pads of the fingers are
• Have you had any pain or swelling of the breasts; if placed, three quarter-size circles are made, the first
so, what is the relationship to the menstrual cycle? with light pressure, the second with medium pressure,
• Have you had any nipple discharge? and the third with firm pressure, thus enabling the
• Have you noticed any lumps or bumps? examination of the various levels of breast tissue. If any
• What is the breastfeeding history (for parous teens)? masses are palpated, the size, shape, location, consis-
• Have you had breast augmentation surgery (not un- tency, mobility, and tenderness are noted. The patient
known in teens)? can be asked to feel a particular area and whether she
• What was the date of the last menstrual period? has noticed this lump before. If there is any ques-
tion about whether this is normal breast tissue, the
Clinical Breast Examination. The provider should same area on the other breast should be palpated. It
first explain the purpose of the clinical breast exami- is unlikely that an abnormal lesion would occur at the
nation. If the patient wants to do a self-examination same location in both breasts. It is normal to find a
at home, the provider should explain that it should firm ridge of tissue at the lower edge of each breast
be done each month about a week after menstruation (inframammary ridge).
begins, as any premenstrual swelling or tenderness Expression of the nipples is optional. If this is done,
should have resolved by then. two fingers are placed on either side of the areola,
To begin the exam, the provider should position the exerting first downward, then inward pressure to bring
patient on the end of the exam table and then ask the the fingers together, and looking for any nipple dis-
patient to drop her gown to her waist. The provider charge. If found, the amount and characteristics (e.g.,
then inspects the breasts, observing shape, contour, bloody, serous, purulent) are noted. The fingers are
and size, looking for dimpling, redness, scaliness, areas then moved to the top and bottom of the areola, and
of skin that resemble an orange peel (a sign of underly- the maneuver is repeated.
ing edema), or anything that looks different from one To examine the axilla, the patient’s arm is supported
breast to the other. This inspection is repeated with with the nonexamining hand of the provider and angled
the patient’s arms raised over her head and again with slightly away from her side. The axilla should be viewed
her hands pushing in on her hips. Any areas of retrac- as an upside-down cup, and the entire inside of the cup is
tion or deviation of the nipple during these maneuvers palpated, pressing against the humerus laterally and the
should be noted. While performing the inspection, the ribs medially. Any palpable lymph nodes in the axilla are
provider should explain to the patient what findings noted. If this breast exam is not part of a general physical
are expected. The provider should also explain that the exam, it may be appropriate to palpate the supra- and
patient can do the same kind of inspection by standing subclavicular lymph nodes as part of the breast exam.
in front of a mirror at home. The procedure is then repeated on the other side.
The patient is then instructed to lie down and put As each part of the exam is performed, the provider
one arm behind her head, keeping the breast that is explains how this can be done at home during a BSE.
not being palpated covered. The provider then uses Some providers also advise that the breasts can be
the pads of the fingers, not the fingertips, and begins examined during a shower, where the soap and water
palpating in little circles about the size of a quarter, may increase the sensitivity of the palpating hand.
starting in a line even with the middle of the axilla Patients should be reassured that most breast masses
and moving in an up and down pattern as far up as the are not cancer but that any changes should be reported
clavicle and down to the ribs (Fig. 20-23). This pattern promptly to the health care provider.
is continued over the entire breast, including the nip- Although this explanation of the breast exam is fo-
ple, until the middle of the sternum is reached. cused on females, any complaints about the breasts by
adolescent boys should also be assessed. Gynecomastia occurs every month and lasts for 8 days. Flow is heavy
is common even in nonobese pubertal boys but usually for first 2 days and then moderate to light for the rest
resolves on its own as the sex hormones achieve a tes- of the menses. She has dysmenorrhea that is relieved
tosterone-dominant state. Breast development is usu- by over-the-counter nonsteroidal anti-inflammatory
ally distressing for a boy, and he and his parents may drugs. Last menstrual period (LMP) February 22. Sexu-
require reassurance that this is usually normal and will ally active; reports oral and vaginal intercourse. Last
likely resolve spontaneously. vaginal intercourse 2 days ago. Does not use any barri-
er method of contraception. Denies abnormal vaginal
discharge or urinary symptoms. No sores or lesions in
COMMON DIAGNOSTIC STUDIES vaginal area.
Various diagnostic tests may be necessary to clarify dif- Objective Data

ferential diagnoses and abnormal conditions involv-
External genitalia: No swelling, lesions, or discharge.
ing the genitourinary and reproductive tract. Some
Tanner Stage 5 breast development.
examples of these diagnostic studies and their indica-
Internal genitalia: Vaginal walls without lesions.
tions are summarized in Box 20-7.
Cervix pink and without lesions. Scant, clear mu-
coid discharge present.
Bimanual exam: No cervical motion tenderness,
DOCUMENTED FINDINGS and no enlargement of uterus. Adnexae nontender,
and ovaries not enlarged.
SAMPLE WRITE-UP: HEALTHY Assessment: Normal pelvic examination
ADOLESCENT
Subjective Data
History: A 16-year-old girl presents for her first pel- SAMPLE WRITE-UP: SYMPTOMATIC
vic exam. Menarche began at age 13. Menstrual cycle CHILD
Subjective Data
History: A 4-year-old Caucasian girl comes to the clin-
BOX 20-7 ic complaining of burning with urination. She has a
Common Diagnostic Tests 3-day history of burning with urination and itching in
Used in Genitourinary vaginal area. Today, the patient has been crying with
Assessment urination. Babysitter gave patient a bubble bath this
weekend.
Urine dip: A urine dip usually includes specific gravity,
pH, glucose, ketones, protein, red blood cells, and
leukocyte esterase. This is often the preliminary test Objective Data
performed in the office to assess for urinary tract Temp: 98.9° F (37.2° C); BP: 102/68.
infection (UTI).
Abdominal exam: Bowel sounds noted in all four
Urinalysis: The urinalysis is same as the urine dip test, quadrants; soft, nondistended, no suprapubic ten-
but this test is sent to the laboratory.
derness; no masses or organomegaly.
Urine culture: Urine culture is the gold standard for External genitalia: Marked erythema of labia. No
diagnosing a UTI. Positive results delineate the infectious
vaginal discharge noted. Urine dip: - protein, - nitrites,
organism.
- leukocytes.
Ultrasonography: Used to evaluate testicular and
Assessment: Vulvovaginitis
scrotal masses and edema
CT scan: Used to evaluate metastasis with testicular cancer
Gonorrhea/Chlamydia swab: A specimen is obtained,
using a laboratory-provided swab. Secretions are SAMPLE WRITE-UP: SYMPTOMATIC
sampled from endocervical swabs on girls and urethral
ADOLESCENT
swabs on boys to check for the presence of Neisseria
gonorrhoeae and Chlamydia trachomatis. Subjective Data
Pap smear: This test evaluates endocervical cells to A 16-year-old boy presents to emergency room (ER)
screen for cervical cancer. It is normally performed with 2-hour history of severe unilateral scrotal and
annually on girls and women, beginning 3 years after flank pain. Began vomiting in the car on the way
intercourse or at the age of 21 years, whichever comes to the ER. Denies fever, chills, or blood in urine.
first (ACOG, 2004). No sick contacts. Had appendix removed at age
12 years.
Objective Data to Arab American and American Muslim patients. American

Journal of Obstetrics and Gynecology, 193(4), 1307–1311.
Oral temperature: 98.4° F (37.8° C) Giardino, A. P., & Finkel, M. A. (2005). Evaluating child sexual
Genitorurinary exam (male): Scrotum edematous, abuse. Pediatric Annals, 34(5), 382–394.
Giger, J. N., & Davidhizar, R. (2008). Social organization. In
erythematous. Unable to palpate testicles. Cremas- Giger, J. N., & Davidhizar, R. Transcultural nursing: Assess-
teric reflex absent. Pain increases with elevation of ment & intervention. (5th ed.). (pp. 68–105). St. Louis: Mosby-
scrotum. Transillumination of the scrotum reveals Elsevier.
Ghory, H. Z., & Sharma, R, (2006). Phimosis and paraphimo-
solid mass. sis. Retrieved November 20, 2009, from http://emedicine.
Assessment: Testicular torsion medscape.com/article/777539-overview.
Horner, G (2004). Ano-genital warts in children: Sexual abuse or
not? Journal of Pediatric Health Care, 18(4), 165–170.
Kass-Wolff, J., & Wilson, E. (2004). Pediatric gynecology: Assess-
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Hammoud, M. M., White, C. B., & Fetters, M. D. (2005). Open- Retrieved February 7, 2009, from http://www.who.int/
ing cultural doors: Providing culturally sensitive healthcare mediacentre/factsheets/fs241/en/index.html.
CHAPTER
Assessment of the
21 Musculoskeletal
System ELLEN M. CHIOCCA
A healthy musculoskeletal system is essential for long bones (e.g., the humerus, femur); short bones (e.g.,
normal growth and development of the child. Linear the carpals); flat bones (e.g., the skull, sternum, scapu-
growth and body movement require healthy bones lae); irregular bones (e.g., the vertebrae), and sesamoid
and muscles. Assessment of the musculoskeletal system bones or bones embedded by tendons (e.g., the patel-
requires strong knowledge of gross and fine motor lae). The long bones are especially important in children
developmental milestones and the impact that physical because of their structure and makeup. Long bones are
growth has on a child’s body image and self-esteem. composed of a rounded end termed the epiphysis and a
Excellent pediatric musculoskeletal assessment skills long shaft, or diaphysis. Between these two portions is
are essential, particularly when musculoskeletal injury the metaphysis, the part of the bone that grows during
has occurred. Repetitive use injuries, epiphyseal plate childhood. Between the epiphysis and metaphysis is
fractures, and intentional injuries to children require the physis or growth plate (Fig. 21-2). This growth plate is
immediate recognition and appropriate referrals. structurally weak because it is made of cartilage and does
not fully ossify until early adulthood. Thus, traumatic
or shearing forces or any epiphyseal fracture can result
in early or incomplete closure of the growth plate, caus-
ANATOMY AND PHYSIOLOGY ing numerous complications, including limb deformity,
shortening of the bone, and arrest of growth (Mehlman
There are 206 bones (207 in an infant), 3 types of & Koepplinger, 2008).
joints, and more than 600 muscles in the human Bone tissue formation, or osteogenesis, is a continu-
body. The primary functions of the musculoskeletal ous process that occurs as active cells (osteoblasts) build
system are to support and protect the inner structures new bone tissue, while tissue destruction (reabsorption)
of the body and to allow mobility. The musculoskeletal is driven by osteoclasts. In childhood and adolescence,
system includes the bones, joints, ligaments, cartilage, bone growth exceeds reabsorption, but in early adult-
muscles, and tendons. These structures allow for various hood, the processes are balanced; beginning in middle
movements that are described in Table 21-1. age, bone tissue reabsorption outpaces bone growth. Be-
cause osteogenesis occurs more rapidly in children, frac-
tured bones in children heal more rapidly than those in
SKELETAL SYSTEM adults (Lindaman, 2001).
Individual bones complete the skeleton, which serves as Joints are the places at which adjoining bones meet.
the body’s framework. It can be broken down into three The joints are held together by ligaments and are
parts, the axial skeleton, appendicular skeleton, and the cushioned by cartilage. Ligaments are strong, fibrous cords
joints. Eighty bones make up the axial skeleton, which of connective tissue that bind the joints firmly together.
consists of the vertebral column, sternum, ribs, and skull. All synovial joints include ligaments. Cartilage is an avas-
The appendicular skeleton is comprised of 126 bones, cular tissue that receives its nutrients from synovial fluid
which include the arms, legs, and hips (Fig. 21-1). In ad- through diffusion. Cartilage is a firm but flexible tissue
dition to providing structure and support to the body, that cushions joints and helps soften any impact.
the bones also produce red and white blood cells, store There are three types of joints: synovial, cartilaginous,
calcium and phosphorus, and release these minerals into and fibrous. Synovial joints are the most common joint
the bloodstream as needed. The skeletal system includes type and also the most mobile. Components of these
five major bone types; their names reflect their shape: joints include a joint capsule, synovial membrane, articular
436
C H A P T E R 21 A s s e s s m e n t o f th e M us culo s keletal S ystem • 437
Cranium
TABLE 21-1
Skeletal Positions Facial bones Clavicle
TERM DEFINITION Mandible Scapula
Abduction Movement away from the midline Humerus
Adduction Movement toward the midline Sternum

Costal Ribs
Flexion Decrease in the angle of a joint; cartilage
opposite of extension Radius
Vertebral
Extension Increase in the angle of a joint; column Carpals
opposite of flexion
Ilium
Hyperextension An increase in the angle of a joint (of pelvis) Ulna
beyond the normal angle
Pelvis
Dorsiflexion Movement of hands or feet upward Meta-
Sacrum carpals
Plantarflexion Movement of hands or feet
downward Phalanges
Femur
Rotation Movement around a central axis
Internal rotation Turning anterior surface of a limb Patella

inward or toward midline
Calcaneus
External rotation Turning anterior surface of a limb Fibula
outward or away from midline
Tibia
Pronation Palmar surface turned downward or
toward posterior surface of body
Tarsals
Supination Palmar surface turned upward or
toward anterior surface of body
Circumduction Rotation or circular movements of Metatarsals Phalanges

the limbs
FIGURE 21-1. The appendicular and axial skeletons.
Inversion Movement of an extremity or part
of an extremity toward the body cartilaginous joints. Fibrous joints are the least mobile of
the three types of joints. These joints tightly connect the
Eversion Movement of an extremity or part articular surfaces of two bones with dense connective tis-
of an extremity away from the body sue. An example of a fibrous joint is the cranial suture in
Subluxation Partial dislocation the infant skull. Examples of major joints and types of
motion are listed in Table 21-2.
Luxation Dislocation
Varus Deviation toward the midline
Valgus Deviation away from the midline
Diaphysis
cartilage, and synovial cavity. This cavity is filled with syno-

vial fluid to lubricate the joint and enhance movement.
There are six types of synovial joints in the body; exam-
ples include the carpals of the wrist, the elbow (between Metaphysis
the humerus and ulna and between the radius and the
ulna), the wrist, the thumb, the shoulder, the knee, and
hip joints. Figure 21-3 illustrates the components of a Growth plate
(physis)
synovial joint of the hip. In synovial joints, cartilage cov-
ers the surface of bones where they meet. Cartilaginous Epiphysis
joints connect two bones with cartilage, allowing only
slight movement. The pubic bone juncture and the joint FIGURE 21-2. The epiphyseal (“growth”) plate of long bones
between the manubrium and sternum are examples of in children.
Articular cartilage
Synovial fluid
Femur
Ligament of the
Greater head of the femur
trochanter
of femur
Synovial membrane
Ligaments and
joint capsule
FIGURE 21-3. Components of a synovial joint (right hip).
TABLE 21-2
Major Joints and Joint Movements
JOINT MOTION JOINT MOTION JOINT MOTION
Scapulothoracic • Forward Wrists • Supination Knee • Flexion
rotation • Pronation • Extension
• Backward • Palmar flexion • Minimal
rotation • Extension rotation
• Adduction • Dorsiflexion
Acromioclavicular • Flexion Fingers • Flexion Ankle • Extension

• Extension • Extension • Dorsiflexion
• Circumduction • Hyperextension • Plantar
• Internal and • Limited abduction flexion
external • Limited adduction
rotation • Circumduction
Vertebral column • Flexion Thumb • Flexion Foot • Flexion

• Hyperextension • Extension • Extension
• Lateral • Circumduction • Inversion
deviation • Abduction • Eversion
• Rotation • Adduction
• Opposition (thumb
moves toward fingers)
Elbow • Flexion Hip and femur • Extension Toes • Flexion

• Extension • Hyperextension • Extension
• Supination • Abduction • Abduction
• Pronation • Adduction • Adduction
• Internal rotation
• External rotation
• Circumduction
The Spine are the largest of the vertebral column because they are
The vertebral column (spine) consists of 33 individual the main weight-bearing portion of the spine and allow
bones (vertebrae) that connect to form a flexible for flexion and extension. The sacrum, a fusion of five
column. The spine can be divided into four curves: cer- vertebrae, articulates with the ilium at the sacroiliac
vical, thoracic, lumbar, and sacral vertebrae (Fig. 21-4). joint. This is a strong joint, joined by ligaments, that
Individual vertebrae can be further divided according allows for the movements necessary for standing, walk-
to anatomic region: seven cervical, twelve thoracic, five ing, turning, and sitting. The four lowest vertebrae are
lumbar, and five (fused) sacral vertebrae, and the coccyx fused to form the coccyx, which articulates with the
(“tailbone”), which comprises 3–4 fused vertebrae. The sacrum. The vertebral column houses the spinal cord
spinous processes of the vertebrae begin at the seventh (see Chapter 22).
cervical vertebra and continue to the sacrum. The
thoracic vertebrae articulate with the ribs and form the Clavicle and Upper Extremities
thoracic cage (see Chapter 17). The lumbar vertebrae There are two clavicles, each articulating with the
sternum proximally and scapula distally. The scapulae
and upper extremities are supported by two strong
ligaments: the trapezoid and conoid. The scapula is
attached by muscles to the thoracic cage. Movement is
possible between the scapula and thorax and between
Occipital bone the scapula and humerus. The humerus extends from
C-1
the shoulder to the elbow. The structures of the shoulder
C-2 are illustrated in Figure 21-5.
C-3 The elbow is composed of the humerus, radius, and
C-4 ulna. The ulna is larger than the radius and runs from
Cervical
C-5 curvature the elbow to the wrist on the lateral side; the radius
C-6 is on the medial side. The bony prominence of the
Vertebra prominens C-7 elbow is the medial epicondyle, which with the lateral
T-1 condyle form an area where the humerus and the proxi-
T-2 mal surface of the ulna articulate. The structures of the
T-3 elbow are illustrated in Figure 21-6.
Superior articular facet
T-4 The distal end of the radius articulates with the dis-
T-5
Facet for tubercle of rib tal end of the ulna to create the proximal portion of
Spinal nerve
the wrist. Eight carpal bones bound by ligaments make
T-6
Thoracic Intervertebral disk up the wrist. The hand and fingers include the eight
curvature T-7 Demifacets for heads of ribs carpals of the wrist, five metacarpals of the palm, and
T-8 Body of vertebra
twelve phalanges of the fingers. Each finger contains
T-9
three phalanges. The thumb is composed of one meta-
Spinous process carpal bone and two phalanges (Fig. 21-7).
T-10
Inferior vertebral notch
T-11 Pelvis and Lower Extremities
Superior articular process
T-12 The pelvic girdle consists of two inominate (hip) bones,
the sacrum, and the coccyx. Each inominate bone is
L-1
divided into the ilium, ischium, and symphysis pubis.
L-2
The femur, the longest and strongest bone in the body,
Lumbar
L-3 curvature
extends from the hip to the knee. The strongest liga-
ment in the body, the iliofemoral ligament, connects
L-4
the femur to the ilium (see Fig. 21-3).
L-5
The articulation of the femur, tibia, and patella
forms the knee joint, which connects the distal end of
Promontory the femur to the proximal end of the tibia (Fig. 21-8).
The tibia and fibula are the two bones below the knee;
Sacral
curvature Sacrum (5 fused vertebrae)
the tibia, the larger of the two, begins at the knee and
extends to the ankle on the medial side. The fibula
Coccyx begins below the knee and extends to the ankle on the
(4 rudimentary fused vertebrae)
lateral side. Proximally, the fibula articulates with the
FIGURE 21-4. Sagittal view of the vertebral column, divided tibia but not with the femur. The patella also articu-
into four sections: cervical, thoracic, lumbar, and sacral. lates with the femur and forms the “knee cap.” The
Acromion
Clavicle
Intertubercular Coracoid
Clavicle process
groove (for
long head Acromion
of biceps
muscle) Coracoid Supraspinatus
process fossa
Glenoid
cavity
Head of
humerus
Scapula Scapula
Humerus
Humerus
A B
Acromioclavicular ligament
Coracoacromial ligament Trapezoid ligament

Coracoclavicular
Conoid ligament
Coracohumeral ligament
ligament
Supraspinatus muscle
Capsule
Biceps
(long head)
C
FIGURE 21-5. The shoulder. A. Anterior view. B. Posterior view. C. Ligaments of the shoulder.
Humerus
Phalanges
Distal
Lateral epicondyle Trochlea Middle

Capitulum
Head of radius
Medial
epicondyle Proximal
Metacarpals
Carpals
Trapezium
Hook of hamate
Trapezoid
Hamate
Capitate
Radius Pisiform
Triquetral
Ulna Lunate
Scaphoid
Head of ulna
Radius
Ulna
FIGURE 21-6. The bones of the elbow. FIGURE 21-7. Bones of the wrist and hand.
Patellar
surface
Femur Posterior Tibia

cruciate
ligament
Talus
Anterior
Lateral cruciate Navicular bone
meniscus ligament Deltoid
ligament
Medial
Fibular meniscus
collateral
ligament Transverse
ligament
Calcaneus
Ligament of Tibial
fibular head collateral
ligament FIGURE 21-9. The bones of the foot.
Patellar
ligament
Patella
MUSCLES AND TENDONS
Fibula Muscles are tissues composed of fibers or bundles of
Tibia cells. They vary in size, shape, and arrangement. The
Quadriceps muscles contract to move bones, while the joints
femoris tendon
A allow the movement to occur. There are three types
of muscles in the body: skeletal, smooth, and car-
diac. Skeletal muscles are voluntary, striated, and ar-
Articular capsule
Femur ranged in bundles, such as the triceps, biceps, and
quadriceps muscles. Smooth muscles are nonstriated
Anterior
Medial femoral cruciate and perform involuntary movements, such as those
condyle ligament in the respiratory, urinary, and gastrointestinal sys-
Posterior tems. Cardiac muscle is the striated, involuntary
meniscofemoral Lateral muscle in the heart. Tendons are firm, strong cords of
ligament femoral
condyle fibrous tissue that connect the muscle to the perios-
Fibular teum of the bone.
collateral
Tibial collateral ligament
ligament
Lateral
meniscus DEVELOPMENTAL
Medial meniscus
CONSIDERATIONS
Popliteus
Posterior cruciate muscle
ligament EMBRYOLOGIC DEVELOPMENT
The axial and appendicular skeletons begin to form
Tibia
in the fourth week of gestation. Limb formation also
Fibula begins in the fourth gestational week when limb buds
develop from outpouchings of the embryonic wall
B and proceed in a proximal–distal fashion. The limb
FIGURE 21-8. The right knee. A. Anterior view, flexed posi-
buds evolve into paddles, then plates, and finally
tion. B. Posterior view, extended. into digits. Limb abnormalities (e.g., polydactyly,
syndactyly) originate during the crucial embryonic
period of days 22–24. The critical period for lower limb
knee joint is composed of and stabilized by cartilage, development occurs between days 26–44; the type of
ligaments, tendon, and muscles. limb abnormality depends on the timing and cause of
At the distal ends of the tibia and fibula, the talus the defect. The joints develop from intra-embryonic
(ankle bone) articulates with the calcaneus (heel). Five mesoderm. Continued differentiation of the meso-
tarsals and three metatarsals form the medial longitu- derm results in the formation of the three specialized
dinal arch; two tarsals and metatarsals form the lat- muscle groups.
eral longitudinal arch. The metatarsals and distal row
of tarsals make up the transverse arch. Two phalanges
comprise the great toe; three phalanges make up each SKELETAL DEVELOPMENT
of the small toes. The bones of the foot are illustrated Numerous differences exist between the skeletal system
in Figure 21-9. of a child and that of an adult. The skeleton grows
continuously but at varying rates among children over MUSCLE DEVELOPMENT

a period of 19–20 years. The bones are not fully ossi-
During infancy, muscles comprise 25% of an infant’s
fied until adulthood, making them more pliable, soft,
weight, compared to 40% in adults (Ball & Bindler, 2006).
and easily bent (Ball & Bindler, 2006). This is clinical-
Infants also have less muscle tone and coordination dur-
ly significant because in very young children, bones
ing infancy, increasing their risk for injury. As myelina-
most often bend rather than break. Therefore, the type
tion proceeds, voluntary muscle control progresses.
and location of any fracture must be fully evaluated in
Muscle growth contributes greatly to weight gain during
reference to the child’s age and developmental level
childhood, and walking and weight-bearing stimulate
to distinguish between intentional and unintentional
the growth of bone and muscle. Muscle growth contin-
injuries (see Chapter 23).
ues into adolescence, with growth occurring more rap-
Until puberty, the percentage of cartilage in the
idly during this time because of the presence of sex hor-
ribs is high, making the ribs flexible and pliant (Ball &
mones, particularly testosterone. Rapid muscle growth
Bindler, 2006). Because of this, rib fractures are uncom-
during this time can cause clumsiness, increasing the
mon in young children, and the ribs provide minimal
adolescent’s risk for injury.
protection to underlying organs and blood vessels.
From birth until approximately 3–4 months, the spine
is C-shaped. This affects the infant’s ability to control his
or her head. Lordosis, or convex curvature of the spine, is CULTURAL AND RACIAL
a normal variation in infants and toddlers, which causes VARIATIONS
the appearance of abdominal distention in this age-
group (see Chapter 19, Fig. 19-5) (Hockenberry & Wil- Some musculoskeletal conditions occur more frequent-
son, 2007). Infants and toddlers have normal physiologic ly in certain racial or ethnic groups, depending on
bowing of the legs (genu varum) because the leg muscles cultural practices, environmental and socioeconomic
bear the weight of a relatively large trunk (Fig. 21-10A). factors, or in some instances, genetics. For example,
Genu valgum (knock-knees) is a normal variation, begin- Blount’s disease (tibia vara) occurs most commonly in
ning at 2–3 years and resolving by approximately 7–8 African American children (Cheema & Harcke, 2007).
years (Fig. 21-10B). Pes planus (flat feet) is a normal varia- Caucasian children have a high incidence of develop-
tion in infants as they first begin to walk; this slowly re- mental dysplasia of the hip (DDH), as do indigenous
solves as they grow, at which point the muscles in the North American people who keep their newborns
foot strengthen, and the arch develops. tightly swaddled because of the cold, thereby keeping
A growth spurt occurs in adolescence, peaking at the hips in adduction. Developmental dysplasia of the
age 12 for girls and age 14 for boys. The skeleton also hip may also have a genetic component (Norton & Po-
grows faster than muscles during this time, causing the lin, 2008). Talipes equinovarus (true clubfoot) is most
hands and feet to grow faster than the body. common in Polynesian groups, particularly in Tonga
(Patel & Herzenberg, 2007).
ASSESSMENT
HISTORY
Musculoskeletal problems in children can be acute or
chronic. The reason for the child’s health care visit
guides the provider in deciding what data to gather for
the health history. For children who are being exam-
ined for the first time, a complete past medical history
(PMH), family history, and social history are obtained
(see Chapter 6). These histories are updated as needed
when the child presents for health maintenance visits,
with special attention to assessment of developmental
milestones and any history of musculoskeletal injury
or infection. The onset of puberty is noted in adolescents
(see Chapter 20) to estimate the amount of remaining
musculoskeletal growth for the child. A developmental
A B history is especially important, as delays in achieving
FIGURE 21-10. A. Genu varum (bowlegs). B. Genu valgum developmental milestones can result from congenital
(knock-knees). musculoskeletal and spinal deformities, indicate a
musculoskeletal injury or infection, or be the result often have gastrointestinal conditions that impede
of neglect. A focused history is required when the child absorption of nutrients essential for bone growth and
presents with a pain, musculoskeletal injury, infection, ossification (Blackman, 2007).
or developmental delay.
Review of Systems
Past Medical History The pediatric review of systems (ROS) includes asking
Prenatal History. The stage of pregnancy at which not only about specific musculoskeletal conditions,
prenatal care began should be noted, as well as but chronic conditions involving other body systems.
whether the child has had any prenatal exposure to These conditions may involve signs and symptoms
drugs, alcohol, or intrauterine infections that can that manifest in the bones, tendons, joint, or muscles;
cause musculoskeletal abnormalities. Intrauterine po- affect physical growth and stature; and interfere with
sition can influence developmental dysplasia of the participation in sports. Some examples include the
hip, torticollis, and metatarsus adductus (positional following:
clubfoot). Oligohydramnios is a risk factor for devel- • Integumentary: Café au lait marks (more than
opmental dysplasia of the hip (Norton & Polin, 2009). five marks suggest neurofibromatosis), nevi (tuber-
ous sclerosis), or hemangioma (Klippel-Trénaunay
Perinatal and Neonatal History. The child’s syndrome)
birth history is reviewed; special attention is paid • Cardiovascular: Congenital heart defects (cause
to whether any perinatal or neonatal asphyxia poor growth)
occurred, which could increase the child’s chances of • Respiratory: Poorly controlled asthma or cystic
developing cerebral palsy. Any history of congenital fibrosis
musculoskeletal deformities should be explored; some • Gastrointestinal: Celiac disease, cystic fibrosis, inflam-
examples of these conditions are listed in Table 21-3. matory bowel disease, or short bowel syndrome
A history of breech or shoulder presentation is noted; • Hematologic: Hemophilia (can cause bleeding in
a fractured clavicle can result from a shoulder presen- bones and joints) or sickle cell disease (can cause
tation. Breech presentation increases the likelihood bone and joint pain)
of developmental dysplasia of the hip (Norton & • Infectious: Tuberculosis (can infect spine and joints),
Polin, 2009). It is essential to assess for any history of osteomyelitis, Lyme disease (can cause arthritis,
prematurity; very low-birth-weight premature infants which affects large joints, especially the knee), or
are prone to osteopenia (Parish & Bhatia, 2004) and septic arthritis
TABLE 21-3
Congenital Musculoskeletal Deformities
DEFORMITY DESCRIPTION
Neck:
Torticollis (“wry neck”) Involuntary muscle contractions of the neck caused by birth trauma
or intrauterine positioning that leads to fibrosis and shortening of the
sternocleidomastoid muscle
Wrist and Hand:

1. Polydactyly 1. Extra digits on hand or foot formed by abnormal soft tissue and bone; may be
2. Syndactyly associated with a syndrome; abnormal hand function possible.
3. Talipomanus (clubhand) 2. Occurs when digits of hands or feet fail to separate; may also be associated with
syndrome complexes.
3. Congenital absence of radial or ulna causes marked inward deviation of hand
and extremely short forearm.
Hip:
Developmental dysplasia Involves a range of disorders affecting the proximal femur and acetabulum from
preluxation to complete dislocation of the femoral head
Foot and Ankle:

1. Pes planus (flatfoot) 1. Laxity of ligaments supporting foot’s longitudinal arch
2. Metatarsus adductus 2. Medial deviation of the forefoot occurring as a result of intrauterine
3. Talipes equinovarus (clubfoot) positioning; does not involve muscles, tendons, and bone
3. Internal rotation of foot with forefoot adduction; involves muscles, tendons,
and bone
• Metabolic: Obesity (can cause slipped capital femo- provider in discerning intentional from unintentional
ral epiphysis and Blount’s disease) injuries (see Chapter 23). Frequent minor injuries may
• Musculoskeletal: Torticollis, metatarsus adductus indicate neglect or poor adult supervision in young
(positional clubfoot), talipes equinovarus (clubfoot), children or risk-taking behavior in the adolescent.
fractures, genu varum (bowlegs), genu valgum (knock-
knees), pes planus (flat feet), developmental dyspla- Surgical History
sia of the hip, scoliosis, spinal deformities, juvenile The provider must determine what surgeries related to
rheumatoid arthritis, limited range of motion, the musculoskeletal system the child has undergone.
polydactyly, syndactyly, achondroplasia, amniotic Some examples include open reduction with internal
bands; sacral sinus or dimple, slipped capital fem- fixation of fractures or musculoskeletal deformities, ten-
oral epiphysis (SCFE), Legg-Calvé-Perthes disease, don-lengthening procedures for cerebral palsy, surgical
Osgood-Schlatter disease, toxic synovitis of the hip, intervention for clubfoot, developmental dysplasia of
osteogenesis imperfecta, or Marfan syndrome the hip, slipped capital femoral epiphysis or scoliosis,
• Renal: Polycystic kidney disease, renal tubular acido- the placement of skeletal traction, or surgical débride-
sis, chronic glomerulonephritis, nephritic syndrome, ment for osteomyelitis.
or Fanconi syndrome
• Endocrine: Growth hormone deficiency, hypo- Current Medications
thyroidism, premature epiphyseal closure (andro-
The provider should inquire about any medications
gen or estrogen excess), or primary or secondary
the child is taking on a regular or as-needed basis,
amenorrhea
including over-the-counter and complementary or
• Neoplastic: Acute lymphocytic leukemia (can cause
alternative treatments (see Chapter 6). In particu-
bone and joint pain), Ewing’s sarcoma, multiple
lar, the provider should note if the child is taking
myeloma, or osteosarcoma
any steroids, nonsteroidal anti-inflammatory drugs,
• Neurologic: Hydrocephalus, spina bifida occulta,
aspirin, acetaminophen, muscle relaxants, sedatives,
meningocele, myelomeningocele, or Erb’s palsy
narcotics, anticonvulsants, or any neuromuscular
• Neuromuscular: Cerebral palsy or muscular
agents. The indication for the drug as well as the dose
dystrophy
must be obtained. Youth who are involved in sports
• Psychosocial: Anorexia nervosa or bulimia nervosa
should be asked about vitamins, iron, or herbal sup-
• Syndromes: Turner syndrome, Noonan syndrome,
plements. Use of anabolic steroids, stimulants, or lax-
Prader-Willi syndrome, or Down syndrome
atives is assessed in a nonjudgmental manner, prefer-
ably with the parent out of the room.
Hospitalizations
It is necessary to note any past hospitalizations for con- Family History
ditions involving the musculoskeletal system, such as A family history of genetic or idiopathic short stature is
traction, including the indication for the traction; frac- an important part of the musculoskeletal history. The
tures; treatment for osteomyelitis; hospitalizations for provider must obtain a family medical history to assess
osteogenesis imperfecta; and chronic problems related the prevalence of conditions or genetic disorders such
to cerebral palsy, muscular dystrophy, or the complica- as achondroplasia (dwarfism), muscular dystrophy,
tions of immobility after spinal cord injury. arthritis, DDH, scoliosis, or osteogenesis imperfecta. If
Any complications of casting or traction must also the child participates in sports, particular attention is
be noted, such as neurovascular compromise, skin paid to any family history of asthma; cerebrovascular
breakdown, compartment syndrome, and osteomy- accident; myocardial infarction before age 50; sudden,
elitis resulting from pin site infection with skeletal unexplained death in an adolescent or young adult
traction. relative; prolonged QT syndrome; Marfan syndrome;
hypertrophic cardiomyopathy, or any other cardiac
Injuries abnormalities (Wilson & Matthews, 2009). A family
An essential part of the musculoskeletal history is to history of hemophilia or sickle cell disease is relevant
determine any past history of injuries. This includes in children with bone or joint pain or with a limp
fractures, dislocations, subluxations, sprains, or strains. (Leung & Lemay, 2004).
Fractured clavicles are very common in neonates and
young children. Specific sports-related injuries are Social History
noted, including whether repeated injuries have taken The social history focuses on the family’s living situa-
place. The type and location of any fracture is espe- tion; persons living in the home; and any risk factors
cially important to note, along with the history of the that could predispose the child to falls, musculoskeletal
mechanism of injury. This information, coupled with injuries, or infections. An essential part of this history
the child’s age and developmental level, assists the includes determining the quality of the caregiver–child
relationship, particularly with children 3 and younger. not receive vitamin D supplements (Neumann, Gewa,
This assessment can assist in determining whether any & Bwibo, 2004). It is particularly important to review
neglect is taking place, which affects the attainment the child’s growth charts, noting trends toward over-
of gross and fine motor developmental milestones and weight, obesity, or underweight, which may signal a
can result in musculoskeletal injuries. Children in this need for vitamin supplements.
age group are also vulnerable to injuries inflicted by
the parent or caregiver (see Chapter 23). If the child is History of Present Illness
involved in sports, the child’s age and type of sport is In an evaluation of musculoskeletal complaints, the
noted, as well as whether appropriate protective gear child’s age and developmental level, concurrent ill-
is used at all times. The amount, type, and frequency ness, history of recent injury, associated findings, and
of exercise is also noted, including weight-lifting regi- past health are relevant when considering differential
mens and warm-up exercises. diagnoses. For example, fever associated with joint
pain, stiffness, and swelling may present different
Developmental History diagnostic possibilities than joint pain and swelling
A comprehensive developmental history is essential alone. Examples of musculoskeletal complaints in chil-
when evaluating the musculoskeletal system. The dren include pain, limp, fractures, and sports injuries.
timing of the child’s acquisition of gross and fine Relevant questions to ask for the focused history can
motor milestones should be reviewed, noting any be found in Table 21-4.
developmental delays (see Chapter 2). Delays in
achieving developmental milestones may be the
result of hearing, vision, language, or learning abnor- PHYSICAL EXAMINATION
malities, which may accompany spinal deformities. Physical examination of the musculoskeletal system in
The child’s growth charts are evaluated, with special children is achieved through inspection and palpation,
attention to slow growth or the child falling off his focusing on general configuration, symmetry and length
or her own growth curve. The child’s growth must of extremities, deformities, masses, crepitus, and point
also be compared to that of the parents and siblings tenderness. A developmental approach to the physical
if possible. examination is necessary because of the child’s mo-
tor development and the normal physiologic varia-
tions in musculoskeletal development. Equipment
Nutritional History
necessary for the musculoskeletal examination in
A nutritional history is often necessary when con-
children includes a reflex hammer, tape measure, and
ducting a musculoskeletal assessment. Children who
scoliometer.
are obese often suffer musculoskeletal complications,
including SCFE, which results when excess weight
places a shear force on the growth plate in the hip
Preparation
(Walter, Lin, & Schwartz, 2008), and Blount’s disease For a thorough, accurate, and comprehensive muscu-
(tibia vara), which results from excess body weight loskeletal examination, the neonate or infant must be
compressing the medial knee, resulting in varus fully undressed and supine. Children toddler-aged and
deformities of both tibia (see Fig. 21-10A) (Cheema & older who are walking must also be undressed except
Harcke, 2007). for underwear. Shoes and socks must be removed to
For children involved in sports, particular attention evaluate standing posture and limb symmetry accu-
is paid to calcium and iron intake, as well as adequate rately. In older children, particularly adolescent girls,
hydration while participating in exercise or sports. modesty must be preserved as much as possible; a
Adequate calcium intake is essential to normal bone gown may be worn when inspecting the posterior tho-
growth; iron is vital to oxygen transport and metabo- rax and spine.
lism, and all child athletes must be assessed for ane-
mia. Body image and weight are especially important Developmental Approach to
to gymnasts, runners, and wrestlers; these children the Examination
and adolescents must be continuously assessed for eat- The child’s age and developmental level are major con-
ing disorders (Lilly & McCambridge, 2008). siderations when conducting the examination of the
Rickets, a condition caused by deficiency of vita- musculoskeletal system. These factors influence the
min D, calcium, or both, is re-emerging as a problem manner in which the examination is conducted, as well
in developing countries. This condition causes soft- as how the assessment findings are interpreted. Because
ening of the bones and is more prevalent in winter infants are not able to cooperate with commands,
months in temperate climates when exposure to sun- joint movement must be assessed through spontane-
light is limited, in dark-skinned children, in children ous movement and through passive range of motion.
who are vegetarians, and in breastfed infants who do Toddlers can be asked to play games such as “Simon
TABLE 21-4
History of Present Illness: Musculoskeletal Complaints
Back pain Recent injury? Involved in sports? Strenuous Contusion, sprain, strain, spondylolysis,
exercise? Does child carry heavy school kyphosis, acute disc herniation, degenerative
backpack? Severity of pain? Aggravating and disc disease, sacroiliac inflammation, diskitis,
relieving factors? Response to pain medication? osteomyelitis, spinal tumor (MacDonald &
Does pain wake child at night? Any fever? D’Hemecourt, 2007), or apophyseal injury (Lilly
& McCambridge, 2008)
Hip pain Recent injury? Recent URI? Limited range of Apophyseal avulsion injury in adolescent
motion? Limb shortening? Swelling? Involved athlete, slipped capital femoral epiphysis (obese
in sports? Is child obese? Severity of pain? child or adolescent), acetabular labral tear,
Aggravating and relieving factors? Response femoral neck stress fracture (Heyworth, Voos, &
to pain medication? Does pain wake child at Metzl, 2007), toxic synovitis of the hip, septic
night? Any fever? arthritis, osteoarthritis, Legg-Calvé-Perthes
disease, or fracture
Knee pain Recent injury? Swelling? Limited range of Cerebral palsy (Senaran, Holden, Dabney, &
motion? Involved in sports? Is child obese? Miller, 2007), anterior cruciate ligament injury,
Severity of pain? Aggravating and relieving meniscus tear, Osgood-Schlatter disease,
factors? Response to pain medication? Does pain osteochondritis, fracture, septic arthritis, JRA, or
wake child at night? Any fever? osteogenic sarcoma
Leg pain Recent injury? Swelling? Limited range of Shin splints, stress fracture, iliotibial band
motion? Involved in sports? Is child obese? syndrome, patellar femoral pain syndrome,
Severity of pain? Aggravating and relieving muscle strain (Lilly & McCambridge, 2008),
factors? Response to pain medication? Does pain osteoarthritis, leukemia, tumor, or sickle cell
wake child at night? Any fever? disease
Ankle pain Recent injury? Swelling? Limited range of Sprain, fracture, septic arthritis, JRA, pes planus,
motion? Involved in sports? Is child obese? metatarsus adductus, ingrown toenail, or poorly
Severity of pain? Aggravating and relieving fitting shoes
factors? Response to pain medication? Does pain
wake child at night? Any fever?
Limp Age of child? Onset of limp? Recent injury? Trauma, fractures, sprains, overuse injuries,
Involved in sports? Strenuous exercise? developmental dysplasia of the hip, septic
Associated pain? Aggravating and relieving arthritis, osteomyelitis, toxic synovitis, Legg-
factors for limp? Past medical history? Family Calvé-Perthes disease, JRA, leukemia, or tumors
history (Leung & Lemay, 2004)? (Leung & Lemay, 2004)
JRA, juvenile rheumatoid arthritis; URI, upper respiratory infection.
says” or “follow the leader.” Children preschool-aged movement of all four extremities. In older children,
and older are able to follow the provider’s commands normal posture is upright with good alignment of the
during the physical examination. head, shoulders, and hips.
Assessment of General Appearance Skin. In each age group, the skin is inspected for any
The musculoskeletal examination begins with simple nevi, café-au-lait marks, or hemangiomas (see Chapter 12),
observation of the child. When the provider enters the which may indicate syndromes associated with muscu-
examination room and while gathering the history, loskeletal complications, such as neurofibromatosis or
much can be learned about the child’s musculoskeletal Klippel-Trénaunay syndrome. Bruising, erythema, swell-
status by observing any spontaneous motor activity. ing, or any scars from past injuries are noted. As needed,
Examples include observing the child’s body position, the skin is also palpated for laxity of ligaments (Ganel,
limb symmetry, and tone, noting range of motion, posture, Dudkiewicz, & Grogan, 2003).
and obvious deformities; observing an infant or child
sit; and watching a child walk or play. In neonates and Head, Neck, and Clavicles. In all age groups, the
infants, head control, the ability to sit, and overall full musculoskeletal examination begins with inspec-
tone are noted, as well as the position and spontaneous tion and palpation of the head, neck, and clavicles and
continues in a head-to-toe sequence. Assessment of

the head and neck is discussed in Chapter 13.
Gait. By 12–15 months, a child should progress be-

yond cruising to walking. The provider must add the
assessment of gait to simple observation of the child’s
spontaneous activity and play. The normal gait cycle
consists of the stance phase and swing phase. The stance
phase begins when one foot is placed on the ground,
heel first, and the opposite foot is lifted off the ground.
Next is the mid-stance, when the center of gravity is
directly on the foot that is on the ground. The terminal
stance occurs last when the center of gravity is over the
supporting foot, and the opposite foot is placed on the
ground. The swing phase begins with the toe off the Normal Positive
ground until the knee is maximally flexed, which
FIGURE 21-11. Trendelenburg sign. The pelvis drops on the
causes the tibia to be perpendicular to the ground. affected side when the hip is raised.
The tibia is then moved down until it becomes verti-
cal, touching the ground (Bogey, 2009). The health of
the child’s joints and muscles affects the child’s gait; Older children with previously undetected DDH
conditions such as juvenile rheumatoid arthritis ( JRA), have a characteristic limp and often toe-walk. To test
muscular dystrophy, and cerebral palsy affect gait. for undiagnosed DDH in an older child, the child is
The child’s age and developmental level impact how asked to hold a chair or the parent or provider’s hands
gait is assessed. Toddlers can just be observed; children and bear weight on each foot, one at a time. When
preschool-aged and older are asked to walk across the bearing weight on the affected hip, the pelvis will drop
room barefoot, wearing only a patient gown (Leung & on the affected side. This is a positive Trendelenburg
Lemay, 2004). Additionally, the provider may ask the sign, an indication of DDH (Fig. 21-11). Toe-walking
child to stoop, climb onto the parent’s lap, or take large may be idiopathic; it may also be caused by congeni-
steps. The examiner observes the child’s gait for balance, tal short Achilles tendon, muscular dystrophy, cere-
noting the child’s ability to bear weight, toe-walking, bral palsy, and autism (Cole, 2008; Schwentker, 2009).
genu valgus, genu varum, toeing-in, or toeing-out. Tod- A scissoring gait suggests cerebral palsy.
dlers are normally bow-legged, have a wide-based gait,
and walk in short, quick steps to keep their balance. Upper Extremities and Shoulders. Assessment of
Until approximately age 7–8 years, slight genu valgum the upper extremities includes inspection and palpation
(knock-knee) is within normal limits. Intoeing can be for equal length, symmetry, strength, spontaneous move-
caused by metatarsus adductus, internal tibial torsion, or ment, swelling, pain, tenderness, and range of motion.
femoral anteversion (Sass & Hassan, 2003). If the child is Muscles are also assessed for size, strength, and tone.
developmentally able to cooperate, instructing the child Any limb contractures are noted.
to toe walk across the room and heel walk back helps to In the newborn, lack of spontaneous movement of
assess motor strength of the S1 and L4 nerve roots (Mac- an upper extremity may result from a fractured clavicle
Donald & D’Hemecourt, 2007). or Erb’s palsy, a birth injury to cranial nerves V and VI.
Any abnormalities in the child’s gait are noted. There may be a palpable, bony prominence in the area
Examples include limp, antalgic gait (gait to avoid pain), of a healed clavicle fracture. Short, bowed extremities
toe-walking, and scissoring. A limp is a symmetrical gait with possible fractures are seen in osteogenesis imper-
abnormality that can be caused by shortening of a fecta (Polovsky & Eilert, 2009). The neonate’s hands are
limb, muscle weakness, paralysis, or pain. A limp can inspected for shape, size, and number of digits. Polydactyly
also result from Legg-Calvé-Perthes disease, SCFE, toxic (multiple digits) can occur in the upper or lower ex-
synovitis, septic arthritis, previously undetected DDH, tremities, a condition that may be inherited (Fig. 21-12).
or JRA (Lin, Schraga, & Stevens, 2009). A marked limp or Syndactyly (fused digits) is often associated with con-
refusal to walk accompanied by fever, point tenderness, genital syndromes (Castriota-Scanderbeg & Dallapiccola,
or limited range of motion in the hip suggests acute he- 2006) (Fig. 21-13). The palms are also inspected for pal-
matogenous osteomyelitis of the proximal femur (hip) mar creases, whorls, finger loops, or ridges. A transverse
or lateral distal tibia (ankle) (Kocher, Lee, Dolan, Wein- or “simian” crease occurs in children with Down syn-
berg & Shulman, 2006). In the adolescent, an antalgic drome (Fig. 21-14).
gait (shortened time standing on affected side), accom- After the neonatal period, the hands and wrists are
panied by an externally rotated hip, out-toeing, and inspected for any swelling, warmth, tenderness, erythema,
thigh or knee pain, points to SCFE (Katz, 2006). deformity, strength, and range of motion. No nodules,
FIGURE 21-12. Polydactyly of the lower extremity.
redness, or swelling should be seen. There should be

no warmth or tenderness with palpation. Warm, tender
joints indicate JRA or Kawasaki disease (Parrillo & Parril-
lo, 2009). Tender joints may also be present with trauma,
infection, tumors, systemic lupus erythematosus, Lyme
disease, or Henoch-Schönlein purpura (Malleson & Beau-
champ, 2001). Symmetrical, painful swelling of the hands
can be caused by sickle cell crisis. Joint deformities occur
with some congenital conditions or syndromes or with
JRA. Long, slender fingers with hyperextensible joints are
FIGURE 21-14. A horizontal palmar crease (“simian crease”)
seen with Marfan syndrome (Polovsky & Eilert, 2009). seen with Down syndrome.
In children preschool-aged and older, upper extremity
strength is evaluated by asking the child to squeeze the
provider’s fingers. The strength of both upper extremi- Unilateral limitation of range of motion in one arm,
ties should be equal; asymmetry may be caused by with resistance of supination or pronation of forearm
pain, hemiparesis, or muscle weakness resulting from or an inability to flex or extend the elbow, suggests
cerebral palsy or muscular dystrophy ( Jones, Morgan, subluxation of the radial head (“nursemaid’s elbow”).
& Shelton, 2007; Mercuri & Longman, 2005). Because ligaments are normally weak in young chil-
If the child is developmentally able to cooperate, dren, this condition is more prevalent in toddlers and
range of motion is evaluated in the shoulders, elbows, is caused by pulling firmly on the child’s arm (Wolfram
fingers, and wrists. Range of motion is assessed by ask- & Boss, 2009). Range of motion in the hands and
ing the child to move the shoulders up and down. wrists is evaluated by asking the child to abduct and
Range of motion of the elbow is evaluated by asking adduct fingers; make a fist; and flex, extend, abduct,
the child to bend and straighten the elbow and pronate and adduct the wrists. Limited range of motion may be
and supinate the hands. Full range of motion should caused by pain, inflammatory disorders, or fracture.
be noted. Decreased range of motion in the shoulder
or elbow may be caused by pain related to repetitive Spine. The spine is assessed for range of motion, congeni-
motion injuries, particularly if the child is involved tal abnormalities, and curvatures. In the newborn and
in sports, such as tennis, baseball, or swimming. infant, the spine is inspected and palpated for pigmented
areas, tufts of hair, dimples, sinuses, or sacs in the lumbar
region. Areas of pigmentation, tufts of hair, or sacral
dimpling can indicate spina bifida occulta. Obvious
sacs in the lumbosacral region indicate meningocele or
myelomeningocele. These abnormalities are illustrated
in Figure 21-15.
Once a child is walking, the spine is inspected with
the child standing and undressed from the waist up,
preserving modesty. The child’s posture is evaluated first.
When standing, the child’s head should be in direct
alignment with the midline of the sacrum (Chin, Price,
& Zimbler, 2001). Range of motion of the spine is assessed
by asking the child or adolescent to bend forward, side
to side, and backward; no pain or limitation of move-
ment should be evident. With the child standing
straight, the provider inspects the child’s spine from an
FIGURE 21-13. Syndactyly. anterior, lateral, and posterior view. Any spinal curva-
A B C D
FIGURE 21-15. Spinal cord abnormalities. A. Normal spinal cord. B. Spina bifid occulta.
C. Meningocele. D. Myelomeningocele.
tures are noted. Lumbar lordosis (convex curvature) is

normal in toddlers. Kyphosis, or concave curvature of
the thoracic spine (Fig. 21-16), can be caused by myelo-
meningocele, tumors of the spinal cord, or simply poor
posture. Unequal shoulder height, an uneven waistline,
or any rib humps can indicate scoliosis (lateral curvature
of the spine). Further assessment of scoliosis includes the
Adam’s forward-bending test. This test is performed with
the child or adolescent standing straight, facing away
from the examiner, feet together, and knees straight.
The examiner then asks the child to bend forward at
the waist, arms dangling, and touch his or her toes.
With the child bending forward, the examiner inspects
the child’s back for spinal alignment, deformity, curva-
ture, or visible hump. A visible lateral curvature of the
spine when the child is standing or a prominent scapula
on the affected side when bending indicates scoliosis
(Fig. 21-17). A scoliometer can also be used to measure
A
B
FIGURE 21-17. A. Visible lateral curvature of the spine. Note
the right shoulder elevation. B. Prominent scapula when
FIGURE 21-16. Kyphosis. bending forward indicates scoliosis.
the degree of curvature. Children with a 10–20 degree Unequal

lateral curvature or more require referral (Chin, Price, & knee height
Zimbler, 2001).
Hips. In the first year of life, evaluation of the hips

is a critical assessment to detect DDH as early as pos-
sible to initiate treatment and prevent hip dislocation.
When evaluating the hips for DDH, the newborn or
infant must be warm, comfortable, and relaxed. The FIGURE 21-19. Uneven knee height noted with DDH.
infant must also be supine with the diaper off. One
hip is evaluated at a time. The important examination the examination table, near the infant’s buttocks. Knee
assessments are the Ortolani and Barlow maneuvers. To height is compared. Uneven knees indicate that one
perform the Ortolani maneuver, the provider places leg is shorter than the other, a sign of unilateral hip
his or her thumb over the infant’s inner thigh, and the dislocation, with shortening of the limb on the affect-
index finger is placed over the greater trochanter. The ed side (Fig. 21-19). This finding is a positive Galeazzi
leg is then abducted and the knees flexed 90 degrees sign (Cady, 2006). With the infant prone, the provider
with gentle pressure placed over the greater trochan- assesses symmetry of thigh folds. Asymmetric thigh
ter. With DDH, a palpable, but not audible, “clunk” and gluteal folds also indicate hip dislocation, with an
is felt when the hip dislocation is reduced. This is a extra skin fold on the affected side (Fig. 21-20).
positive Ortolani sign, signifying a dislocated hip. In older children, the hips are evaluated for pain,
Continuing with the hips adducted, slight, gentle pres- swelling, redness, position, and limited range of motion.
sure is applied to the posterior hip. If the hip is dislo- The hips should have full range of motion without
cated, a “clunk” is palpable, but not audible, as the pain. Hip pain in an older child is always a concern
hip dislocates out of the acetabulum. This is a positive that requires immediate evaluation. Older children
Barlow sign, which occurs with DDH (Fig. 21-18) (Cady, may be unable to bear weight and experience pain
2006). With the infant remaining supine, the provider or resistance to movement with passive range of mo-
inspects thigh lengths. To do this, the infant’s hips and tion. Redness, swelling, or point tenderness of the hip
knees are flexed with the soles of the feet placed on suggests infection. Limited range of motion with de-
creased internal rotation suggests SCFE, particularly
in pre-adolescent and adolescent males (Katz, 2006).
Table 21-4 reviews possible differential diagnoses for
Limited abduction
hip pain in children.
Lower Extremities, Feet, and Ankles. The lower

extremities are inspected and palpated for equal length,
symmetry, spontaneous movement, strength, swelling, pain,
A tenderness, and range of motion. Muscles are assessed
for size, strength, and tone. Any limb contractures are
noted. There should be no obvious swelling, deformity,
or erythema. The lower limbs should be symmetrical
and equal in length. In the neonate, lower extremity
deformities and contractures are often seen in children
with myelomeningocele and osteogenesis imperfecta
Unequal
folds of
skin
B
FIGURE 21-18. Assessing for hip clunk with the Ortolani
maneuver (A) and Barlow maneuver (B). FIGURE 21-20. Asymmetric thigh and gluteal folds.
(Polovsky & Eilert, 2009). In older children, limb length Knee joint laxity can be assessed by performing the
is evaluated with the child supine, legs extended, and McMurray test. With the child lying supine, the provider
legs aligned. Limb length discrepancies can be caused has the child flex the affected knee and hip. With one
by DDH, SCFE, cerebral palsy, scoliosis, or after a femo- hand, the examiner holds the child’s knee and flexes
ral fracture (Katz, 2006; Gogi, Khan, & Varshney, 2006; it to 90 degrees while holding the child’s foot with the
Leung & Lemay, 2004; Chin, Price, & Zimbler, 2001). other hand. The examiner then externally rotates the
Lack of spontaneous movement can indicate pain or an lower leg while extending the knee to 90 degrees. Pain
underlying condition that causes muscle paralysis. or clicking during this maneuver indicates a sprain or
The examiner tests for limb strength by asking the other damage to the meniscus.
child to push firmly with the soles of the feet against The feet and ankles are inspected and palpated for
the palms of the examiner’s hands. Lower extremity position, alignment, range of motion, and any visible
strength should be firm and equal. Unequal lower limb swelling or deformities. In newborns and infants, foot
strength can be caused by pain, hemiparesis, or paraly- position and alignment are inspected. Forefoot adduc-
sis. Pain, swelling, or tenderness in the lower extremities tion may be due to metatarsus adductus, the positional
can be caused by trauma, infection, or tumor, leukemia, incurving of one or both feet caused by intrauterine
sickle cell disease, hemophilia, or Henoch-Schönlein positioning (Fig. 21-21). Physical findings reveal the
purpura (Kocher et al., 2006). Pain with plantarflexion heel in varus position, with a flexible forefoot that can
can indicate Achilles tendonitis; pain in the arch or be abducted beyond the midline. This condition usu-
heel is caused by plantar fasciitis; both conditions are ally resolves spontaneously, particularly with weight-
seen in adolescent runners (Gottschlich, Eerkes, Lin, & bearing.
Schwartz, 2008; Singh & Silverman, 2008). Talipes equinovarus, or true clubfoot, is a rigid
With the child standing straight facing the examiner deformity involving muscles, tendons, and bone. Three
with the ankles together, the knees are inspected for clinical findings are evident on inspection: (a) forefoot
contour, deformity, tenderness, warmth, redness, swelling, adduction, (b) forefoot supination, and (c) equinus
alignment, and range of motion. Genu varum (“bow-legs) of the ankle (plantarflexion of the foot at the ankle)
is normal until age 3–4 (see Fig. 21-10A). Genu valgum (Fig. 21-22). Internal torsion of the tibia may also be
(“knock knees”) is normal until age 7–8, after which seen. Talipes equinovarus may be idiopathic, neuro-
time it can be caused by rickets (see Fig. 21-10B). If genic, or occur as a feature of a syndrome. Children
genu varum persists beyond that time, it is termed with talipes equinovarus must be assessed for associat-
tibial torsion, which can be caused by rickets, JRA, os- ed syndromes or spinal deformities (Polovsky & Eilert,
teomyelitis, neoplasia, or trauma (Polovsky & Eilert, 2009). Unlike metatarsus adductus, talipes equinovarus
2009). Blount’s disease also causes a varus deformity requires serial casting and possible surgery to correct
of both tibias (see Fig. 21-10A). Genu varum differs the deformity.
from Blount’s disease in that both the femur and tibia Pes planus (flat foot) is a congenital condition of
are involved with genu varum, while Blount’s disease the foot involving laxity of the ligaments supporting
affects only the tibia. the foot’s longitudinal arch, causing flattening of the
There should be full range of motion of the knee with foot arch. Physical findings reveal a convex medial
normal alignment; limited knee flexion may be caused border of the foot. This condition may be permanent
by abnormalities of the quadriceps. Laxity of the knee or occur only when the child bears weight. The ankle
joint points to a tear in the anterior or posterior cruci- is palpated for swelling, tenderness, and range of motion.
ate ligament. The knees are palpated on either side of
the patella to assess for tenderness, swelling, or bogginess.
The patella should not move when palpated. Tender-
ness, warmth, and bogginess over the knee can indicate
synovitis, sprain, or a torn meniscus. Tenderness and
swelling over the tibial tubercle may indicate Osgood-
Schlatter disease. If swelling is seen or felt in the knee,
further examination is required. Elicitation of the Bal-
lottement sign is useful in this instance. The examiner
asks the child to extend the knee. The examiner then
grasps the patella with the thumb and index finger of
the dominant hand, pushing the patella down while
applying pressure. If fluid is present in the knee, this
moves the patella down toward the femur. Pressure is
then released quickly. If the examiner can feel a “tap,”
this is the patella striking the femur; this is a positive
Ballottement sign and indicates joint effusion. FIGURE 21-21. Metatarsus adductus.
Ninety-second Musculoskeletal Screening

Examination
The goal of the 90-second preparticipation sports
musculoskeletal examination is to find previously
undetected musculoskeletal conditions and to pre-
vent injury. The requisite health history is outlined
in Chapter 9. The standardized preparticipation mus-
culoskeletal examination includes the components
listed in Table 21-5.
Assessment of Motor Function

Assessment of motor function, an essential portion of
the pediatric musculoskeletal examination, includes
evaluation of muscle tone, strength, and size and assess-
FIGURE 21-22. Talipes equinovarus (true clubfoot). Note the
forefoot adduction, forefoot supination, and plantarflexion at ment of involuntary movements. Muscle tone, move-
the ankle. ment, and posture are routinely evaluated in newborns
and young infants through assessment of the primitive
reflexes and gestational age (see Chapter 11).
Full range of motion should be noted. Limited range
of motion accompanied by swelling, redness, or ten- Muscle Tone. Muscle tone, the state of partial con-
derness can be caused by JRA or more serious contraction of a muscle while at rest, is assessed by passive
ditions such as osteomyelitis. Symmetrical, painful range of motion in infants and children. Muscle tone
swelling of the ankles and feet can be caused by sickle changes in accordance with myelination and develop-
cell crisis. ment of the cerebral cortex. Normal muscle tone shows
TABLE 21-5
The 90-Second Musculoskeletal Screening Examination
INSTRUCTION TO CHILD AREA OF ASSESSMENT
Stand facing examiner. Acromioclavicular joints; extremity symmetry, general
posture, and ease of mobility
Look up, down, left, and right; touch ears to shoulders. Cervical spine range of motion
Shrug shoulders as examiner applies resistance. Trapezius strength
Hold arms outstretched at side, and lift them as examiner Shoulder range of motion
applies resistance.
Raise elbows at side 90 degrees, and rotate hands backward. Deltoid strength
Shoulder motion
Hold arms at sides with palms upward; flex and extend Elbow range of motion
elbows.
Hold arms down in front of body; flex elbows so that hands Wrist range of motion
are straight out. Rotate hands face up and face down.
Spread fingers, then make a fist. Hand and finger strength; range of motion or deformities
Stand on one leg, bent at the knee; repeat with other leg. Symmetry of legs; knee or ankle effusion
“Walk like a duck” by squatting and walking four steps away. Hip, knee, and ankle range of motion
Stand with back to examiner and with knees straight, and Shoulder symmetry, scoliosis, hip range of motion, and
bend over to touch toes. hamstring tightness
Stand on tiptoes and then heels. Calf symmetry and leg strength
Source: McCarthy, V. M. (2006). Getting into the game: keys to performing an efficient sports physical. Advance for Nurse Practitioners, 14(6),
67–69; Garrich, J. G. (1977). Sports medicine. Pediatric Clinics of North America, 24, 737–747.
TABLE 21-6
Motor Strength Grading
0/5 No muscle movement
1/5 Visible muscle movement, but no

movement at joint
2/5 Movement without gravity
3/5 Movement against gravity
4/5 Movement against gravity resistance

FIGURE 21-23. Normal flexed tone of newborn infant. 5/5 Normal strength
a mild degree of tension while at rest and is evaluated

by looking at resting posture, upper and lower extrem- to motor dysfunction, spasticity, cerebral palsy, and
ity tone, and head control. Tone is assessed for flaccid- quadriparesis (Nakagawa & Conway, 2004).
ity (hypotonia), rigidity, or spasticity (hypertonia)
and can vary between the upper and lower extremi- Muscle Strength and Size. Both upper and lower
ties. Assessment of general muscle tone is done by first extremity muscle strength and size are evaluated with
observing the infant or child in a resting state to evalu- assessment of motor function. Muscle weakness is the
ate overall posture. In term newborns, normal tone is most common presenting symptom of neuromuscular
demonstrated by the arms and legs in a semi-flexed disease. Muscle strength is graded on a scale of 0 to 5
position with the hips slightly abducted (Fig. 21-23). (Table 21-6), and symmetry is assessed.
Hypotonic infants will be positioned with the legs in In infants, upper extremity strength can be evaluat-
external rotation or in a frog-leg position. Lack of flexed by rotating each arm at the shoulder, elbow, and
ion is also seen in premature infants and as a result of wrist while noting muscle strength. Upper extremity
central nervous system (CNS) trauma before or during strength can be assessed in children by assessing prona-
delivery (see Chapter 11). When the term infant is hor- tion, grip, and fine motor abilities. To assess pronation,
izontally suspended with the thorax firmly supported, the examiner asks the child to stand, eyes closed, with
the extremities should maintain flexion tone. In hypo- arms extended, palms facing upward; this position is
tonic infants, the extremities dangle limply. Abnormal maintained for 30 seconds. The examiner then notes
muscle tone in an infant indicates neurologic injury any tendency the child has to turn the palms down
or dysfunction, likely because of prenatal or perinatal (pronation), lower the arms, or bend them at the
or hypoxic–ischemic injury. In children toddler aged elbows; any tremors are also noted. If these responses
and older, muscle tone and posture are evaluated by occur, upper motor neuron disease must be consid-
observing the child playing or walking. ered. Muscle strength can be determined by testing
Muscle tone in the head and extremities of the infant the child’s elbow flexion and extension. This is done
is assessed by gently pulling the infant from a sitting to a by holding the child’s upper arm with one hand and
standing position; no head lag should be evident by age grasping the wrist with the other, then asking the child
6 months (see Chapter 13, Fig. 13-11), and the extremi- to pull his or her arm toward the body as the exam-
ties should have normal, symmetrical tone. Abnormal iner pulls the child’s arm away from the body. This is
positioning of the head, neck, or extremities indicates done on both arms, and the results are compared. To
neurologic dysfunction. Decreased muscle tone (hypoto- test wrist dorsiflexion, the examiner asks the child to
nia) is seen in genetic disorders, such as Down syndrome, hold his or her right arm at the side of the body, elbow
trisomy 13, Werdnig-Hoffman disease, and develop- flexed, and the forearm extended forward. While the
mental disabilities, such as cerebral palsy and congenital child makes a fist, the examiner places his or her left
hypothyroidism. Hypotonia is also seen after CNS infec- hand on the child’s forearm, just behind the wrist, and
tions, including encephalitis and meningitis and as a the right hand over the child’s fist. The examiner then
complication of kernicterus and traumatic brain injury exerts downward pressure on the child’s fist while ask-
(e.g., shaken baby syndrome. Hypertonia (i.e., increased ing the child to resist. Normally, the child should be
muscle tone, spasticity, rigidity, persistent primitive able to resist the pressure. This assessment is done on
reflexes, delay of normal motor skill acquisition) is seen both arms, and the results are compared for symme-
in children with upper motor neuron lesions, such as try. Continued assessment of upper extremity muscle
cerebral palsy and genetic or metabolic diseases that strength includes testing the child’s grip. This is done
damage the child’s developing CNS (Mandingo & by asking the child to grasp the examiner’s extended
Anderson, 2006). Shaken baby syndrome can also lead middle and index fingers firmly. Both hands should be
tested simultaneously. As the child grasps the exam-

iner’s fingers, the examiner attempts to extract his or
her fingers from the grip; it should be difficult to do
so. When noting upper extremity strength, the exam-
iner also notes any marked preference for one hand
displayed by the child. Marked handedness in children
younger than early school age can indicate cerebral
palsy or paresis on the affected side.
Muscle strength in the lower extremities can be
assessed in the infant, beginning at 4–6 months, by
pulling the infant from the sitting to the standing
position. With children toddler aged and older,
lower extremity muscle strength can be evaluated by
observing the child’s gait and balance or by asking the A
child to press the soles of his or her feet against the
examiner’s hands while the examiner pushes back;
the child should be able to resist. When evaluating
muscle strength in ambulatory children, the provider
assesses for the Gower sign, which is seen in children
with myopathies. This occurs when a child with mus-
cle weakness of the extensors of the hips attempts to
stand up from the floor. The child first sits up, then
shifts his or her body weight to the hands and knees,
and then uses the hands and arms to climb up his or
her own legs to stand (Fig. 21-24).
When assessing muscle size, the provider begins by
inspecting the muscles for enlargement, contractures,
or atrophy, and then measures the circumference of
both upper and lower extremities, comparing sides.
For example, enlargement of the calf muscles occurs
with Duchenne muscular dystrophy (Wilson, 2007).
The manner of assessment to evaluate fine motor
abilities depends on the child’s age (see Chapter 2). Fine
motor coordination does not begin until approximately
5 months with raking, progressing to a fine pincer grasp B
by 12 months. Depending on the child’s age, fine mo-
tor abilities can be assessed by asking the child to pick
up small pieces, turn the pages in a book, stack blocks,
complete a puzzle, draw a picture, or cut with scissors.
Involuntary Movements. During assessment of motor

function, the examiner notes any involuntary move-
ments, including tremors, seizures, clonus, myoclonus,
dystonia, tics, chorea, and athetosis, Tremors, or coarse,
repetitive shaking movements, are considered normal in
the neonate in the first few days of life but must be distin-
guished from seizures. Neonatal seizures may manifest as
ocular movements, lip-smacking, chewing, or pedaling
(Sheth, 2009). Seizures in older children are characterized
by simple twitching, tonic–clonic movements (jerking
with stiffness), or automatisms (lip-smacking, gestur-
ing, repeating words), depending on the type of seizure
(Wolf & McGoldrick, 2006). Clonus is a rapid and rhyth-
mic, jerking movement of the foot caused by the sudden C
stretching of a tendon. Clonus is normal in the newborn
FIGURE 21-24. Gower sign. A. First the child sits, then shifts
(see Chapter 11). Sustained clonus beyond six to eight the body weight to hands and knees (B), then uses his hands
beats or clonus that continues past the neonatal period to “climb up” to stand (C).
may indicate an upper motor neuron abnormality, such cerebral palsy, metabolic and glycemic abnormalities,
as cerebral palsy ( Jones, Morgan, Shelton, & Thorgood, and the side effect of several classes of drugs (Robertson,
2007). Myoclonus is a brief, rapid (less than 0.25 seconds) Mohamed, & Moorjani, 2008). Chorea often occurs with
muscle jerk that can occur in isolation or be associated athetosis, which is characterized by slow, writhing move-
with seizures. Dystonia is a muscle contraction that lasts ments, often occurring in the hands and feet. Athetosis is
longer than myoclonus and can result in a muscle spasm seen in children with certain types of cerebral palsy.
that can cause hyperextension of the joint. Tics are invol-
untary muscle contractions or vocalizations that result in
stereotyped movements. Tics may herald the onset of To-
urette syndrome (Howley & Gray, 2008). Chorea is char- COMMON DIAGNOSTIC
acterized by brief, irregular, purposeless, nonrepetitive STUDIES
jerking and writhing movements that move from one
muscle to the next in an unpredictable way (Robertson, Various diagnostic tests may be necessary to clarify dif-
Mohamed, & Moorjani, 2008). Chorea in children is as- ferential diagnoses of abnormal conditions involving
sociated with inborn errors of metabolism, hyperthyroid- the musculoskeletal system. Some examples of these
ism, hypoparathyroidism, pertussis, diphtheria, varicella, diagnostic studies and their indications are summa-
bacterial endocarditis, viral encephalitis, Lyme disease, rized in Table 21-7.
TABLE 21-7
Diagnostic Studies to Evaluate Musculoskeletal Conditions in Children
DIAGNOSTIC STUDY INDICATION COMMENTS
Arthrocentesis Joint effusion To evaluate for septic arthritis
Complete blood count Fever, joint pain, limp, and fracture Can diagnose or rule out bone infection
(osteomyelitis, septic arthritis, toxic synovitis),
and hemorrhage after traumatic bone injury;
also aids in diagnosing hemoglobinopathies,
chronic infections, and malignancy (Leung &
Lemay, 2004)
C-reactive protein Joint inflammation or infection Aids in diagnosis of osteomyelitis or septic

arthritis
Blood cultures Fever or joint inflammation Aids in diagnosis of osteomyelitis or septic

arthritis
Erythrocyte Joint inflammation or infection Aids in diagnosis of osteomyelitis or septic

sedimentation rate arthritis
Computed To evaluate severity of osteomyelitis, Especially useful in diagnosing pelvic and spinal
tomography scan Legg-Calvé-Perthes disease, or slipped problems (Leung & Lemay, 2004)
capital femoral epiphysis
Ultrasound To diagnose developmental dysplasia Preferred diagnostic study for evaluating the
of the hip hips for developmental dysplasia of infants age
6 months and younger (Norton & Polin, 2008);
also helps diagnose joint effusion or abscess
Magnetic resonance Helpful in diagnosing diskitis and Requires the child to be completely still during
imaging spinal cord tumor (Leung & Lemay, examination so young children require sedation
2004); also useful for diagnosing but adolescents may be able to remain still
fractures in the presence of marked
edema
Radiographs To diagnose fracture, joint effusion, or Differentiates between metatarsus adductus and
avascular necrosis talipes equinovarus
Radionuclide bone Aids in diagnosis of occult fracture, More sensitive than plain radiographs (Leung &
scintigraphy osteomyelitis, diskitis, avascular Lemay, 2004)
necrois, bone infarct, and tumor
(Leung & Lemay, 2004).
Cady, R. B. (2006). Developmental dysplasia of the hip: defini-

DOCUMENTING FINDINGS tion, recognition, and prevention of late sequelae. Pediatric
Annals, 35(2), 92–101.
SAMPLE WRITE-UP: NORMAL Castriota-Scanderbeg, A., & Dallapiccola, B. (2006). Hands. In
Castriota-Scanderbeg, A., & Dallapiccola, B. Abnormal skeletal
MUSCULOSKELETAL EXAMINATION phenotypes: From simple signs to complex diagnoses. (pp. 361–
454). New York: Springer.
Subjective Findings Cheema, J., & Harke, H. D. (2007). Blount disease. Retrieved
Three-day-old male November 14, 2008, from http://www.emedicine.com/radio/
TOPIC83.htm.
Prenatal history: Prenatal care begun in first tri-
Chin, K. R., Price, S., & Zimbler, S. (2001). A guide to early detec-
mester; no prenatal exposure to drugs, alcohol; no tion of scoliosis. Contemporary Pediatrics, 18(9), 77–98, 103.
history of maternal infection Cole, L. L. (2008). Autism in school age children: A complex col-
lage of development, behavior and communication. Advance
Perinatal history: Normal, spontaneous, vaginal
for Nurse Practitioners, 16(3), 38–48.
delivery; no distress at birth; Apgars 8 and 9 Ganel, A., Dudkiewicz. I., & Grogan, D. P. (2003). Pediatric ortho-
pedic physical examination of the infant: A 5-minute assess-
ment. Journal of Pediatric Health Care, 17(1), 39–41.
Objective Findings Garrich, J. G. (1977). Sports medicine. Pediatric Clinics of North
General: Alert, good muscle tone America, 24, 737–747.
Gogi, N., Khan, S. A., & Varshney, M. K. (2006). Limb length dis-
Musculoskeletal: Chest symmetrical, no obvi-
crepancy following titanium elastic nailing in paediatric fem-
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at clavicles; upper limbs present, equal length and Gottschlich, L. M., Eerkes, K. J., Lin, D. Y., & Schwartz, E. (2008).
Achilles tendonitis. Retrieved December 11, 2008, from
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equal; negative Ortolani and Barlow maneuvers;
Jones, M. W., Morgan, E., & Shelton, J. E. (2007). Primary care
feet in normal anatomic position; no equinovarus of the child with cerebral palsy: a review of systems (Part II).
deformity. Journal of Pediatric Health Care, 21(4), 226–237.
Jones, M. W., Morgan, E., Shelton, J. E., & Thorgood, C. (2007).
Cerebral palsy: Introduction and diagnosis (Part I). Journal of
Pediatric Health Care, 21(3), 146–152.
SAMPLE WRITE-UP: CHILD WITH Katz, D. (2006). Slipped capital femoral epiphysis: the impor-
tance of early diagnosis. Pediatric Annals, 35(2), 103–111.
MUSCULOSKELETAL COMPLAINT Kocher, M. S., Lee, B., Dolan, M., Weinberg, J., & Shulman, S. T.
Subjective Findings (2006). Pediatric orthopedic infections: early detection and
treatment. Pediatric Annals, 35(2), 112–122.
Fifteen-year-old obese male presents with complaints Leung, A. K. C., & Lemay, J. F. (2004). The limping child. Journal
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Lilly, K., & McCambridge, T. M. (2008). Running injuries. Con-
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Lindaman, L. M. (2001). Bone healing in children. Clinics in Po-
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MacDonald, J., & D’Hemecourt, P. (2007). Back pain in the ado-
Weight: 190 lbs (86 kg) (⬎97th percentile); height: lescent athlete. Pediatric Annals, 36(11), 703–712.
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Mandingo, C. E., & Anderson, R. C. E. (2006). Management of
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Mehlman, C. T., & Koepplinger, M. E. (2008). Growth plate (physeal)
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CHAPTER
Assessment of the
22 Neurologic System
ELLEN M. CHIOCCA
The purpose of the pediatric neurologic examination is conduct impulses to and from the CNS and transmit
to identify neurologic problems, developmental delays, impulses between nerve centers within the CNS. Glial
and acute neurologic injuries. The child’s neurologic cells (neuroglia) are nonexcitable cells that support
system may be adversely affected during the prenatal and protect the neurons; most of the cells in the ner-
and postnatal periods as a result of various insults, such vous system are glial cells.
as hypoxemia, ischemia, trauma, or infections (e.g., Neurons have three components: the dendrite, cell
bacterial meningitis). Complaints of headaches, signs body, and axon (Fig. 22-1). Dendrites are short, twig-
of increased intracranial pressure (ICP), developmental like projections that receive impulses from adjacent
delays, or any injury to the head or spine necessitate cells and relay them to the cell body. A nucleus with-
a thorough neurologic assessment. It is important for in the cell body maintains complex metabolic func-
the pediatric health care provider to be adept at this tions to keep the cell functioning. The axon is a long
assessment to ensure early diagnosis and treatment of projection that transmits impulses away from the cell
neurologic disorders or developmental delays. Illnesses body. Most neurons are insulated by myelin, a white,
and injuries involving the neurologic system can cause fatty substance that allows nerve impulses to travel
long-term effects and impact a child’s physical and quickly and smoothly. Both spinal and CNs are my-
psychosocial growth and development. elinated; myelinated neurons are also located in the
white matter of the brain and spinal cord. Support
of the neuron by glial cells is accomplished by hold-
ANATOMY AND PHYSIOLOGY ing the neuron in place and forming myelin, thereby
OF THE NEUROLOGIC SYSTEM creating myelin sheaths; insulating the conduction of
nerve impulses, and supplying oxygen and nutrients
The neurologic or nervous system is the most complex, to the neurons.
intricately balanced system in the body, controlling all
body functions. It is composed of two parts: the central CENTRAL NERVOUS SYSTEM
nervous system (CNS) and the peripheral nervous system
(PNS). The CNS consists of the brain and spinal cord. The Brain Structures
PNS is divided into the somatic nervous system (SNS) and The brain is divided into the cerebrum, cerebellum,
the autonomic nervous system (ANS). The SNS includes all and brainstem (Fig. 22-2). The brain is housed by the
of the neurons associated with voluntary skeletal mus- skull, or cranium; the major cranial bones are labeled
cles, skin, and sense organs. The ANS divides into the according to the lobe of the brain they cover: fron-
parasympathetic and sympathetic systems and controls the tal, parietal, temporal, and occipital. These bones
involuntary functions in the body. The PNS includes 12 are connected by immoveable joints (sutures) (see
pairs of cranial nerves (CNs) and 31 pairs of spinal nerves. Chapter 13).
The cell is the basic unit of the nervous system. The brain is covered by three protective layers of
meninges: the dura mater, arachnoid, and pia mater. A
narrow groove called the subdural space separates the
NERVE CELLS dura mater from the arachnoid; a second groove, the
Two major cell types make up the nervous system: subarachnoid space, lies between the arachnoid and pia
neurons and glial cells. Neurons, the basic brain units, mater (Fig. 22-3).
458
C H A P T E R 22 A s s e s s m e n t o f th e Ne urologic S ystem • 459
outer layer of the cerebrum contains furrows termed

sulci. These sulci separate the cerebral hemispheres
into four lobes: frontal, temporal, parietal, and occipital
(see Fig. 22-2). Each lobe has distinct functions:
• Frontal Lobe. The frontal lobe contains the precen-
tral gyrus, which controls voluntary musculoskeletal
Cell body
movement. The prefrontal area controls high-level
functions such as personality, thought processes, in-
Nucleus tellectual functions, and the ability to concentrate;
in addition, this area partially controls respirations,
gastrointestinal activity, circulation, pupillary reac-
tions, and emotions. Broca’s area in the frontal lobe
controls the ability to articulate speech. Damage
Dendrites to this area causes expressive aphasia. The written
speech area of the frontal lobe controls the ability to
write words.
• Parietal Lobe. The parietal lobe controls sensory
function. The postcentral gyrus receives impulses from
the spinal cord and interprets the sensations, such
Axon as temperature, pressure, pain, vision, hearing, taste,
FIGURE 22-1. Structure of a neuron.
and smell; in addition, the parietal lobe allows intact
proprioception.
• Occipital Lobe. The occipital lobe is the visual sen-
Each of the brain’s four ventricles contains a bun- sory area of the brain. It interprets and integrates vi-
dle of capillaries, the choroid plexus. This is where sual images, and it associates visual images with past
cerebrospinal fluid (CSF), a clear, colorless, odorless flu- experiences.
id, is produced; its functions are to lubricate the brain • Temporal Lobe. The temporal lobe perceives and in-
and spinal cord, protect these structures from injury, terprets sounds. It also integrates sound stimuli into
and to transport waste and nutrients. CSF flows from pitch, quality, and loudness and plays a role in con-
the ventricles and circulates through the brain and trolling behavior and emotion.
spinal cord. The spinal cord exits the cranium via the • Wernicke’s Area. This area is where the parietal and
foramen magnum, an opening located at the base of temporal lobes meet. It works in conjunction with
the skull. the temporal lobe in interpreting spoken and writ-
ten language. Injury to this area of the brain causes
Cerebrum. The cerebrum is the largest part of the receptive aphasia.
brain. Its outer surface or cerebral cortex is covered by Embedded deep within the cerebrum is the dien-
a thin layer of unmyelinated neurons, called the gray cephalon, which contains the thalamus, hypothalamus,
matter, and an inner core called the white matter, which and epithalamus (see Fig. 22-2). The thalamus relays
contains myelinated axons. The cerebral cortex (gray sensory input, assists in motor function, and regulates
matter) consists of a complex network of neurons that consciousness and alertness. The hypothalamus, which
control most of the brain’s high-level functions, includ- is part of the ANS, regulates appetite, thirst, body tem-
ing memory, behavior, and reasoning. The basal ganglia perature, heart rate, and blood pressure, sleep and
are located deep within the white matter; they affect wake cycles, and emotions, such as anger and fear. It
motor function by regulating voluntary body move- also contains neurons that regulate adrenocorticotrop-
ments, inhibiting excessive body movement, control- ic hormone, follicle-stimulating hormone, lutenizing
ling fine motor movements, and maintaining muscle hormone, prolactin, and growth hormone. The epi-
tone. Alterations to the basal ganglia can result in motor thalamus contains the pineal body, an endocrine gland
tremors and rigid muscle tone. that produces melatonin, a hormone that regulates the
The cerebrum is divided into two hemispheres, left sleep/wake cycles.
and right. A band of tissue, the corpus collosum, located The limbic system is also contained within the dien-
at the base of the fissure that divides the two hemi- cephalon; it includes the hippocampus and the amyg-
spheres, allows communication between them. The dala. The hippocampus is responsible for long-term
right hemisphere controls the left side of the body, and memory and olfaction (smell). The amygdala controls
the left hemisphere controls the right side of the body. emotions, such as fear, aggression, and affection; it
Thus, a lesion in one cerebral hemisphere causes signs also is involved in memory formation and behavior
and symptoms on the opposite side of the body. The patterns related to mating.
ANTERIOR POSTERIOR
CEREBRUM
Corpus callosum
DIENCEPHALON:
Thalamus
Sagittal plane
Hypothalamus
Pituitary gland
BRAINSTEM:
Midbrain
Pons
Medulla
oblongata
Spinal cord CEREBELLUM
Frontal lobe Parietal lobe Temporal lobe Occipital lobe
Pons
Medulla
oblongata
Cerebellum
Spinal cord
B
FIGURE 22-2. A. Structures of the brain. B. Lobes of the brain.
Cerebellum. The next largest part of the brain, the a cerebellar hemisphere produce signs and symptoms
cerebellum, is located posterior and inferior to the on the same side of the body.
cerebrum between the occipital lobes and brainstem
(see Fig. 22-2). The cerebellum is also divided into BrainStem. The brainstem lies between the cerebral
two hemispheres, each of which is composed of gray cortex and the spinal cord; it is primarily composed of
and white matter. The cerebellum does not initiate nerve fibers. It contains three structures: the midbrain,
movement; it coordinates voluntary movements, pons, and medulla oblongata that control primarily in-
such as walking, balance, coordination, and mainte- voluntary functions (see Fig. 22-2). CNs III–XII also
nance of muscle tone. The cerebellum is integrated arise from the brainstem.
with the vestibular system, which also influences the The midbrain conducts and relays impulses between
maintenance of balance and equilibrium. Lesions in the higher cerebral centers (the cerebrum) and the
Arachnoid villi
Superior sagittal sinus
Skin
Periosteum
Subdural space Bone
Subarachnoid space
Dura mater
Arachnoid
Pia mater
Falx
cerebri
FIGURE 22-3. Meninges of the brain.
lower cerebral centers (the pons, medulla, cerebellum, basilar artery, which supplies blood to the pons, cer-
and spinal cord). A tubular structure, the aqueduct of ebellum, and posterior cerebrum. The internal carotid
Sylvius, runs through the center of the midbrain to arteries supply blood to the anterior and middle brain.
transport CSF between the third and fourth ventricles. The vertebral and carotid arteries are connected at the
The midbrain also houses nuclei for CNs III and IV base of the brain by an arterial anastamosis, the circle of
(Table 22-1). Willis. This connection ensures continued blood flow
The pons, located between the midbrain and medul- to the brain if one of the arteries becomes occluded.
la oblongata, connects the cerebellum to the cerebrum Venous drainage from the brain occurs through sinus-
and the midbrain to the medulla. It contains ascend- es in the dura mater, to the cerebral veins, and to the
ing and descending fiber tracts. The pons also contains superior vena cava, and then ultimately to the right
nuclei for CNs V (motor and sensory nuclei) VI, VII, atrium. Cerebral blood flow is maintained through ce-
and VIII (see Table 22-1). Neurons within the pons al- rebral autoregulation or a steady state of blood flow
low humans to recognize and remember other human irrespective of systemic blood pressure changes.
faces, which is essential for maternal–infant bonding
(Wilson, 2008). Blood–Brain Barrier
The medulla oblongata, a continuation of the spinal
The blood–brain barrier is a semipermeable membrane
cord, lies between the pons and cerebellum; it con-
composed of tightly packed endothelial cells. It pro-
tains all ascending and descending fiber tracts that
tects the brain from harmful substances (e.g., drugs,
connect the brain to the spinal cord. Motor nerve fi-
toxins, chemicals), while allowing essential metabolic
bers cross to the opposite side (pyramidal decussation)
functions to occur (e.g., the passage of water, waste,
in the medulla. The medulla controls the body’s respi-
nutrients, oxygen, carbon dioxide, glucose). To pass
ratory function, heart rate, blood pressure, and other
through the blood–brain barrier, molecules must be
life-supporting reflexes such as gagging, coughing,
small, lipid-soluble, and have low ionic permeability.
and swallowing. This structure also contains nuclei
For example, water-soluble substances, such as sodium
and motor components for CNs VIII–XII (see Table
and potassium, have difficulty reaching the brain,
22-1). Together with the thalamus and hypothala-
whereas lipid-soluble substances, such as alcohol, nar-
mus, this structure comprises the reticular activating
cotics, anticonvulsants, or drugs easily pass through.
system, which is essential for maintaining arousal,
Hypertension, increased ICP, hyperosmolality of a
wakefulness, and consciousness.
substance, radiation, infection, inflammation, trauma,
Cerebral Blood Supply ischemia, or injury to the brain can result in a break-
down of the blood–brain barrier.
The brain is supplied with blood through four arteries:
two vertebral arteries and two carotid arteries, which arise
from the aortic arch or its branches. The vertebral arter- Spinal Cord
ies supply blood to the posterior portion of the brain. The spinal cord is a long, cylindrical structure that is
The point where the two vertebral arteries meet is the an extension of the medulla oblongata. It begins at the
TABLE 22-1
Summary of Cranial Nerve Function and Location
NUMBER NERVE TYPE FUNCTION ANATOMIC LOCATION
I Olfactory Sensory Smell Olfactory bulb and tract
II Optic Sensory Visual acuity and peripheral Optic nerve, chiasm, and tract
vision
III Oculomotor Motor Extraocular movement, pupil Midbrain

Sensory constriction, and accommodation
of upper eyelid elevation
IV Trochlear Motor Extraocular eye movement Midbrain
V Trigeminal Motor Mastication, lateral mandibular Pons

movements
Sensory Facial sensation; corneal reflex
VI Abducens Motor Extraocular eye movement (i.e., Pons

lateral gaze)
VII Facial Sensory Taste (on anterior two thirds of Pons

tongue); stimulates submaxillary
and sublingual gland secretions;
stimulates tears from lacrimal
glands
Motor Facial muscle movement
VIII Acoustic Sensory Hearing and balance Pons

(vestibulocochlear)
IX Glossopharyngeal Sensory Taste (on posterior one third of Pharynx

tongue)
Motor Swallowing, gag reflex, and
cough
X Vagus Motor Controls swallowing, gag reflex, Medulla

movement of palate and larynx,
and speaking; controls heart
rate, diaphragm, abdomen, and
production of gastric acid
Sensory Sensation from the throat,
larynx, heart, lungs, bronchi,
gastrointestinal tract, and
abdominal viscera
XI Spinal accessory Motor Provides motor function for Cervical

sternocleidomastoid and trapezius
muscles (i.e., head and shoulder
movement; head rotation)
XII Hypoglossal Motor Provides motor function to the Medulla

tongue
foramen magnum and extends to the lumbar region tract conveys impulses from the spinal cord to the
(L1–L2). Like the brain, the spinal cord is covered with brain; the descending tract transmits impulses from
the dura mater, arachnoid, and pia mater. The spinal the brain to the motor neurons of the spinal cord.
cord is housed and protected by the vertebral column Within the white matter is the H-shaped gray matter,
(Fig. 22-4). with anterior and posterior horns (Fig. 22-5). Cell bod-
The spinal cord itself is composed of white and gray ies in the anterior horn relay motor impulses from the
matter. The white matter contains thousands of my- CNS to the skeletal muscles.
elinated nerve fibers, which form the ascending (sen- The posterior portion relays sensory impulses from
sory) and descending (motor) tracts. The ascending the body to the CNS.
Spinal pret clinical findings and formulate differential

Spinal cord diagnoses.
nerves segments Vertebrae
C1 The sensory pathways can be divided into the spi-
1
Cervical plexus 2 2 nothalamic tract and posterior (dorsal) columns, two as-
3 3
4 4 cending neural pathways. In the sensory pathways,
5 5 Cervical sensory impulses travel to the brain via afferent fibers
6
Brachial plexus 6 7 in a peripheral nerve, through the posterior (dorsal)
7 8
(ventral primary 1
rami) 8 2 root, and then into the spinal cord. The spinothalamic
T1 3 tract relays sensations of pain, temperature, and crude
2 4
3 5
or light touch; the posterior columns transmit sensa-
4 6 tions of position, vibration, and fine touch.
5 7 The motor pathways are two descending neural path-
6
7 8 ways, the corticospinal (pyramidal) tract and extrapyramidal
Thoracic
8 9 tract. The corticospinal tract transmits motor impulses to
9 10 the muscles from the medulla, where they cross to the
10 11 opposite side of the body. These impulses produce vol-
12
11 1 untary movements that involve skill. The extrapyrami-
2
12 3 dal tracts contain motor neurons, arising from the motor
4
5 cortex, basal ganglia, brainstem, and spinal cord that are
L1
outside the corticospinal tract. These neurons conduct
Lumbar plexus
2 impulses that help to maintain muscle tone and control
3 Lumbar of gross body movements, such as walking.
4
Sacral plexus PERIPHERAL NERVOUS SYSTEM
5
Key
The PNS includes the SNS, and the ANS, the spinal
S1 Sacrum
C1-8 Cervical nerves nerves, and the cranial nerves. The peripheral nerves
2
T1-12 Thoracic nerves 3 contain a sensory (dorsal) and a motor (ventral) root,
L1-5 Lumbar nerves 4 which transmit impulses to the CNS via sensory (af-
5
S1-5 Sacral nerves Co 1 ferent) fibers and send messages from the CNS via the
Coccyx
Co1 Coccygeal nerve
efferent fibers. The PNS, which is not protected by
FIGURE 22-4. The spinal cord and vertebral column. bone like the CNS, is vulnerable to injury.
Somatic Nervous System

PATHWAYS OF THE CENTRAL The SNS controls all voluntary muscle function in the
NERVOUS SYSTEM body with the exception of the reflex arc. The reflex arc
There are two major neural pathways of the CNS: is an involuntary process that functions at an uncon-
sensory and motor. Knowledge of these neural scious level. Reflexes allow the body to respond quickly
pathways helps the health care provider inter- to potentially harmful or painful situations and help to
maintain normal muscle tone. Spinal nerves transmit
impulses to the spinal cord and back to the muscle to
Posterior root create the reflexes, such as deep tendon and superficial
Posterior ganglion
root reflexes.
Posterior Afferent sensory
horn fiber
Autonomic Nervous System
The ANS controls all unconscious, automatic body
functions and is involved in emotional responses to
stress and situations requiring increased energy. Im-
pulses from the ANS are carried by both cranial and
spinal nerves; these nerves carry both somatic and
autonomic nerve fibers. Somatic fibers innervate the
skeletal (voluntary) muscles; the autonomic fibers in-
Efferent sensory Muscle
fiber nervate the smooth (involuntary) muscles, cardiac
Anterior
horn Anterior
muscle, and glands.
Anterior root The ANS is divided into the sympathetic and
horn cell
parasympathetic nervous systems, which function to-
FIGURE 22-5. Cross-section of the spinal cord. gether to maintain homeostasis. Impulses from the
sympathetic and parasympathetic nervous systems These nerves innervate the torso and extremities to
have antagonistic effects to accomplish this; for ex- carry touch, temperature, pain sensations, and motor
ample, the sympathetic nervous system regulates impulses that control the skeletal muscles and invol-
the body’s energy in times of stress and evokes such untary muscles of the viscera. The area of the body that
responses as pupillary dilation, bronchodilation, is innervated by the plexus (nerve network) of a spinal
increased heart rate, and decreased peristalsis. The nerve is called a dermatome (Fig. 22-6). In the event
parasympathetic nervous system restores balance in of a spinal cord injury or lesion, the spinal nerves no
the body after stress by decreasing heart rate, and by longer function above the injury level.
controlling the body’s normal, daily activities, such
as digestion and elimination. Cranial Nerves
There are 12 pairs of CNs that arise from the brainstem,
Spinal Nerves innervating the same side of the body from which they
There are 31 pairs of spinal nerves that originate in the originate. These nerves transmit sensory and motor
spinal cord and exit the vertebral column, each hav- impulses. Table 22-1 summarizes the number, name,
ing a motor and sensory root. These spinal nerves are and functions of the cranial nerves.
named according to their exit point on the spinal cord
(see Fig. 22-4). There are:
• Eight pairs of cervical spinal nerves (C1–C8) UPPER AND LOWER MOTOR NEURONS
• Twelve pairs of thoracic spinal nerves (T1–T12) Upper motor neurons are located completely within the
• Five pairs of lumbar spinal nerves (L1–L5) CNS. They originate in the motor area of the cerebral
• Five pairs of sacral spinal nerves (S1–S5) cortex or the brainstem and convey impulses to the
• One pair of coccygeal spinal nerves lower motor neurons in the spinal cord. Cerebral palsy is
C-2
C-2
C-3
C-3 C-4
C-4 C-5
T-2 C-6
C-5 T-3 T-2
T-4 T-6 T-3
T-5 T-7
T-6 T-8 C-7
T-7 T-9
T-1 T-8 T-10
T-11 C-8
T-9
C-6 T-10 T-12 T-1
T-11
T-12 C-6
C-7 L-1 L-1
L-1 S-3 L-1
S-3 S-3
L-2 L-2
S-4
C-8 L-2 L-2
L-3 L-3
S-2 S-2
L-5 L-5 L-4
L-4 L-4
L-5
S-1 S-1 S-1
Anterior view Posterior view

FIGURE 22-6. Dermatomes, anterior and posterior view.
an upper motor neuron disease. Lower motor neurons are Neuronal Development and Myelination
located mainly in the PNS. They connect the brainstem Neuronal proliferation, migration, organization, and
and spinal cord to muscle fibers, permitting the nerve myelination are processes that are essential to the de-
impulses to travel from the upper motor neurons to the veloping brain and that occur during the embryonic
muscles. Spinal cord lesions, muscular dystrophy, and period; toxic exposures or maternal nutritional defi-
poliomyelitits are lower motor neuron diseases. ciencies can adversely affect these processes.
Neuronal Proliferation. Neuronal proliferation oc-

DEVELOPMENTAL curs between 2 and 4 months’ gestation; any exposure
in utero to toxins or particular genetic diseases can
CONSIDERATIONS impact the number of neurons. For example, chemi-
cal (i.e., maternal ingestion of cocaine [Hu, Cheeran,
CENTRAL NERVOUS SYSTEM Sheng, Ni, Lokensgard, & Peterson, 2006]), environ-
Brain and Spinal Cord Development mental, or infectious exposures can reduce the number
The development of the brain and spinal cord begin of neurons, causing microcephaly; excess neurons can
with the formation of the neural tube, which is com- cause macrocephaly. Inadequate maternal folic acid
pleted and closed by 28 days’ gestation, which allows intake can also result in a CNS malformation. By 36
the CNS and cranial nerves to form. The growth of the weeks’ gestation, neuronal proliferation is almost com-
neural tube eventually leads to the appearance of the plete; this contributes in large part to the process of
skull and vertebrae. Failure of the neural tube to close brain growth and the development of brain function.
dorsally results in defects such as myelomeningocele,
encephalocele, and anencephaly. Failure of the anterior
Neuronal Migration. Neuronal migration peaks be-
tween 3 and 5 months’ gestation. By 6 months, neu-
neural tube to close results in facial and forebrain de-
rons migrate to their permanent neural circuit in the
fects, such as cleft lip or palate or holoprosencephaly.
cortex. This process is essential for the development of
The full-term neonate’s brain weighs approximately
the cerebral cortex. Failure of this process to occur cor-
325 grams (g). Brain growth is very rapid in the first year
rectly results in structural abnormalities in the brain,
of life; the cranial sutures are not fully fused at birth
which can lead to agenesis of the corpus collosum or
through age 1 to accommodate the rapid brain growth.
cranial nerves; seizures in the neonate may be the first
Cranial sutures begin to fuse by 6 months and gradually
clinical manifestation of these disorders.
ossify during childhood (see Chapter 13, Fig. 13-2). The
cranial sutures can be separated by increased ICP until Neuronal Organization. Neuronal organization, in-
approximately age 12 years. Fontanelles are areas of concluding cell differentiation, development of cell syn-
nective tissue between the sutures, which gradually close apses, neurotransmitters, and myelination, occurs at
and ossify; the posterior fontanelle closes by 2 months, approximately 27 to 28 days’ gestation and provides
and the anterior fontanelle by 12 to 18 months (see the underpinning for brain function. Neuronal orga-
Chapter 13, Fig. 13-2). Cranial bones that are not fully nization and myelination play a large role in brain
ossified leave the infant more vulnerable to skull fracture growth and maturation.
and subsequent brain injury after falls or other trauma.
By 1 year of age, the infant’s brain weighs approxi- Myelination. Myelination begins early in the third
mately 1000 g; by 12 years of age, the brain reaches trimester, occurs rapidly in the first 2 years of life,
approximately 75% of its adult size. In the term in- and is completed by approximately age 7 years of age
fant, the head size increases approximately sixfold in (Chidananda & Mallikarjun, 2004). The neurologic
the first year of life, during which time the infant is system is anatomically complete at birth, but since it is
very vulnerable to head and spinal cord injuries, par- not fully myelinated, it is functionally immature until
ticularly shaking injuries. Any neurologic injuries, myelination is complete. The first areas of the nervous
infections, or diseases occurring at this time can per- system to become myelinated are the motor–sensory
manently impact the growth of the brain. roots, special senses, and brainstem, all of which are
The young child depends on continuous blood flow necessary for intact reflex function and survival. My-
to the brain to meet its high demands for oxygen, elination otherwise occurs in a cephalocaudal and
which occur through autoregulation. However, pre- proximodistal pattern that correlates with the head-
mature infants have limited cerebral autoregulation; to-toe acquisition of motor developmental milestones.
in addition, their cerebral vessels are thin walled and For example, with cephalocaudal development, head
fragile, predisposing these infants to intraventricular control develops first, then trunk control (sitting), fol-
hemorrhage (Macfarlane, 2006). The blood–brain bar- lowed by control of the lower extremities (walking).
rier is underdeveloped at birth and, therefore, more Proximodistal development begins with shoulder con-
permeable, not fully developing until the middle of the trol, then control of the upper extremities, followed by
first year of life (Chidananda & Mallikarjun, 2004). fine motor control (e.g., pincer grasp).
PERIPHERAL NERVOUS SYSTEM during pregnancy are noted, particularly infectious dis-
At birth, the neonate has little voluntary motor control; eases (e.g., hepatitis) and infections (e.g., toxoplasmosis,
primitive reflexes (e.g., Moro, rooting, palmar) control syphilis, rubella, cytomegalovirus, herpes, tuberculosis,
most movement. These reflexes are present in the nor- chorioamnionitis, sexually transmitted infections, hu-
mal term infant at birth and diminish as the infant’s man immunodeficiency virus). Episodes of bleeding
CNS matures over the next 4 to 6 months. As the in- during pregnancy, gestational diabetes, pre-eclampsia,
fant’s neurologic system develops, advanced cortical or toxemia are also important components of an assess-
functions and voluntary motor control prevail, and the ment. It is important to determine the mother’s age as
primitive reflexes diminish. As this occurs, postural re- well as her alcohol consumption, drug ingestion (e.g.,
flexes (e.g., the Landau, parachute) replace the primitive methamphetamine, cocaine, heroin), prescribed and
reflexes; this occurs cephalocaudally and proximodis- over-the-counter (OTC) medications, cigarette smoking,
tally. The postural reflexes emerge at 3 to 8 months of and exposure to radiation during pregnancy. A history of
age. Persistence of primitive reflexes or a failure of the previous spontaneous abortions or stillbirths is relevant,
postural reflexes to develop indicates an upper motor including the etiology, if known (e.g., genetic disease).
neuron abnormality (e.g., cerebral palsy).
Perinatal History. The provider must determine if
the child was diagnosed with any perinatal conditions
AUTONOMIC NERVOUS SYSTEM that could lead to a hypoxic–ischemic insult, which
can cause permanent neurodevelopmental deficits in
Parasympathetic and sympathetic functions in neonates
the child. For example, infants who experience as-
and infants are undeveloped; these functions are less able
phyxia during the perinatal or neonatal period are at
to control blood pressure and may respond to pain with
increased risk for various disabling neurologic condi-
tachycardia or increased blood pressure (Chidananda &
tions (e.g., cerebral palsy, periventricular leukomalacia
Mallikarjun, 2004).Cerebral vessels are thin-walled and
[PVL], hearing and visual impairments, developmental
fragile in premature infants, predisposing them to intra-
delay). Additionally, it is important to ask about meco-
ventricular hemorrhage (Macfarlane, 2006).
nium aspiration, abruptio placentae, or nuchal cord.
The provider notes if the child was born by normal,
spontaneous vaginal delivery or by cesarean section,
ASSESSMENT OF THE including the reason for the surgical birth (e.g., abrup-
NEUROLOGIC SYSTEM tio placentae, fetal distress, nuchal cord). The child’s
Apgar scores should be reviewed, noting if the mother
received pain medications during labor; if there was
HISTORY
any fetal distress, birth trauma, or use of forceps; or if
Neurologic problems in children can be acute or the infant required any resuscitation and for how long.
chronic. The reason for the child’s health care visit Complications of birth trauma, such as cephalohema-
guides the provider in deciding what type of data are toma, should be noted, as it may lead to hyperbilirubi-
relevant for the health history. For children who are nemia or kernicterus.
examined for the first time, a complete past medical It is particularly important to note any history of
history, surgical history, family history, and social history prematurity and low birth weight. These infants are at
are obtained. These histories are updated as needed high risk for neurodevelopmental complications, such
when the child presents for health maintenance visits, as cerebral palsy; hearing and visual impairment; and
with special attention to assessment of developmental speech, language, and motor delays, which result in an
milestones and any history of neurologic injury or in- abnormal neurologic examination (Blackman, 2007).
fection. A developmental history is especially important, Preterm infants are also more likely to have other neu-
as delays in achieving developmental milestones can rologic complications, such as seizures, learning diffi-
indicate a neurologic injury or illness. A focused history culties, attention-deficit hyperactivity disorder (ADHD),
is required when the child presents with a neurologic PVL, intraventricular hemorrhage (IVH), as well as
complaint or developmental delay. psychologic and behavioral problems as they reach
childhood (Vanderbilt, Wang, & Parker, 2007).
Prenatal History. The prenatal history is essential when Neonatal History. The provider must inquire about
completing a pediatric neurologic assessment; any pre- any conditions that may have occurred during the neo-
natal insult (e.g., intrauterine hypoxia, infection, toxic natal period, such as severe respiratory distress, extreme
exposure) can cause long-term neurodevelopmental se- hypoxia, or extreme acidosis, which lead to permanent
quelae. The provider should determine when prenatal neurologic complications. These conditions may neces-
care was initiated and whether the mother took prenatal sitate the use of extracorporeal membrane oxygenation,
vitamins, specifically folic acid. Any maternal illnesses which predisposes the neonate to stroke. The provider
• Ears: Low-set ears (can indicate a syndromic feature),

BOX 22-1
hearing loss, vertigo, or tinnitus
Causes of Hyperbilirubinemia • Cardiovascular system: Hypertension, widened pulse
in Neonates pressure, orthostatic hypotension, bradycardia, vaso-
• Biliary atresia vagal syncope, fainting spells, arrhythmia, stroke, con-
• Cephalohematoma genital heart disease, or rheumatic heart disease
• Respiratory system: Irregular respirations, condi-
• Cystic fibrosis
tions that cause hypoxia, or acid–base imbalance
• Galactosemia
• Genitourinary system: Tanner staging or urinary
• Hepatitis
tract disease
• Sepsis • Musculoskeletal system: Spasticity of extremities, dif-
• Syphilis ficulty with balance, coordination, or muscle strength;
• TORCH infections cerebral palsy, paralysis, or muscular dystrophy
• Neurologic: Encephalocele, spina bifida occulta, me-
TORCH, toxoplasmosis, other (e.g., coxsackievirus, Listeria, human par- ningocele, myelomeningocele, Chiari II malformation,
vovirus), rubella, cytomegalovirus/Chlamydia, herpes simplex/hepatitis aneurysm, infantile spasms, IVH, hypoxic–ischemic en-
B/human immunodeficiency virus.
cephalopathy, seizures (including type), status epilepti-
cus, tremors, spasms, parasthesias, ipisilateral or bilateral
must determine if hyperbilirubinemia or bilirubin en- weakness, dizziness, bacterial meningitis, viral menin-
cephalopathy (kernicterus) occurred in the neonatal gitis, encephalitis, Reye’s syndrome, Guillain-Barré syn-
period; both of these conditions can lead to mental drome, episodes of loss of consciousness, memory loss,
retardation and deafness. Box 22-1 lists some causes of changes in concentration, CNS neoplasm, ataxia, apha-
hyperbilirubinemia in the neonate. Meningitis, sepsis, sia, head trauma, irritability, lethargy, chronic fatigue,
hypoxia, seizures, IVH, periventricular hemorrhage, and sleep disorders, ADHD, or tics.
episodes of apnea/bradycardia in the neonatal period • Metabolic disorders: Diabetes mellitus (hyperglyce-
can lead to neurologic complications such as cerebral mia causes lethargy, confusion, coma; hypoglycemia
palsy ( Jones, Morgan, Shelton, & Thorgood, 2007), as causes confusion, lethargy, loss of consciousness,
can hypoglycemia and hypothyroidism. A history of seizures), thyroid disorders (hyperthyroidism causes
poor tone and difficulty with sucking and swallowing in tremors, irritability, restlessness, fatigue, difficulty
the neonatal period can be associated with cerebral palsy sleeping, muscle weakness, and possible mental sta-
and must be noted ( Jones et al., 2007). The examiner tus changes; hypothyroidism causes enlarged pos-
notes the presence of congenital heart defects, focusing terior fontanelle, lethargy, and coma), or hyper- or
on the type of defect; defects that cause decreased pul- hypokalemia, which can cause seizures
monary blood flow can lead to repeated hypoxic events • Hematologic: Sickle cell disease (predisposes child
and resultant neurologic sequelae. A phenylketonuria to stroke), polycythemia, or coagulopathies
(PKU) screen is necessary because if PKU is not treated, • Immunity: Leukemia, lymphoma, history of radia-
mental retardation and seizures may result. tion, or chemotherapy
• Psychosocial: Drug or alcohol addiction, stress, emo-
Review of Systems. Obtaining the review of systems tional lability, irritability, breath-holding spells, behav-
as it relates to the neurologic system involves deter- ioral disorders, eating disorders, anxiety, depression,
mining if the child has ever had any of the following history of suicidal ideation, schizophrenia, hallucina-
conditions: tions, bipolar disorder, or mood changes
• General: Alteration in growth patterns (i.e., height, • Developmental: Age of achievement of major de-
length, weight, body mass index, head circumfer- velopmental milestones, intelligence, memory, abil-
ence), history of high fevers, changes in appetite or ity to adapt to new environments or tasks, or speech
weight, and fatigue and language disorders
• Skin: Café-au-lait lesions (e.g., neurofibromatosis),
hemangiomas, port wine stains (e.g., Sturge-Weber Immunizations. The provider must determine whether
syndrome), or pigmentation changes the child’s immunizations are up to date for age. Cer-
• Head/Face/Neck: Microcephaly, macrocephaly, hy- tain diseases for which children are immunized can
drocephaly, craniosynostosis, plagiocephaly, wide su- cause serious neurologic complications. For example,
tures, bulging fontanelles, altered head control, facial Haemophilus influenzae type B, Streptococcus pneumoniae,
pain, nuchal rigidity or pain, headaches, migraines, and Neisseria meningitidis can cause bacterial meningi-
or facial dysmorphism (e.g., fetal alcohol syndrome) tis. Varicella can cause acute postinfectious cerebellar
• Eyes: Blurred vision, diplopia, nystagmus, strabis- ataxia, encephalitis, Reye’s syndrome, aseptic meningi-
mus, sunset eyes (indicates increased ICP), pupillary tis, Guillain-Barré syndrome, and polyradiculitis (Mehta
changes, or photophobia & Chatterjee, 2009).
Hospitalizations. The provider must ask about past hos- developmental delays. For example, the provider must as-
pitalizations, including dates and length of stay, focusing sess the child’s home environment for lead exposure, es-
on the reason for the hospitalization and whether it bears pecially in homes built before 1960, which have old, chip-
any relevance to the child’s neurologic status. Examples ping paint; children living in these homes are at risk for
of specific conditions about which to inquire include lead poisoning. The provider must ask about the safety of
bacterial meningitis, head trauma, shock, brain tumor, the home or apartment (e.g., whether there are balconies
seizures, hydrocephalus, and myelomeningocele. or high windows from which the child could easily fall).
It is very important to inquire about the caregiver–child
Injuries. The provider should inquire about any history relationship to determine whether neglect is a factor; ne-
of injuries that could impact the child’s neurodevelop- glect can affect the shape and symmetry of an infant’s
mental status, including traumatic brain injuries (TBIs), skull (e.g., flattened occiput if the infant is consistently
spinal cord injuries, poisoning, ingestions, dehydration, placed in a supine position and left in this position for
and near drowning (Table 22-2). Musculoskeletal injuries long periods of time), the child’s neurodevelopmental sta-
may suggest problems with coordination (e.g., posterior tus, and the achievement of developmental milestones.
fossa brain tumors) or impulsive behavior (e.g., ADHD). It is important to identify who lives in the home and
The provider should obtain the date and time of the each person’s relationship to the child. More detailed as-
injury, the details of the injury (i.e., how and why the sessments include determining whether the child’s care-
injury occurred), whether anyone witnessed the injury, givers have social supports, consistent employment, or
what the child’s symptoms have been since the injury, a history of substance abuse or domestic violence, all of
and if the child has any physical or neurodevelopmen- which are risk factors for abuse of a child (Centers for Dis-
tal deficits as a result of the injury. The provider also ease Control and Prevention, 2008). Questions about fam-
assesses whether the child has had to miss school or has ily discipline practices that involve corporal punishment
experienced any changes in social relationships since are vitally important because shaking injuries involve
the injury. When obtaining the history, the provider long-term neurologic consequences, such as mental and
should continually evaluate whether abuse or neglect cognitive impairments, hearing and visual impairments,
played a role in the child’s injuries (see Chapter 23). seizure disorders, developmental delays, motor deficits,
spasticity, cerebral palsy, quadriparesis, hydrocephalus,
Surgical History or microcephaly (Castiglia, 2001; Gutierrez, Clements, &
The provider must determine what surgeries the child Averill, 2004; Nakagawa & Conway, 2004). Inflicted head
has undergone that are related to his or her neurologic trauma in children can result in all of the aforementioned
status or diagnoses. The dates and any complications of consequences in the long-term; the short-term neurologic
all surgeries should be included. Examples of the kinds clinical presentation can include unexplained loss of con-
of surgical procedures that are important to include are: sciousness, respiratory distress, apnea, irritability, hypoto-
• Surgery after head trauma to evacuate a hematoma nia, seizures, coma, recurrent vomiting, or poor feeding
• Surgery to remove a brain tumor in an infant or young child (Hymel & Hall, 2005).
• Shunt placement, including the reason for placement The provider should ask the child’s primary care-
(e.g., obstructive or nonobstructive hydrocephalus), giver if there are any prescription medications or ille-
type of shunt (ventriculoperitoneal, atrioventricular), gal drugs in the home. Children of all ages may ingest
number of revisions, any shunt infections these drugs inadvertently or intentionally, resulting
• Surgery to treat epilepsy in mild-to-severe neurologic impairment, depending
• Surgical repair of meningocele, myelomeningocele, on the child’s age, weight, and the quantity ingested.
or encephalocele The older school-aged child and adolescent should be
asked (with the parent out of the room) about their
Family History drug use. Cocaine use and glue sniffing predispose the
The provider must obtain a family medical history to as- child to stroke; alcohol toxicity can lead to brain dam-
sess the prevalence of neurologic conditions or genetic age. Traumatic brain injury can occur with alcohol use
disorders, such as Tay-Sachs disease, congenital hypo- if it is associated with a motor vehicle collision.
thyroidism, galactosemia, maple syrup urine disease, Providers must ask about the child’s school prog-
PKU, or primary adrenal hypoplasia. Any consanguinity ress or any behavior problems reported by either the
should be determined, as this increases the child’s risk parent or the teacher. Difficulty in school, inattentive-
for genetic disorders (Yunnis, El Rafei, & Mumtaz, 2008). ness, and even school failure may indicate hearing
The provider also determines if there is a family history impairment, developmental delay, mental retardation,
of seizures, migraines, learning disorders, or ADHD. ADHD, or depression.
Social History Developmental History

The social history focuses on aspects of the family’s liv- It is imperative to obtain an accurate developmen-
ing conditions, lifestyle, and any risk factors that could tal history, particularly for children 6 and younger.
predispose the child to neurologic infections, injuries, or This includes ascertaining when the child attained
TABLE 22-2
Types of Traumatic Brain Injuries in Children
CATEGORY AND DESCRIPTION
OF BRAIN INJURY CAUSES ASSESSMENTS
Concussion: Functional impairment of the • Motor vehicle collision A thorough history and physical
brain that does not cause abnormalities on • Sports injuries examination are conducted related to:
neuroimaging studies (Anderson, Heitger, & • Violence • Head
Macleod, 2006); neurologic alterations are • Falls • Eye
transient (⬍6 hours) and reversible. • Bicycle-related injuries • Ear
• Face
• Neurologic system
• Vision
Circumstances surrounding injury,
history of soft tissue injuries, and
loss of motor or sensory function
are noted (Hymel & Hall, 2005).
Examiner asks about a history
of fatigue, sleep disturbances;
impaired coordination, memory, and
concentration; anxiety; depression;
anger; or irritability, all of which may
be post-concussion symptoms (Sotir,
2001). Use of bicycle helmets and
other protective sports equipment,
booster seats, and seatbelts in motor
vehicles are noted; a history of abuse
or neglect is noted.
Diffuse axonal injury (DAI): Shearing type of • Motor vehicle injuries Thorough neurologic history and
brain injury causing disruption in axons and • Shaking injuries physical are necessary; DAI is typically
nerve fiber tracts, usually caused by violent the underlying injury in SBS (see
motion such as motor vehicle collision; loss of Chapter 23).
consciousness lasts ⱖ6 hours in the absence of
any focal deficits
Skull fracture: Break in one or more of the As with concussion PLUS: As with concussion PLUS: Type of
cranial bones caused by injury to the head • Neglect skull fracture is noted; history of rib
Linear skull fracture: • Abuse or long bone fractures and injuries
• Basilar skull fracture to nose or mouth are noted (Hymel
& Hall, 2005); history of seizures,
Depressed skull fracture: including type and onset, and history
• Simple of repeated injuries are noted (may
• Compound point to abuse; see Chapter 23). Basilar
• Closed skull fractures cause leakage of CSF
• Open from the nose or ear, blood behind
the TM, and ecchymosis behind the
ear (Battle’s sign) or under the eyes
(raccoon eyes).
Epidural hematoma: Bleeding between the • Blow to head As with concussion and fractures
skull and dura mater in the epidural space; • Skull fracture PLUS: Examiner assesses for history
often caused by linear skull fractures; without • Falls of seizures, headaches, weakness,
rapid intervention, patients with arterial hemiplegia, or personality changes;
epidural hematomas quickly deteriorate alterations in speech, ataxia, and
and die. blurred vision are noted (Molofsky,
2006).
Subdural hematoma: Bleeding between As above PLUS: As with concussion and fractures
the dura mater and the arachnoid into the • SBS PLUS: Examiner assesses for history
subdural space; signs and symptoms include • Arachnoid cyst of seizures, headaches, weakness,
gradual onset of headache, drowsiness, • Use of anticoagulants hemiplegia; personality changes,
confusion, occasional focal deficits, and alterations in speech, ataxia, and
seizures. blurred vision (Molofsky, 2006).
(continued)
TABLE 22-2
Types of Traumatic Brain Injuries in Children (Continued)
CATEGORY AND DESCRIPTION
OF BRAIN INJURY CAUSES ASSESSMENTS
Subarachnoid hemorrhage: Bleeding in the Traumatic: Examiner assesses for any long-term
subarachnoid space; neurologic function may • Acute head injury neurologic sequelae.
be normal but may cause acute neurologic • Birth trauma
abnormalities. • SBS
Nontraumatic:
• Sickle cell disease
• Polycythemia
• Coarctation of the aorta
• Intracranial aneurysm
• AVM
• Brain tumor
AVM, atriovenous malformation; CSF, cerebrospinal fluid; SBS, shaken baby syndrome; TM, tympanic membrane.
age-appropriate language, gross and fine motor mile- History of Present Illness
stones, and social and cognitive milestones, all of When a child presents with a neurologic complaint (e.g.,
which reflect the child’s neurodevelopmental status. head or spinal injuries, recurrent headaches, persistent fe-
If a child has lost a skill or has regressed, referral to a ver, developmental delays, identified neurologic disorder),
pediatric neurologist is needed (see Chapter 2 for a full the provider must obtain a focused history (i.e., history
discussion of the developmental history). of the present illness [HPI]), including information about
onset (sudden or gradual), duration, and progression. For
Medications infants and young children, the parent provides the infor-
The provider should inquire about any medications the mation. Older children may have difficulty with memory
child is taking on a regular or as needed basis, includ- or speech after a head injury, and the parent may need to
ing OTC medications and complementary or alterna- provide the historical information. With adolescents, the
tive treatments (see Chapter 6). Some medications have history may need to be obtained with the parent out of
neurologic, vestibulotoxic, or sedating side effects that the room to glean the most accurate information, espe-
must be noted. Examples of these include medications cially concerning drug and alcohol use or a possible preg-
prescribed for migraines, muscle relaxants, anticon- nancy, which can be associated with fainting. Assessment
vulsants, antidepressants, antihistamines, narcotic or of acute neurologic injury is discussed at the end of this
opioid analgesics, antipsychotics, anxiolytics, central chapter. Some examples of neurologic problems seen in
nervous system stimulants (e.g., methylphenidate or the pediatric population are listed in Box 22-2. Relevant
pemoline for ADHD), or aminoglycosides, as neurotox- questions to ask for the HPI can be found in Table 22-3.
icity can occur with high doses and prolonged therapy
of these drugs. The examiner must determine whether
BOX 22-2
adolescent girls are using oral contraceptives, as these
may predispose them to stroke. The indication, ordered
Selected Pediatric
dose, and time of last dose of any medications should Neurologic Problems
also be noted, as the side effects of some of these medi- • Ataxia
cations may affect the neurologic examination. • Cerebral palsy
• Developmental delay
Allergies • Headaches
Assessment of allergies, including the type of reac- • Head injuries
tion, should be included as part of a pediatric neuro- • Lead poisoning
logic assessment. For example, chronic environmen-
• Meningitis
tal allergies may cause nasal congestion, affecting
• Myelomeningocele
smell; anaphylaxis can result in loss of consciousness
• Seizures
if not treated promptly. A history of severe allergies
or anaphylaxis should be considered when an atop- • Spinal cord injuries
ic child presents for care and has an altered level of • Status epilepticus
consciousness (LOC).
TABLE 22-3
History of Present Illness: Neurologic Complaints
Ataxia Neonatal and birth history? Social history? What is the Acute onset often caused by toxic
age of the child? Fever? Is the child on medications? ingestion (unintentional in young
Type? Dose? Time of last dose? Associated headache? children or intentional in older child)
History of migraines? Onset? Recent alcohol ingestion? of drugs or alcohol; infectious etiologies
Nystagmus? Results of sensory examination? (e.g., meningitis; encephalitis); hemorrhage
or brain tumor that cause increased
ICP. Chronic ataxia may be caused by
neurodegenerative disorders, migraine,
cerebral palsy, or the sequelae of head
trauma or lead poisoning (Schnitzler, 2008).
Behavioral Irritability? Change in appetite, attention span, school Behavioral changes may be clues to ADHD,
changes performance? Emotional lability? History of drug or drug use, depression, or other mental
alcohol use? health problems.
Changes in cry Prenatal, perinatal, and neonatal history? Focal High-pitched cry is a sign of increased ICP
(infants ⬍6 neurologic findings? Duration of cry? Character of cry? in young infants. Intractable crying in an
months) Pain assessment? Social history? infant may be due to injury.
Developmental Prenatal, perinatal, and neonatal history? Home Premature infants and those who
delay environment (e.g., lead exposures)? Vision or suffer intraventricular hemorrhages or
hearing impairments? Current developmental hypoxic–ischemic insults are likely to
milestone assessment? Loss of milestones or chronic have developmental delay; FAS, injury,
developmental delay? Past medical history (metabolic lead poisoning, lack of stimulating
disorders, seizures, cerebral palsy, sleep disorders)? Any environment; abuse or neglect can also
neurologic soft signs present? Social history? School cause developmental delay (see Chapter 2).
progress? Behavior issues? Family history? Medication
history? Acute or chronic illness? History of injury?
What are parental concerns (see Chapter 2)?
Dizziness Associated tinnitus, vertigo? Current medications, Thorough neurologic exam is needed.
including OTC medications and herbal remedies? Dizziness can be caused by migraine,
Eating disorders? History of hypoglycemia or diabetes? demyelinating disease, acoustic tumors, or
Has child ever fallen as a result of dizziness? Any cerebellar lesions.
significant cardiac or neurologic history? Nystagmus?
History of drug or alcohol use?
Fever Height of fever? Child’s age? Concomitant infection? Generalized seizure may accompany fever,
Nuchal rigidity? Immunization status? History of febrile especially in children with a previous
seizures? history or family history of febrile seizures.
Fever with seizure often indicates bacterial
meningitis.
Headaches Onset? Location? Character of headache? Duration? Different types of headaches have different
Intensity of pain (use pain scale)? History of previous characteristics (e.g., nausea and vomiting,
headaches or migraines? Aura? Associated vomiting? photophobia, or phonophobia occur
Visual changes? Vertigo or dizziness? Any triggers with common migraine; chronic tension
(e.g., menses, certain foods, stress)? Photophobia? headaches are mild to moderate in intensity
Phonophobia? Speech disturbances? Sleep problems? without nausea or vomiting (Rowley, 2005).
Seizures? Current illness (e.g., viral upper respiratory Headaches in children can be caused by
infection; sinusitis)? Teeth pain? Chronic ear infections? cervical spine abnormalities, arteriovenous
Does the child wear glasses? Pain on palpation of malformations, ear infections, muscular
sinuses? Temporomandibular joint pain? Caffeine, pain, and sinusitis or vision abnormalities
tobacco, or drug use? Current medications (e.g., OTC (Linder, 2005).
medications; herbal remedies)? Medications used to
treat headache and time of last dose? What makes
headache worse or better?
(continued)
TABLE 22-3
History of Present Illness: Neurologic Complaints (Continued)
Head injury Mechanism of injury? Time of occurrence? Events It is very important to get a detailed
surrounding injury? Did the injury involve a fall? From neurologic history and physical
what height did the child fall and onto what surface? examination regarding the type of head
Motor vehicle collision? Sports-related injury? Area injury; symptoms of different types of TBIs
of head injured? Loss of consciousness at the time overlap but some are mild and transient;
of injury? Since the injury? Any evidence of abuse others are serious and life-threatening and
or neglect? Any vomiting, ataxia, seizures, or visual can lead to prolonged disability.
disturbances? Any associated injuries (e.g., lacerations,
fractures)? Drainage from the nose or ear?
Hearing loss Onset? Associated injury or infection? Other neurologic Hearing loss may indicate cranial nerve
signs or symptoms? Current medications? Past medical damage.
history?
Hypotonia Onset? Duration? History of prenatal or perinatal Hypotonia can be caused by asyphxic
(“floppy asphyxia? Delay in reaching developmental milestones? insults before or during birth, CP, CNS
infant”) Family history? Social history? infections, myopathies, or neglect.
Incoordination Onset? Recent injury? Current medications? Medical Motor incoordination in children may
history? Diagnosis of CP? History of drug or alcohol result from CP, autism, exposure to
abuse? Developmental delay? toxins, side effects of medications, or
intoxication.
Irritability Age of child? Onset? Associated vomiting or headache? Irritability, vomiting, headache, and
Fever? Ataxia? Recent injury? Current medications? Past ataxia in children 6 and younger points
medical history? History of mental health disorders or to medulloblastoma (Fuchs, 2002).
addiction? Is the infant or child easily consoled? Cause in infant may be benign or simple
(e.g., fatigue, hunger, thirst, colic, hair
tourniquet) or the result of an inflicted
injury. Irritability occurs with acute
otitis media, headache, head trauma,
hypoglycemia, sleep disorders, and
chronic pain. Irritability may be the
side effect of some medications, such as
albuterol and some anti-epileptic drugs.
Irritability is also associated with alcohol
and drug withdrawal, anxiety, and
depression.
Memory loss Recent head injury? Traumatic emotional event? Memory loss is associated with TBI; it can
History of drug or alcohol use? also be related to stressful or traumatic
events.
Muscle wasting Prenatal, perinatal, and neonatal history? Past medical Muscle atrophy in children likely caused
history (e.g., musculoskeletal or neurologic disorders; by muscular dystrophy, Werdnig-
chronic endocrine or metabolic illnesses)? History Hoffmann disease (spinal muscular
of trauma? Weakness? Pain? Weight loss? Loss of atrophy), CP, paralysis associated with
sensation? Alcohol or drug use? Steroid use? myelomeningocele, hypothyroidism,
protein deficiency, rheumatoid arthritis,
spinal cord injury, or prolonged bedrest.
Nuchal rigidity Onset? Associated fever? Nuchal rigidity is caused by meningeal

irritation and points to CNS infection.
Paresthesia Location? Associated symptoms? Fainting? History Numbness and tingling in children may
of seizures? Past medical history? History of breath- be due to hypothyroidism, diabetes, as a
holding spells? Current medications, including OTC complication of trauma, lead poisoning,
medications and herbal remedies? Cardiac history? drug overdose (e.g., some antibiotics,
chemotherapy), or breath-holding spells.
Direct nerve compression can be caused
carrying heavy objects, such as a heavy
school backpack.

Seizures Age of child? Onset (sudden or gradual)? Cyanotic Type of seizure needs to be differentiated
during seizure? Did the child report an aura? Loss of to define etiology of seizure and treat
consciousness? Has child regained consciousness? Type appropriately; partial seizures may progress
of motor movements (e.g., bilateral? Tonic–clonic?) to generalized seizures. CNS injury or
Child febrile? Height of fever? Associated head injury? infection needs to be treated; CNS imaging
Duration of seizure? Loss of bowel or bladder control? studies may need to be obtained to
Visual, auditory, or olfactory disturbance? Behavioral diagnose space-occupying lesion.
change? Previous known seizures? Compliance with
anticonvulsant regimen? Medication history? Drug
and alcohol use? Recent ingestions (e.g., poisons,
medications)? Focal neurologic findings (abnormal deep
tendon reflexes)? Bulging fontanelle or nuchal rigidity
with fever suggests bacterial meningitis? Current blood
sugar, electrolytes, and oxygen saturation?
Slurred speech Onset? Medical history? Recent head injury or an Cardiac and hematologic disorders;
intracranial or craniofacial infection? coagulopathies, vascular anomalies and
trauma can cause stroke in children. Head
injuries or infections can cause cranial
nerve damage, causing difficulty speaking.
Syncope Paresthesia? Menstruating female? History of seizures? A detailed and complete history is
Past medical history (e.g., diabetes, vertigo, breath- important to obtain to identify cardiac
holding spells, orthostatic hypotension)? Family etiology of syncope during physical activity
history? Cardiac history (e.g., prolonged QTC)? Fainting and to differentiate syncope from seizures.
related to athletic activity? History of eating disorders?
Pain Onset? Acute or chronic pain? Recent injury or illness? Important to identify source of pain to
Location of pain? Associated symptoms? make accurate diagnosis and develop
appropriate treatment plan.
Photophobia Onset? Associated with fever? Headache? Immunization Photophobia can indicate meningeal
status? irritation or migraine.
Vertigo Onset? Gradual or acute onset? Associated head injury? Vertigo indicates inner ear abnormality;
Aggravating/alleviating factors? Child taking any may also be caused by cranial nerve VII
medications? Has child ever fallen because of vertigo? abnormality or side effect of medication;
Any problems with hearing? Nystagmus? vertigo is also associated with migraines.
Visual changes Type of visual change? Diplopia? Loss of vision? Onset? Visual changes can indicate increased
Associated head injury or infection? Other neurologic intracranial pressure or cranial nerve
signs or symptoms? abnormalities.
Vomiting Onset? Associated head injury or infection? Other Vomiting can be a sign of increased ICP,
neurologic signs or symptoms? Fever? migraines, or viral illness.
ADHD, attention deficit hyperactivity disorder; CP, cerebral palsy; CNS, central nervous system; FAS, fetal alcohol syndrome; ICP,
intracranial pressure; OTC, over the counter; TBI, traumatic brain injury.
PHYSICAL EXAMINATION sessment of mental status, speech, language, CN function,

The pediatric neurologic examination can be completed by sensation, motor function, muscle strength, gait, balance,
general observation integrated within the overall physical coordination, deep tendon reflexes, and primitive reflexes.
assessment or by a more purposeful, specific neurologic as- The necessary equipment includes the following:
sessment, which is generally performed when a child pre- • Tape measure for measuring head circumference
sents with a developmental delay or neurologic complaint. • Penlight
Both approaches require that the examination be tailored • Ophthalmoscope
to the child’s age and developmental level. Physical assess- • Tongue blades
ment of the neurologic system includes a general physical • Reflex hammer
examination of relevant body systems (see Developmen- • Tuning fork
tal Approach to Neurologic Assessment), a developmental • Familiar small objects (e.g., coins, paperclips, pencil)
assessment, and a focused neurologic examination. The • Aromatic substances familiar to children (e.g., bubble
focused pediatric neurologic examination includes an as- gum, mint, chocolate, soap, isopropyl alcohol)
• Sweet and sour items for tasting (glucose, salt, lemon (macrocephaly or hydrocephalus) reflect neurologic ab-
juice) normalities in infants and children. Hydrocephaly is of-
• Two small tubes: one containing hot water and the ten accompanied by an enlarged frontal area, tense ante-
other containing cold water rior fontanelle, and in some cases, sunset eyes. The head
• Safety pin is also inspected for symmetry and shape. In neonates,
• Cotton balls positional molding and craniosynostosis need to be dif-
• Cotton-tipped applicators ferentiated. Some genetic conditions and chromosomal
• Snellen chart anomalies are known to be associated with craniosynos-
• Toys, such as stuffed animals, finger puppets, or tosis (e.g., Apert, Crouzon, and Pfeiffer syndromes) (Rice,
hand-held windmill to engage young children Rice, & Thesleff, 2003). In infants and toddlers, the fon-
• Small ball tanelles are inspected and palpated until age 2; a bulging
• Denver Developmental Screening Test fontanelle indicates increased ICP. Signs of increased ICP
are delayed in children with open fontanelles.
Developmental Approach to the Head control is assessed in young infants; lack of head
Neurologic Examination control beyond age 6 months is likely a result of cerebral
When performing the pediatric neurologic examina- palsy. Auscultation over the skull above the eyes can reveal
tion, the provider must consider the child’s age, devel- a cranial bruit, which may indicate an intracranial vascu-
opmental level, and temperament; children preschool lar malformation. The skull should be percussed for any
aged and younger may not be able to cooperate devel- split cranial sutures (Macewen’s sign) (see Chapter 13).
opmentally with parts of the examination. The first step
is to just observe the child’s spontaneous activity (e.g., Integument. The skin is inspected for dermatologic
feeding, talking, playing, walking), followed by a more manifestations of neurocutaneous syndromes. Some
purposeful examination. Abnormal findings in any as- examples are given in Table 22-4.
sessment area may indicate a developmental delay or
underlying neurologic abnormality. Young children re-
spond well to a playful approach to the examination; TABLE 22-4
the use of finger puppets or stuffed animals, for exam- Dermatologic Abnormalities
ple, is helpful in engaging a young child. School-aged and Associated
children and adolescents can be examined in an orga- Neurocutaneous Syndromes
nized and systematic way. With all ages, the least pleas-
ant aspect of the examination should be done last (e.g., DERMATOLOGIC NEUROCUTANEOUS
ABNORMALITY SYNDROME
eliciting the gag reflex, inspecting the fundus), as these
maneuvers often cause crying, particularly in young Oculocutaneous telangiectasia Ataxia telangiectasia
children, which may alter examination findings. (Moe, Benke, Bernard, & (Louis-Bar syndrome)
Levisohn, 2009).
General Physical Examination
Linear, yellowish, hairless nevi Linear sebaceous nevus
When conducting the pediatric neurologic examina- found in craniofacial area
tion, a general physical examination is included. The (Schwartz & Jozwiak, 2009).
essential parts of this examination that should be not-
ed include the following. Six or more café-au-lait Neurofibromatosis 1
macules over 5 mm in greatest
diameter (prepubertal children);
Vital Signs. When vital signs are assessed, the follow- over 15 mm in greatest
ing measurements are recorded: temperature (i.e., fever), diameter in postpubertal
heart rate, respiratory rate, blood pressure (e.g., wide pulse children; axillary or inguinal
pressure indicates increased ICP). Fluctuations in heart freckling (Moe, Benke, Bernard,
rate, blood pressure, and body temperature accompanied & Levisohn, 2009).
by sweating may indicate autonomic instability. Port-wine stain over the face Sturge-Weber syndrome
that covers the forehead
Somatic Growth. Height and weight are measured and upper eyelid (i.e., the
and plotted on growth charts (see Appendix B) and ophthalmic division of the
compared to previous measurements (see Chapter 8); trigeminal nerve) (Moe, Benke,
these percentiles should also be compared with head Bernard, & Levisohn, 2009).
circumference measurements. Hypopigmented macules Tuberous sclerosis
(“ash-leaf spots”) that
Head. Measurement of head circumference, which is follow dermatomes, facial
the most accurate reflection of brain growth, is measured hamartomas (Moe, Benke,
and plotted on the appropriate growth chart for age Bernard, & Levisohn, 2009).
and sex. A small head (microcephaly) or a large head
and congenital anomalies (e.g., hydrocephalus, arach-

noid cysts) (Kaplowitz, 2009).
Spine. The lumbosacral area of the spinal column

should be inspected for abnormalities, including tufts
of hair, sinuses, or dimples (or sacs). A dimple or small
sac with a tuft of hair in the lumbosacral area indicates
FIGURE 22-7. Sunset eyes; a sign of increased intracranial spina bifida occulta. The spine is assessed for scoliosis
pressure. in children school-aged and older.
Developmental Assessment
Dysmorphic Features. Facial dysmorphism should The pediatric neurologic examination must include an as-
be noted; this often accompanies syndromes or genetic sessment of the child’s neurodevelopmental milestones.
conditions that include macrocephaly, microcephaly, Achieving these milestones is an important indicator
and mental retardation. of CNS maturation and development; any delays or ab-
normal patterns in achieving developmental milestones
Neck. The neck is assessed for nuchal rigidity, which may signal underlying neurologic disease. The health
indicates meningeal irritation. Muscle tone of the neck care provider must be familiar with the timing of ma-
is also assessed. jor age-appropriate developmental milestones (e.g., head
control, walking, talking, playing) to conduct a develop-
Eyes. The eyes are inspected for the presence of the mental assessment competently (see Chapter 2).
“sunset sign,” which suggests increased ICP (Fig. 22-7).
Nystagmus and strabismus are noted, which may be
signs of PVL. The pupils are examined, noting if they are NEUROLOGIC EXAMINATION
equal in their reaction to light, if they are round, and if The pediatric neurologic examination is conducted in
accommodation is normal. Extraocular eye movements the following sequence, beginning at the highest level
are assessed (CN III, IV, VI), and any ptosis is noted. A of neurologic functioning and concluding with the low-
red reflex and blink are elicited. A fundoscopic eye ex- est: cerebral functioning (behavior and mental status),
amination is performed as part of a complete pediatric CNs, motor function, sensory function, and reflexes.
neurologic examination. Any retinal hemorrhages in
the lethargic neonate may indicate SBS (Nakagawa & Mental Status Evaluation
Conway, 2004). Papilledema on fundoscopic exam indi- The mental status evaluation is an essential portion of
cates increased ICP. Assessment of the child’s vision is in- the pediatric neurologic examination. It begins with ini-
cluded in the neurologic assessment (see Chapter 15). tial contact with the child and continues until the end of
the encounter. This examination is conducted according
Ears. The ears are inspected for any deformities. Low- to the child’s age and developmental level. Much of this
set ears may be seen in children with chromosomal ab- portion of the neurologic examination can be integrated
normalities and other syndromes. The child’s hearing throughout the complete history and physical examina-
is assessed, which evaluates CN VIII (see Chapter 14). tion. Abnormal findings in pediatric mental status evalu-
ation may indicate anxiety, depression, neurologic illness
Cardiovascular System. The blood pressure is mea- or injury, or a metabolic disturbance.
sured in more than one reading. Abnormally high read- The pediatric mental status examination includes
ings can predispose the child to hemorrhagic stroke. the assessment areas described below.
A child who presents with headaches, hemiplegia,
aphasia, dystonia, seizures, and sensory motor deficits Appearance. The provider assesses the child’s overall
may be experiencing an ischemic stroke. Any congeni- appearance, including whether the child appears to be
tal or acquired cardiac abnormalities predispose the the stated age, is clean and well groomed, and is dressed
child to ischemic stroke (Molofsky, 2006). appropriately for age and weather. Appearing younger
or older than stated age may indicate neglect. In ado-
Abdomen. The abdomen is palpated for organo- lescents, lack of grooming or cleanliness may indicate
megaly, which can indicate the presence of any of the depression; in young children, it often indicates neglect.
storage diseases (e.g., Tay-Sachs disease, Niemann-Pick Thus, an assessment of the family’s socioeconomic sta-
disease) that involve CNS degeneration. tus is important, as poverty and homelessness can have
a major impact on the child’s dress and hygiene.
Tanner Staging. Sexual maturity rating is done in chil-
dren of all ages (see Chapter 20). Precocious puberty can Level of Consciousness. The LOC, which is assessed
be caused by brain tumors, CNS injury (e.g., head trau- according to age and can be quantified by the pediat-
ma, surgery, inflammation, radiation therapy, abscess), ric Glasgow Coma Scale (GCS) score (Table 22-5), is the
TABLE 22-5
Adapted Glasgow Coma Scale for Infants and Children*
EYE OPENING
SCORE INFANTS AND CHILDREN ⬍1 YEAR INFANTS ⬎1 YEAR

4 Open spontaneously Open spontaneously
3 To loud noise To verbal command
2 To pain only To pain only
1 No response No response
MOTOR RESPONSE
SCORE INFANTS AND CHILDREN ⬍1 YEAR INFANTS ⬎1 YEAR

6 Movements purposeful and spontaneous Obeys commands
5 Localizes pain Localizes pain
4 Flexion withdrawal to pain Flexion withdrawal to pain
3 Flexion involuntary and abnormal (decorticate rigidity) Flexion involuntary and abnormal (decorticate rigidity)
2 Involuntary extension (decerebrate rigidity) Involuntary extension (decerebrate rigidity)
1 No response No response
VERBAL RESPONSE
SCORE BIRTH TO 23 MONTHS CHILDREN AGE 2–5 YEARS CHILDREN ⬎5 YEARS

5 Smiles, coos, cries, vocalizes Appropriate words and phrases Oriented and converses
4 Cries Inappropriate words; confused Disoriented and converses
3 Inappropriate crying and/or Cries and/or screams Inappropriate words

screaming
2 Grunts Grunts Incomprehensible, non-specific

sounds
1 No response No response No response
*Score is obtained by determining the score for each of the three criteria (eye-opening, best motor response, best verbal response) and
adding them. 13–15 ⫽ mild head injury; 9–12 ⫽ moderate head injury; and ⬍8 ⫽ severe head injury.
Source: Barkin, R. M., & Rosen, P. E. (2003). Emergency pediatrics: A guide to ambulatory care. (6th ed.) St. Louis: Mosby.
most sensitive indicator of a child’s neurologic status. to stay focused. Abnormal thought processes occur with
The GCS assesses three major areas: eye opening, motor mental retardation, schizophrenia, and depression.
response, and verbal response. Decreased responsiveness
to commands or decreased pinprick or pain response in Mood and Affect. Mood is how the child feels, and
any age-group indicates a deteriorating LOC. affect is the observable emotion that manifests the
mood. Children who are preschool aged and older can
Thought Processes. A thorough evaluation of thought be asked directly how they are feeling (e.g., happy, sad,
organization and appropriateness of responses is an worried). The child’s affect should match the stated
important assessment, keeping in mind the child’s age mood and be appropriate to the child and family’s cur-
and developmental level. This is assessed in toddlers by rent circumstances (e.g., it is normal for children to
asking the child to point to pictures or body parts; pre- have a sad or depressed mood after a loss of a family
schoolers can be asked to identify colors. In children old- member or pet). An affect that is flat, blunted, euphoric,
er than 4 to 5, the provider can ask the child questions or labile may indicate depression or drug use; a flat,
about his or her life, family, friends, and pets, and then euphoric, or labile affect may indicate bipolar disorder.
judge the appropriateness of the answers, at the same time Poor eye contact may indicate depression or may be
assessing the child’s demonstration of logic and ability the cultural norm for that child (see Chapter 4).
Language and Speech. In children of all ages, re- child to explain the plot of a story or to explain a com-
ceptive and expressive language skills are assessed. In mon proverb. The provider must be certain that the child
children age 6 years and older, the provider assesses is developmentally able to think abstractly and that the
the volume, rate, and tone of the child’s speech, not- child has the linguistic and cultural abilities to interpret
ing any speech impediments or stuttering. Children the story or proverb. Abstract reasoning is impaired with
younger than age 6 years may still have articulation mental retardation, severe anxiety, or mental illness.
difficulties that are within normal limits for age. Slow
speech may indicate depression or mental retardation; Cranial Nerve Assessment
rapid speech may indicate a manic episode of bipo- As part of a complete pediatric neurologic examination,
lar disorder. In children that are preschool aged or CN function is assessed. Some of the assessments can
older, written speech is also assessed, keeping in mind be made during observations of spontaneous activity
whether the child has attended preschool. during the health care encounter. For example, ptosis
(CN III), facial asymmetry (CN VII), hoarse voice (CN
Judgment and Impulse Control. Evaluation of judg- X), expressive language difficulties (CNs V, VII, X, and
ment and impulse control is based on the child’s de- XII), abnormal eye position (CNs III, IV, and VI), and
velopmental level. Examiners can ask preschool-aged abnormal pupillary reactions (CNs II and III) can easily
and school-aged children what they would do if con- be evaluated by observation. CNs IV, VI, IX, XI, and XII
fronted by a stranger; adolescents can be asked what can only be assessed in children who are developmen-
they would do if they found a gun. Past history of pat- tally able to cooperate with the assessment. CN I is not
terns of behavior can also be assessed. An inability to typically assessed in neonates and young infants unless
use judgment or control impulses in a developmentally an olfactory abnormality is suspected. Preschool-aged
appropriate manner may indicate mental retardation, and school-aged children often enjoy this portion of
ADHD, brain tumor, bipolar disorder, schizophrenia, the examination, especially when the assessments in-
substance abuse, or long-term inhalant use. volve the use of toys or games to elicit the cranial nerve
responses. Table 22-6 summarizes cranial nerve testing
Insight. This assessment determines whether the chil- in the neonate and infant. Table 22-7 lists cranial nerve
dren are able to articulate their perceptions of them-
testing for children toddler age and older.
selves. The child must be school aged or older to
complete this assessment. The provider may ask the Assessment of Cerebellar Function
child about why he or she is seeking care or to explain
Normal cerebellar function is determined by assess-
certain likes and dislikes. Children and adolescents with
ment of balance and coordination. A child must be
mental illness such as bipolar disorder, mental retarda-
developmentally able to cooperate with these assess-
tion, or severe anxiety are likely to have poor insight.
ments; typically, children preschool ages and older are
Memory. Both short- and long-term memory are assessed. able to do so, depending on the assessment.
Short-term memory is evaluated by asking the child to Cerebellar function can be assessed by evaluation of
recall something that happened very recently (e.g., ask gait, the Romberg test, hopping in place, heel-to-toe
the child what he or she had for dinner the night before). walking (tandem walking), heel-to-shin test, and the
Long-term memory is assessed by asking the child about finger-to-nose test. When making these assessments,
something that occurred in the past, such as the name the examiner notes symmetry and smoothness of
of a former babysitter or teacher. The provider should movements. Impairment in the ability to perform these
validate this information with the parent. Memory im- tests (e.g., nystagmus, ataxia, weakness, or inability to
pairment occurs in children who have suffered asphyxic complete the test) indicates a cerebellar dysfunction.
brain injuries, brain tumor, or TBI or who have ADHD.
Gait and Balance. The child’s gait can be assessed by
Attention Span. Older infants and toddlers normally observing as the child walks across the room, turns, and
have very brief attention spans. Preschool-aged children walks back. Uncooperative or fearful toddlers can be
can be expected to have an attention span long enough asked to walk toward their parent instead of the exam-
to be able to complete a simple task, such as draw a per- iner. The examiner can evaluate the child’s coordina-
son with three to six parts or follow simple directions, tion and stance while also noting any limp or ataxia;
such as copying a square. In children who are school the child’s gait should be smooth and symmetrical with
aged and older, attention can be assessed through rote an easy alternate arm swing. The toddler normally has
memory (e.g., asking the child to repeat a series of words a wide-based gait as a result of physiologic lordosis; a
or letters 5 minutes after they heard them). Attention wide-based gait is abnormal beyond toddler age. It is
span is shortened with ADHD and mental retardation normal for preschool-aged children to be knock-kneed
and after a neurologic infection or TBI. when ambulating. Some abnormalities in gait include
cerebellar ataxia, scissors gait, and toe-walking. Cerebel-
Abstract Reasoning. Abstract reasoning is assessed in lar ataxia can occur with a brain tumor, cerebral palsy,
children aged 11 and older. It can be done by asking the cerebellar dysfunction, alcohol intoxication, or as the
TABLE 22-6
478
Assessment of Cranial Nerve Function in Neonates and Infants
CRANIAL NERVE ASSESSMENT METHOD NORMAL FINDINGS ABNORMAL FINDINGS
CN I, olfactory Cranial nerve I rarely tested in neonates and infants; Neonate or infant startles, grimaces, sniffs, or Congenital anosmia may indicate Kallman’s
when tested, place a strong smelling substance (e.g., cries in response to strong odor. syndrome, which runs in families; it also
isopropyl alcohol) under infant’s nose. occurs in albino children (Lalwani, 2008).
CN II, optic Assess infant’s response to bright light; test pupillary Neonate and infant blink, and pupils constrict No response to light may indicate congenital
reaction with ophthalmoscope (see Chapter 15). equally in response to light; able to fix and blindness or retinoblastoma.
follow for 60 to 90 degrees.
CN III, oculomotor; Sensory Function: Pupillary response to light and Sensory: Pupils round, equal in size, and reactive Sensory: Absent blink reflex may indicate
CN IV, trochlear; blink reflex are assessed. directly and consensually in response to light congenital blindness.
CN VI, abducens Motor Function: Infant’s spontaneous ability to and accommodation; infant blinks in response to Motor: Disconjugate gaze or asymmetrical
gaze in all directions is noted; “Doll’s eye” maneuver bright light. light reflex after 6 months requires referral to
is performed (gently rotate the infant’s head side Motor: Disconjugate gaze within normal limits avoid neurologic blindness (see Chapter 15).
to side; eyes should move in opposite direction of through 6 months; Doll’s eye maneuver normal, When Doll’s eye manueuver is performed
rotation); blink reflex is assessed. which indicates brainstem is intact. and eyes remain fixed in original gaze,
brainstem injury should be suspected.
CN V, trigeminal Sensory Function: Infant’s cheek is touched with a Sensory: Infant should turn cheek toward Sensory: Absent corneal reflex in neonate is
wisp of cotton; corneal reflex is assessed. stimulus; corneal reflex elicits blinking or tearing. associated with severe brain damage.
Motor Function: Infant’s ability to suck and swallow is Motor: Infant should suck vigorously on gloved Motor: There is difficulty sucking or
assessed by placing gloved finger into infant’s mouth. finger. swallowing.
CN VII, facial Sensory Function: Taste is not usually tested in Sensory: Taste not usually tested in infants; Motor: Facial asymmetry is noted; difficulty
infants. infants prefer sweet tastes. with sucking or swallowing.
Motor Function: Symmetrical facial movement is Motor: Symmetrical facial movement is noted
assessed when the child cries or smiles; the ability to when the child is crying or smiling; there is no
suck and swallow is assessed. difficulty sucking or swallowing.
CN VIII, acoustic Response to startle (up to 4 months) and acoustic Infant responds to sound by quieting to voice No response to sound may be because of
(vestibulocochlear) blink reflex (up to 12 months) is assessed; objective or blinking to hand clap; objective hearing conductive or sensorineural hearing loss,
hearing assessment (i.e., ABR) is performed (see assessments (i.e., ABR) are within normal limits). depending on age of infant and past medical
Chapter 14). history (see Chapter 14).
CN IX, Sensory Function: Gag reflex and ability to suck Sensory: Gag reflex intact; infant is able to suck Sensory: Inability to suck or swallow.
glossopharyngeal; and swallow are assessed. and swallow. Motor: Shrill, high-pitched cry indicates
CN X, vagus Motor Function: Infant’s cry is evaluated for pitch Motor: Normal cry is loud and lusty and not increased ICP; high-pitched cat-like cry
and strength, stridor, or hoarseness. hoarse. indicates cri du chat syndrome.
CN XI, spinal With infant lying supine, the examiner turns the Infant should bring head to midline. Inability to bring head to midline may
accessory infant’s head to one side. indicate CN XI dysfunction or torticollis.
CN XII, Infant’s ability to suck and swallow is evaluated Sucking and swallowing should be coordinated, Difficulty sucking or swallowing is evident.
hypoglossal when feeding; infant’s tongue is inspected for lateral and there should be no tongue deviation.
deviation when crying or cooing.
ABR, automated auditory brainstem response; CN, cranial nerve; ICP ⫽ intracranial pressure.
TABLE 22-7
Assessment of Cranial Nerve Function in Children and Toddler-aged and Older
CN I, olfactory Testing is started at preschool age: nares are checked Child can identify familiar smell. Anosmia (lack of olfaction) in children
to be sure they are not occluded by mucus. With one may be temporary or permanent; upper
nare occluded and eyes closed, the examiner asks respiratory infections, allergies, sinusitis,
the child to smell something familiar such as soap, nasal polyps, or a deviated septum may
bubble gum, chocolate, or mint. This is repeated on cause temporary anosmia; permanent
untested nostril, using a different odor. anosmia may be due to Kallman’s
syndrome, head injury, brain tumor, or
CHARGE syndrome (Chalouhi, Faulcon, Le
Bihan, Hertz-Pannier, Bonfils, & Abadie,
2005).
CN II, optic Each eye is tested for visual acuity; fundoscopy is Visual acuity normal; no papilledema visualized; Abnormalities in vision may be caused by
performed; visual fields and pupillary response on peripheral vision intact; child able to fix on cataracts, conditions that cause increased
both eyes are assessed (see Chapter 15). object and follow for 60 to 90 degrees; pupils ICP (e.g., brain tumors), or uncorrected
constrict in response to light. strabismus.
CN III, oculomotor; Sensory Function: Direct and consensual pupillary Sensory: Pupils are round, equal in size, and Sensory: Absence of pupillary constriction
CN IV, trochlear; response to light; pupil size and accommodation are constrict directly and consensually in response to in response to light or accommodation
CN VI, abducens assessed (see Chapter 15). light and accommodation. indicates abnormality in sensory portion of
Motor Function: Extraocular eye movements Motor: Extraocular movements normal; no lid CN III; physiologic anisocoria (difference
are tested through the six cardinal fields of gaze; lag, ptosis, or nystagmus seen. in pupillary size by up to 20%) is within
upper eyelid elevation and convergence of eyes are normal limits.
assessed; “Doll’s eye” maneuver (see Chapter 15) is Motor: Inability to look upward,
performed; the child is asked to clench teeth. downward, or inward is noted; any ptosis
or lid lag indicates abnormality in CN
III; inability to gaze downward or inward
is also caused by abnormality in CN IV;
inability to move eyes laterally is caused by
abnormality in CN VI; these abnormalities
may be the result of head trauma or space-
occupying lesions. Diplopia is an abnormal
finding attributatble to CN III abnormality.
An abnormal Doll’s eyes test indicates
vestibular abnormality and often results
from brainstem lesions.
(continued)
479
480
TABLE 22-7
Assessment of Cranial Nerve Function in Children and Toddler-aged and Older (Continued)
CN V, trigeminal Sensory Function: This is tested by touching the Sensory: Child moves away from stimulus; Sensory: Diminished or absent corneal reflex
child’s forehead, cheek, and chin with a cotton ball assessment of the corneal reflex elicits blinking may be caused by a sensory (CN V) or motor
while the child’s eyes are closed; the child’s reaction and tearing. (CN VII) abnormality.
to the stimulus is observed; this is repeated with Motor: The function of the jaw should be strong Loss of sensation over either cheek indicates
both a safety pin and a cotton ball, and the child and symmetrical. compression of CN V.
is asked to distinguish sharp and dull; tubes of hot Motor: Deviation of the mandible to one
and cold water are placed on the cheek to assess side when mouth is opened or inability
temperature perception; the corneal reflex is assessed to chew, bite down, or swallow indicates
by gently touching a cotton ball to the child’s cornea. paralysis of CN V.
(This test is often avoided because of the discomfort
involved.)
Motor Function: This is tested by observing the
child chewing and swallowing; if a young child does
not cooperate, the examiner asks the child to make a
“mean” face to assess jaw muscles; the masseter and
temporal muscles are palpated (at temple and jaw
areas) as child bites down.
CN VII, facial Sensory Function: This is tested by asking the child Sensory: Child is able to identify familiar flavors. Sensory: Ageusia (loss of taste) to anterior
to identify a familiar taste by placing a familiar Motor: Movement of facial muscles is two thirds of tongue indicates CN VII
flavor on anterior two thirds of tongue. symmetrical; there are no facial drooping, tics, or dysfunction, which can be caused by space-
Motor Function: This is tested by inspecting the eyelid sagging noted. occupying lesions proximal to CN VII.
child’s face at rest, noting any facial asymmetry or Motor: Paralysis of the facial muscles (Bell’s
drooping; the examiner asks the child to smile, raise palsy), facial asymmetry, or impairment of
eyebrows, make a funny face, puff out cheeks, or eye closure indicates abnormality in CN VII.
show his or her teeth.
CN VIII, acoustic Sensory Function: Hearing is assessed to differentiate Hearing is normal and correlates with language Sensorineural hearing loss is caused by
(vestibulocochlear) conductive and sensorineural hearing loss; the development. No vertigo or dizziness reported. disorders of CN VIII; lateralization to the
whisper test is performed; Weber and Rinne tests and unaffected ear occurs; vertigo can be caused
audiometric testing are performed as needed. by abnormalities in vestibular branch of CN
Vestibular Function: Assess for vertigo by VI, such as tumors or ear infections (i.e.,
performing Romberg test (see Chapter 14). blocked eustachian tube) (see Chapter 14).
CN IX, Sensory Function: Taste receptors are assessed by Sensory: Child able to identify familiar tastes; Sensory: Ageusia (loss of taste) on the posterior
glossopharyngeal; placing a familiar flavor on posterior one third of child can feel touch on palate and gag reflex one third of the tongue is evident; loss of
CN X, vagus tongue and also by eliciting gag reflex with tongue being elicited (CN IX). sensation to soft palate or pharynx indicates
blade. Motor: Gag reflex is intact (CN X); tongue is CN IX dysfunction, which can be caused by
Motor Function: This is tested by assessing tongue strong; uvula and palate should rise promptly and intracranial lesions proximal to CN IX.
strength and swallowing movements; the examiner symmetrically with ipisilateral deviation of uvula Motor: Lesions to CN X result in the absence
asks the child to say “ah” and inspects the palate; when soft palate is touched (“palatal reflex”) (CN of the gag and palatal reflexes; unilateral CN
voice quality, hoarseness, or stridor are noted. X); child is able to swallow without difficulty and IX and CN X paralysis result in deviation of
controls oral secretions (CN IX and CN X); voice uvula to unaffected side when soft palate is
quality and ability to articulate palatal sounds are touched; mild difficulty swallowing is noted;
intact; there is no hoarseness. bilateral paralysis of CN X results in severe
dysphagia; there is no palate elevation with
stimulation and hoarseness of voice.
CN XI, spinal The examiner tests the function of the SCM by Child able to apply resistance using SCM; normal Head or neck trauma, CNS tumors, or
accessory asking the child to lower his or her chin against strength of SCM and trapezius muscles is seen. infections can cause paralysis of SCM or
the resistance; the examiner asks the child to shrug trapezuis muscles.
shoulders upward with and without resistance
against the examiner’s hand; the child is asked to
nod the head and turn head from side to side against
resistance to assess trapezius function.
CN XII, The examiner asks the child to stick out his or her Tongue thrust should be smooth and symmetric; Lesions of CN XII cause tongue deviation or
hypoglossal tongue and move it from side to side; the examiner child should be able to move tongue blade with paralysis, resulting in difficulty articulating
listens to child speak and notes articulations; tongue tongue. Fasciculations are noted; examiner notes lingual sounds (dysarthria).
strength is assessed by asking the child to press the if the tongue deviates toward one side.
tongue against a tongue blade; child’s ability to
pronounce the letter “r” is evaluated.
CHARGE syndrome (colomba, congenital heart disease, choanal atresia, mental and growth retardation, genital anomalies, ear malformations and hearing loss); CN, cranial nerve; CNS, central nervous
system; SCM, sternocleidomastoid.
481
side effect of some medications (e.g., anticonvulsants, turn his or her hands over with palms up, then lift
antihistamines). A scissors gait is described as a gait with them off the thighs in quick alternating movements.
short steps where the thighs overlap with each step; The child is then asked to repeat the process as rapidly
this is often seen in children with cerebral palsy. Toe- as possible for 10 seconds; movements should be quick
walking is considered normal until age 3; after this age, and rhythmic. Inability to perform rapid alternating
it is likely a result of muscle spasticity, most commonly movements is likely a result of cerebellar tumor.
caused by spastic cerebral palsy (Schwentker, 2009).
Finger-to-Nose Test (for Children 8–9 Years or
The Romberg Test. This test assesses propriocep- Older). This examination tests fine motor movements
tion and is primarily performed in children who are in the child. It involves having the child close his or
preschool aged and older; young children may not be her eyes and hold the arms out in front of the body.
able to cooperate fully. To conduct this test, the child The examiner asks the child to touch the tip of his or
stands upright with the feet together, eyes closed, and her nose with the right index finger, then the left index
arms at his or her sides while the provider observes finger, repeating this process several times, with gradu-
the child’s balance for several seconds. The provider ally increasing speed. Movements should be smooth
always stands behind the child in case the child loses and accurate (Fig. 22-9).
balance. Only mild swaying should occur. If the child
leans to one side or loses his or her balance, this indi-
cates a problem with proprioception.
Hopping in Place. By age 4, the child should be able

to hop in place. The examiner asks the child to stand
straight, bend one knee, and then hop in place, first on
one leg and then on the other. The child with intact
cerebellar function should be able to maintain balance
on one leg.
Heel-to-toe Walking (Tandem Walking). The child is

asked to walk heel-to-toe in a straight line; children are
typically able to do this by age 6 (Fig. 22-8). If a child has a
hemispheric lesion, walking in this manner decreases sup-
port for the upper body; some side-to-side swaying is nor-
mal. Ataxia, lack of coordinated movement, or impaired
judgment of distance indicates cerebellar dysfunction.
Rapid Alternating Movements (for Children 8–9

Years or Older). To assess rapid alternating move-
ments, the examiner instructs the child to place his or
her hands face down on the thighs and then rapidly
FIGURE 22-8. Assessment of heel-to toe walking. FIGURE 22-9. Finger-to-nose test to assess cerebellar function.
Heel-to-Shin Test (for Children 8–9 Years or Older). Vibration. Vibration perception is assessed by using a
This test assesses coordination of the lower extremities. low-pitched tuning fork placed on a bony prominence
The provider asks the supine child to place the right heel (e.g., on the wrists, elbows, medial malleoli, patella). The
on the left shin, just below the knee, and then slide the examiner strikes the tuning fork and then holds the base
heel down the shin to the top of the foot. This maneuver of the tuning fork on the bony prominence. The child is
should be repeated as quickly as possible and then re- asked to state when the vibration stops; this is then re-
peated with the opposite foot. The child should be able peated on the opposite side of the body for comparison.
to perform this maneuver without difficulty. If not, the The child should correctly identify the sensation.
provider should suspect an alteration in motor strength,
proprioception, or a cerebellar lesion. An asymmetric Tactile Discrimination. Children 5 and older are usu-
finding suggests an ipisilateral cerebellar lesion. ally able to cooperate with tests to evaluate tactile and
spatial discrimination through assessment of graphes-
Sensory Examination thesia, stereognosis, and two-point discrimination. Loss of
The sensory examination evaluates the child’s ability to sensation often signals an alteration in the peripheral
perceive and discriminate sensation. This includes as- nervous system, spinal cord, brainstem, or cerebral cor-
sessment of light touch, deep pressure, pain, propriocep- tex. Some examples of conditions that illustrate these
tion, temperature, and vibration. Evaluating response alterations include brain or spinal cord tumors, spinal
to a painful stimulus can determine sensory function in cord injuries, myelomeningocele, CNS infections, and
the neonate. This examination is limited in infants and inherited demyelinating neuropathies. The child’s eyes
young children because of their inability to cooperate; must be closed with each of these examinations.
most children over age 3 can cooperate. For each por-
tion of the sensory examination, the child’s eyes should Graphesthesia. The ability to identify shapes traced
be closed and the provider should compare both sides on the palm of the hand is tested by asking the child to
of the body. If sensory discrimination is absent, the ex- close his or her eyes, at which point the examiner draws
aminer should describe boundaries. The sensory exami- a large number or letter on the palm of the child’s hand
nation includes the following assessments. with a blunt end of a pencil. The test should be done
on both palms to ensure accuracy. The child should be
Light Touch. The examiner lightly touches the child’s able to identify the number or letter; an inability to do
skin in various areas with a stretched cotton ball. The so may indicate a sensory, spatial, or proprioceptive
child should be able to identify the area of the body that deficit. Sensory impairments in children, including
is being touched. The provider asks the child to describe impaired proprioception, can be caused by cerebral
any difference in sensation in different areas tested. palsy (Odding, Roebroeck, & Stam, 2006).
Proprioceptive Sensation. The examiner assesses Stereognosis. The ability to recognize objects by
motion and position sense of the limbs by grasping touch is tested by placing a familiar object in the child’s
the child’s toe and moving it up and down and then hand, such as a coin, paperclip, or pencil, and asking the
asking the child what direction the toe is being moved child to name the object; this is repeated in the opposite
and what position it is in; this process is repeated on hand. Impaired stereognosis in children can be caused
the other foot. The child should correctly identify the by cerebral palsy (Odding, Roebroeck, & Stam, 2006).
direction of movements.
Two-point Discrimination. This tests spatial discrimi-
Pain. Using the sharp and dull ends of a reflex ham- nation by asking the child to discriminate touch. At dif-
mer, the examiner checks for mild pain sensation by ferent spots on the skin, first with two points in proxim-
asking the child to identify sharp or dull sensations ity and then with one point, the examiner asks the child
verbally (see Chapter 6 for a detailed discussion of pain to identify if one or two pinpricks were felt. The child
assessment). The child should be able to differentiate should be able to correctly identify the points touched.
between sharp and dull sensations.
Reflex Testing
Temperature. Assessment of the child’s ability to Reflex testing is a particularly useful portion of the
identify hot and cold temperature is only done when neurologic examination. Because the results are quan-
the child’s perception of pain is abnormal. When test- tified, reflex testing provides concrete, objective data
ed, the examiner uses two tubes, one filled with hot about the level of functioning of the nervous system.
water and the other with cold water, and then touches Reflex testing is especially useful with children because
the skin in different areas, asking the child if the sen- it requires minimal cooperation. Both deep tendon and
sation felt is hot or cold. The child should be able to superficial reflexes are assessed, with attention paid to
distinguish between hot and cold temperatures over symmetry and strength of reflexes tested. Assessment
various areas of the skin. of neonatal reflexes is discussed in Chapter 11.
Deep Tendon Reflexes. Deep tendon reflexes (DTRs), Hyperactivity of DTRs indicates upper motor neu-
are elicited by tapping a tendon briskly with a reflex ron lesions, hypocalcemia, or hyperthyroidism. The
hammer, which causes the tendon to suddenly stretch following DTRs are assessed as part of the pediatric
and contract. These reflexes are assessed to evaluate neurologic examination.
the function of the reflex arcs and the spinal cord seg-
ments. When assessing DTRs, they should be tested bi- Biceps Reflex (C5–C6). The examiner flexes the
laterally, and the response is graded as follows: child’s arm at the elbow with the palm slightly lower
• 0 Absent than the elbow. The examiner then places his or her
• 1⫹ Hypoactive thumb on the child’s biceps tendon in the antecubital
• 2⫹ Normal space, then strikes the thumb with the reflex hammer.
• 3⫹ Hyperactive without clonus The normal response is a slight flexion of the arm at
• 4⫹ Hyperactive with clonus the elbow and a contraction of the biceps (Fig. 22-10).
A B
C D
FIGURE 22-10. DTRs. A. Triceps reflex. B. Biceps reflex. C. Patellar reflex. D. Achilles tendon reflex.
Triceps Reflex (C7–C8). This reflex appears at reflexes. Superficial reflexes are evaluated as present or
approximately 6 months. With the child’s arm flexed absent; symmetry is also evaluated. Superficial reflexes
at the elbow (see procedure for biceps reflex), the are absent in the presence of motor neuron lesions or
examiner strikes the child’s triceps tendon slightly spinal cord damage.
proximal to the olecranon between the epicondyles.
A normal response is triceps contraction and elbow Abdominal Reflex (T8, T9, and T10 Innervation
extension (see Fig. 22-10). in Upper Quadrants; T10, T11, and T12 Innervation
in Lower Quadrants). With the handle of the reflex
Brachioradialis Reflex (C5–C6). The examiner begins hammer, the examiner gently strokes the abdomen
by asking the child to rest his or her forearm on the toward the umbilicus. The abdominal muscles should
abdomen so that the palm is slightly lower than the contract, and the umbilicus should move toward the
elbow. The examiner then strikes the brachioradialis stimulus in all four quadrants. This reflex may be dif-
tendon (approximately 1 to 2 inches above the wrist), ficult to elicit in obese children, and it may be absent
over the radius. The forearm should rotate laterally after a child has abdominal surgery; neither are abnor-
with the palm supinated (see Fig. 22-10). mal findings.
Plantar Reflex (L4–L5, S1–S2). This is tested by

Patellar Reflex (L2–C4). This reflex is present at stroking the lateral aspect of the sole of each foot with
birth. For older children, the examiner asks the child the end of the reflex hammer. The examiner observes
to sit on the examination table, knees bent, and for flexion of the toes, which is normal (Fig. 22-11).
legs hanging freely. The examiner then strikes the An abnormal finding is extension of the big toe and
child’s distal patellar tendon with the reflex hammer. fanning of the other toes (Babinski sign) (Fig. 22-
The knee should extend, and the quadriceps muscle 12). For children who are not yet walking, a positive
should contract (see Fig. 22-10). Babinski sign is normal for the age group, because of
the immaturity of the nervous system. If the child has
Achilles Tendon Reflex (S1–C2). The child is asked a positive test, it may indicate lesions of the pyramidal
to dorsiflex his or her foot slighty at the ankle; the tract or motor nerves.
examiner then strikes the Achilles tendon. Plantar
flexion is the normal response (see Fig. 22-10). Cremasteric Reflex (T12, L1). This is tested in
the male patient. To elicit this reflex, the provider
Superficial Reflexes. Superficial reflexes are motor lightly strokes the child’s inner thigh with the end
responses to stimulation of the skin. These include of a cotton applicator. A normal response is eleva-
the abdominal, plantar, cremasteric, and anal wink tion of the scrotum on the same side; the cremas-
FIGURE 22-11. Plantar reflex. FIGURE 22-12. Babinski reflex.

teric muscle contracts as the ipsilateral testis rises in

BOX 22-3
the scrotum.
Primitive Reflexes
Anal Wink Reflex (L4–S1). This is tested by stimu- • Moro reflex
lating the perianal area with a cotton tip applicator. • Rooting
A normal response is quick contraction of the anal • Sucking
sphincter. • Stepping (placing)
• Palmar grasp
Primitive and Postural Reflexes. The primitive • Ankle clonus
reflexes are involuntary reflexes found in the infant. • Galant (truncal incurvation) reflex
These reflexes (Box 22-3) are present at birth, and most • Asymmetric tonic neck reflex
disappear by 4 to 6 months. Asymmetrical, absent,
or persistent primitive reflexes indicate a neurologic
abnormality (see Chapter 11, Table 11-12). Primitive
reflexes should be tested in children who are 1 and Neurologic Soft Signs
younger (see Chapter 11, Table 11-12). Postural re- Neurologic soft signs (NSS) in children are minor ab-
flexes replace primitive reflexes at 5 to 6 months, and normalities found in the neurologic examination in
assessment of these reflexes should begin at this time. the absence of any diagnosed neurologic disorder. Neu-
Some of these reflexes are described in Table 22-8 and rologic soft signs are normal in infants but are often
illustrated in Figs. 22-11 to 22-14. present in children with cognitive or behavioral dys-
TABLE 22-8
Postural Reflexes
AGE AGE HOW TO
REFLEX APPEARS DISAPPEARS ELICIT RESPONSE COMMENTS
Positive support 3 to 4 months Persists The infant is held Infant should Reflex absent
throughout life upright, firmly extend legs in in infant with
supported under an attempt to corticospinal tract
arms with feet bear weight. By disease.
touching a flat 5 to 6 months,
surface. infant is able
to fully support
own weight; by
7 months, infant
able to bounce.
Landau 4 to 5 months 12 months to Infant is placed Infant should raise Absence of

2 years prone on flat head and legs and Landau reflex
surface or arch back (see Fig. suggests problem
suspended firmly 22-14). with motor
supporting development,
abdomen. (e.g., cerebral
palsy).
Parachute 8 months Persists Infant is Infant should Response should

throughout life suspended extend arms be symmetric.
prone and firmly and legs in
supported, then “protective”
quickly lowered manner (see
toward flat Fig. 22-15).
surface.
Protective 5 to 7 months Persists Infant is placed in The arms should Asymmetric

extension-sitting throughout life a sitting position, abduct, and infant response is often
position then gentle force should extend an early sign of
is applied to his or her arm hemiparesis.
displace infant’s outward on the
center of gravity. side of the fall,
palm open, to
stop the fall.
FIGURE 22-13. Landau reflex.
function. Children with a history of perinatal trauma

FIGURE 22-14. Parachute reflex.
or infection, ADHD, autism, or those who have been
neglected are more likely to have NSS on examination.
Typically, NSS resolve by late school age to adolescence
(Ianetti, Mastrangelo, & Di Netta, 2005). Box 22-4 lists whether the trauma was intentionally inflicted on
the NSS seen in children (Ianetti, Mastrangelo, & Di the infant or child in the form of forceful shaking
Netta, 2005). or blows to the side of the head. The provider must
always ascertain whether the history is compatible
Neurologic Assessment of the Acutely Ill with the type and degree of injury that the child
or Injured Child has sustained to rule out intentional injury (see
A focused neurologic assessment is required if an Chapter 23).
infant, child, or adolescent presents with an acute
neurologic injury or illness. Some pediatric neu- History. A focused neurologic assessment begins by
rologic emergencies include acute ataxia, head asking the following questions:
trauma, increased ICP, meningitis, acute onset of • When did the neurologic symptoms begin?
seizures, and status epilepticus. If the child was • Was the onset sudden or gradual?
injured, types of injuries about which to inquire • Has the child had a fever?
include trauma to the head or face, including skull • Has the child ingested anything?
fractures sustained in falls or motor vehicle colli- • Is the child currently taking any medications, in-
sions. If the injury involved a bicycle or scooter, it cluding OTC medications and herbal remedies?
is important to ask if the child was wearing a hel- • Were the symptoms associated with any injury or
met. If the injury involved a motor vehicle colli- trauma?
sion, the provider should ask if the child was in an • How, when, and where and did the injury take place?
approved vehicle restraint. In cases of head trau- What was the mechanism of injury?
ma or skull fractures, the provider must consider • Did the child lose consciousness?
BOX 22-4
Neurologic Soft Signs
• Astereogenesis: Inability to recognize familiar object through tactile recognition
• Dysgraphesthesia: Inability to recognize numbers or letters written on the skin
• Apraxia: Inability to perform purposeful movement in the absence of any other neurologic disturbance
• Dysdiadochokinesis: Inability to perform rapid alternating movements
• Hypotonia: Decreased resistance to passive movement
• Incoordination: Low level of competence in motor skills in the absence of neurologic disease
• Choreiform movements: Rapid, purposeless, asymmetrical movements of the extremities, with an inability to stand
still for 30–40 seconds, eyes closed, feet together, and supinated arms outstretched
• Mirror movements: Simultaneous, contralateral, involuntary, identical movement that accompanies intentional
movement
• Does the child have a headache? Nausea or vomiting?

Visual changes? Photophobia? Tinnitus or vertigo?
Memory loss? Lacerations?
• Has there been any follow-up since the event? Any
diagnostic imaging studies?
• Any pain? What is the location of the pain? How FIGURE 22-15. Decorticate posturing; extremities flexed.
does the child rate the pain (see Chapter 6)?
• Any numbness or tingling?
• Are there changes in behavior? Changes in the qual-
ity of the cry? Any somnolence? child, decorticate (abnormal flexion of arms with
• Does the child have a fever? legs flexed; seen with lesions of corticospinal tract)
• What is the child’s past medical history? Does the (Fig. 22-15) or decerebrate posturing (rigid exten-
child have a ventriculoperitoneal shunt? Brain tu- sion of arms and legs seen with brainstem lesions)
mor? Learning or behavior disorder? Seizures? (Fig. 22-16). To evaluate sensory function, the ex-
• Does the child or teen abuse drugs or alcohol? aminer tests the child’s responses to touch, pain,
• Any history of depression or ADHD? and temperature in all four extremities, the trunk,
• Has the child ingested any toxic substance? and the face. Deep tendon reflexes and the Babinski
reflex (in children younger than age 1 year) are
also assessed.
Physical Examination. In acute neurologic ill- The provider looks for any signs of increased ICP,
ness or injury, the physical examination begins such as headache, nausea, vomiting, visual changes,
with an assessment of physiologic status. Airway, seizure activity, sunset eyes, a bulging anterior fonta-
breathing, circulation, and color are assessed along nelle in infants, papilledema, or altered pupillary re-
with vital signs. The provider should note fever actions. The presence of Cushing’s triad is a late sign
or temperature instability, bradycardia, difficulty of increased ICP. Cushing’s triad includes bradycardia,
breathing, or wide pulse pressure, all of which may hypertension with widened pulse pressure, and irregu-
indicate increased ICP. Next, a thorough neurologic lar respirations.
examination should be done, including assessment Assessment of cranial nerve function is rou-
of the child’s LOC , orientation, memory , eyes , pupils , tinely done with acute head injury or any type of
cranial nerves, reflexes, and motor and sensory func- neurologic impairment (see Tables 22-6 and 22-7).
tion . Using the acronym AVPU (a lert, verbal, pain, Included in the neurologic assessment is an as-
unresponsive), LOC can be assessed quickly in the sessment of the total body for other injuries that
infant (Box 22-5), or it can be quantified, using the may have been sustained in the incident. Inspec-
adapted GCS for infants and children and adoles- tion of the skin includes observation for bruises,
cents (see Table 22-5). Orientation and memory hematomas, or lacerations, which may indicate
can be tested in children preschool aged and older serious injury. Specifically, the examiner looks for
by asking simple questions such as what his or her conjunctival hemorrhages, ecchymosis around the
name is, what day it is, or to remember three num- mastoid region (Battle’s sign), or periorbital ecchy-
bers in sequence and repeat them after 5 minutes. mosis (raccoon eyes); these signs likely indicate
Pupil size, reactivity, and equality are also assessed basal skull fracture. The nose, mouth, ears, and
along with extraocular movements. The provider hypopharynx are inspected for any injuries; clear
also performs a funduscopic examination to assess drainage from the nose or ear may be CSF. The
for retinal hemorrhages or papilledema, which may examiner palpates the skull for tenderness, swell-
indicate SBS or increased ICP, respectively. In acute ing, deformity, or crepitus and the fontanelles in
injury, the provider assesses motor response as infants and assesses for rib or long-bone fractures
spontaneous, spastic, or flaccid, or in the comatose (Hymel & Hall, 2005).
BOX 22-5
Assessment of Responsiveness
Alert, fully awake, responsive, smiles
Verbal, reactive to voice; cooing, babbling, vocalizing
Pain, responsive to pain only
Unresponsive to painful stimulation
FIGURE 22-16. Decerebrate posturing; extremities extended
and pronated.
Assessment of Meningeal Irritation

Assessment of meningeal irritation should be done in
cases of CNS irritation, infection, or with intracranial
hemorrhage. If the provider suspects any of these con-
ditions, he or she should begin by assessing for general
signs of meningeal irritation, such as irritability, leth-
argy, severe headache, or photophobia. With bacterial
meningitis, fever, nausea, and vomiting may also ac-
company these signs. Neonates and infants 2 months
of age and younger are not able to localize infection,
so meningeal irritation may not be recognized until FIGURE 22-18. Assessing for Kernig’s sign.
late stages, for example, when a bulging anterior fon-
tanelle is visible.
To assess for meningeal irritation in older chil-
dren, the provider begins by assessing for nuchal ri- Brudzinski’s Sign. With the child lying supine, the
gidity. To begin, the provider first ensures that the examiner places one hand under the child’s neck and
child has no injury to the neck. The child is placed the other on the child’s chest to prevent movement of
supine, and then the neck is flexed forward until the the torso. The provider then flexes the child’s neck to-
child’s chin touches the chest. The child should be ward the sternum (Fig. 22-19). A positive Brudzinski’s
able to flex the neck forward easily. Pain, stiffness, sign is spontaneous hip and knee flexion upon flexion
or resistance upon flexion may be a sign of menin- of the neck.
geal inflammation, irritation, or neck injury. Opis-
thotonos (Fig. 22-17), or severe arching of the back,
is also a sign of meningeal irritation, but can also COMMON DIAGNOSTIC
occur with tetanus, subarachnoid hemorrhage, brain STUDIES
tumor, and severe head injury. Opisthotonos is more
common in infants and children than adults because There are several diagnostic imaging studies that can
of their immature neurologic systems. Children with be done to evaluate neurologic conditions. Because the
opisthotonos require immediate intervention. Signs etiology of a neurologic impairment may include met-
of meningeal irritation also include Kernig’s sign and abolic disorders, drug reactions or overdoses, syncope
Brudzinski’s sign. or stroke, and neonatal hyperbilirubinemia, other di-
agnostic tests may be ordered in addition to imaging
Kernig’s Sign. With the child lying supine, the pro- studies, based on historical and clinical findings. These
vider lifts the child’s leg, flexes the hip at a right angle, diagnostic studies are summarized in Table 22-9 and
then flexes the knee 90 degrees (Fig. 22-18). The pro- Box 22-6.
vider then attempts to extend the child’s knee. Pain
and resistance with knee extension and hip flexion
and an inability to straighten the leg indicates a posi- DOCUMENTING FINDINGS
tive Kernig’s sign.
SAMPLE WRITE-UP: NORMAL
NEWBORN
Subjective Data
A 48-hour, term male, born via normal spontaneous
vaginal delivery; no significant prenatal or perinatal
history; no hyperbilirubinemia or birth injury.
FIGURE 22-17. Opisthotonos. FIGURE 22-19. Assessing for Brudzinski’s sign.

TABLE 22-9
Diagnostic Studies Used to Evaluate Neurologic Conditions in Children
TYPE OF TEST INDICATION
Computerized tomogaphy (CT); To diagnose intracranial tumors and hemorrhage, hydrocephalus, and
CT angiography inflammatory disorders; CT angiography used to diagnose aneurysms or
arteriovenous malformations
Electroencephalography (EEG), sleep-deprived To diagnose and categorize seizure disorders
Electromyography To diagnose neuropathies and myopathies
Magnetic resonance imaging, magnetic To detect neurologic injury such as hemorrhage; useful in identifying
resonance angiography (MRA) demyelinating disease and cerebral infarction; more specific than CT
scan; MRA used to diagnose suspected intracranial vascular abnormality
or neurologic problems with accompanying visual changes
Positron emission tomography scan To evaluate blood flow, oxygen use, and glucose metabolism
in the brain
Ultrasound To diagnose hydrocephalus and intraventricular hemorrhages,

particularly in neonates
Video EEG To diagnose seizures after equivocal results from sleep deprived EEG or
capture nocturnal episodes
BOX 22-6 Objective Data

Laboratory Studies for Posture: Quiet-alert state; lying supine in flexed
Neurologic Assessment position, no jitteriness or tremors noted
Skin: No lesions or birthmarks
• Albumin (serum)
Head: Normocephalic; mild cranial molding; head
• Blood type and Rh symmetrical; fontanelles soft and flat; sutures open;
• Blood culture no hair whorls
• Blood urea nitrogen Neck: No extra skinfolds; neck supple
• CSF culture, gram stain, cell count Face: Symmetrical features; no dysmorphism
• Chromosomal studies Eyes: Symmetrical light reflex, conjugate gaze, cor-
• Complete blood count neal and blink reflexes intact
• Coombs test (if not done at birth) Ears: Helix of ear in line with outer canthus of eyes
• Creatinine (serum) Chest: No respiratory distress or apnea
• Drug screen Spine: Intact, no dimples, sinuses, or tufts of hair;
no masses
• Electrolytes, calcium, magnesium, phosphate levels
Movements: Symmetrical, spontaneous body move-
• Erythrocyte sedimentation rate
ments
• Glucose (serum)
Muscle tone: No flaccidity, normal ventral suspen-
• Hepatitis B and C tests sion; mild head lag
• Human immunodeficiency virus Reflexes: Strong grasp and Babinski (bilaterally),
• Liver function studies suck, Moro, and gag
• Lead level (blood) Cranial nerves: PERL; EOM full and conjugate;
• Platelet count strong suck and swallow; lusty cry
• PT, PTT Assessment: Normal newborn
• Reticulocyte count
• Total and direct bilirubin SAMPLE WRITE-UP: WELL CHILD
• Urinalysis
Subjective Data
• Urine culture
A 3-year-old girl presents for annual health mainte-
nance visit accompanied by her grandmother, who is
PT, prothrombin time; PTT, partial thromboplastin time. the primary caregiver. According to the grandmother’s
report, the child has been in preschool for past 3 Barkin, R. M., & Rosen, P. E. (2003). Emergency pediatrics: A guide
to ambulatory care. (6th ed.). St. Louis: Mosby.
months; the child is able to wash and dry own hands;
Blackman, J. A. (2007). NICU micropreemies: how do they fare?
pedals tricycle; speaks in sentences. Contemporary Pediatrics, 24(2), 64–73.
Castiglia, P. T. (2001). Shaken baby syndrome. Journal of Pediatric
Health Care, 15(2), 78–80.
Objective Data Centers for Disease Control and Prevention. (2008). Child mal-
treatment prevention scientific information: Risk and protec-
Alert, cooperative with exam; follows simple direc- tive factors. Retrieved May 6, 2008, from http://www.cdc.gov/
tions 2 of 3 instances; gait steady, hops on one foot; ncipc/dvp/CMP/CMP-risk-p-factors.htm.
threw ball overhead; DTRs 2⫹ bilaterally; muscle Chalouhi, C., Faulcon, P., Le Bihan, C., Hertz-Pannier, L., Bon-
fils, P., & Abadie, V. (2005). Olfactory evaluation in children:
strength equal bilaterally; CN II–XII intact; copied Application to the CHARGE syndrome. Pediatrics, 116(10),
a circle; language 90% intelligible (4 to 5 word sen- e81–e88.
tences); Denver II not indicated. Chidananda, M. N. S., & Mallikarjun, D. (2004). Applied aspects
of anatomy and physiology of relevance to pediatric anesthe-
Assessment: Well child; neurologically intact; no sia. Indian Journal of Anesthesia, 48(5), 333–339.
developmental delay Gutierrez, F. L., Clements, P. T., & Averill, J. (2004). Shaken baby
syndrome. Journal of Psychosocial Nursing, 42(12), 22–29.
Hu, S., Cheeran, M. C.-J., Sheng, W. S., Ni, H. T., Lokensgard, J. R.,
& Peterson, P. K. (2006). Cocaine alters proliferation, migra-
tion, and differentiation of human fetal brain-derived neural
SAMPLE WRITE-UP: ACUTELY precursor cells. Journal of Pharmacology and Experimental Ther-
ILL CHILD apeutics, 318(3), 1280–1286.
Hymel, K. P., & Hall, C. A. (2005). Diagnosing pediatric head
Subjective Data trauma: Guidance for pediatricians on distinguishing be-
A 9-year-old boy is brought to urgent care center ac- tween accidental and inflicted injuries. Pediatric Annals, 34(5),
358–370.
companied by his mother. Approximately 3 hours Ianetti, P., Mastrangelo, M., & Di Netta, S. (2005). Neurological
ago, child was hit in head with a baseball while bat- “soft signs” in children and adolescents. Journal of Pediatric
ting during a baseball game. Mother says child was Neurology, 3(3), 123–125.
Jones, M. W., Morgan, E., Shelton, J. E., & Thorgood, C. (2007).
struck on forehead above left eye and was briefly Cerebral palsy: Introduction and diagnosis (Part I). Journal of
“stunned.” Child left game and then became sleepy Pediatric Health Care, 21(3), 146–152.
but did not fall asleep. Now feels nauseated but de- Kaplowitz, P. B. (2009). Precocious puberty. Retrieved
November 21, 2009, from http://www.emedicine.com/
nies vomiting, syncope, memory loss, or diplopia. ped/topic1882.htm.
Complains of “bad headache,” not relieved by acet- Lalwani, A. K. (2008). Olfactory dysfunction. In Lalwani,
aminophen given 1 hour ago. A. K. Current diagnosis and treatment in otolaryngology-
head and neck surgery. (2nd ed.). (pp. 232–237). New York:
McGraw-Hill.
Linder, S. L. (2005). Comprehensive pediatric headache examina-
Objective Data tion. Pediatric Annals, 34(5), 442–446.
General: Vital signs stable; alert, responsive, re- Macfarlane, F. (2006). Pediatric anatomy, physiology and the
basics of pediatric anesthesia. Retrieved April 27, 2008, from
sponding appropriately to questions; GCS ⫽ 15. http://www.frca.co.uk/article.aspx?articleid⫽100544.
Skin: Small contusion noted on forehead over left Mehta, P. N., & Chatterjee, A. (2009). Varicella. Retrieved
eyebrow, no ecchymosis noted under eyes or be- November 21, 2009, from http://www.emedicine.com/
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hind ears Moe, P. G., Benke, T. A., Bernard, T. J., & Levisohn, P. (2009).
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on palpation M. J., Sondheimer, J. M., & Deterding, R. R. Current pediatric
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clear; vessels within normal limits bilaterally nals, 35(5), 379–384.
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Ears: No drainage recognizing and responding to a lethal danger. Contemporary
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and mild head injury. Practical Neurology, 6, 342–357. DERM/topic732.htm.
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SECTION 5
A S S E S S M E NT O F T H E
W H O L E CH I L D
CHAPTER
Assessment of Child
23 Abuse and Neglect

ELLEN M. CHIOCCA
One of the most critical assessments the pediatric

health care provider can make is to determine wheth- TYPES OF CHILD
er a child is being emotionally, verbally, physically, MALTREATMENT
or sexually victimized. In 2006, nearly 3.6 million
children in the United States underwent a Child Pro- There are five types of child maltreatment: neglect, phys-
tective Services (CPS) investigation; approximately ical abuse, verbal abuse, emotional abuse, and sexual
905,000 children were confirmed victims of mal- abuse. It is important to note that emotional abuse is a
treatment. There were 1530 child deaths from abuse component of all types of child maltreatment.
in 2006; 78% of these children were younger than 4
(U.S. Department of Health and Human Services Ad-
ministration on Children, Youth and Families [USD- NEGLECT
HHSACF], 2008). Domestic violence is a risk factor Child neglect involves acts of omission, such as depri-
for child abuse, with children often becoming vic- vation of basic necessities, including clean and safe
tims of the physical and emotional violence that is housing and the provision of adequate amounts of
taking place in the home (Berkowitz, 2005). nutritional food, basic hygiene, weather-appropriate
Pediatric health care providers must be able to clothing, education, and emotional support. Neglect
differentiate intentional from unintentional inju- also includes poor or inadequate supervision (Dubowitz,
ries in children, recognize suspicious injuries, and 2004). Frequently, family poverty and parental knowl-
intervene appropriately. Signs of emotional vio- edge deficits are factors that lead to child neglect (Block,
lence, sexual abuse, and neglect must also be as- Krebs, and the Committees on Child Abuse and Neglect
sessed. Children who suffer any type of abuse are and Nutrition, 2005). For example, while a severe diaper
at high risk for developing numerous psychosocial rash may result from parental negligence, it may also
complications, including posttraumatic stress disor- result from poverty (e.g., families cannot afford dispos-
der (PTSD), as well as physical sequelae related to able diapers or a washing machine).
severe abuse or neglect. At each health care encoun- Various subtypes of neglect exist. Emotional neglect
ter, the provider must evaluate the child and family results from the parent or caregiver failing to meet the
for risk factors for abuse; assess discipline practices; child’s emotional needs in age-appropriate ways, such
and teach families about age-appropriate behavior, as ignoring the child, failing to provide emotional sup-
normal developmental milestones, and alternatives port, or being emotionally unavailable. Medical neglect
to corporal punishment. is failure to obtain necessary health maintenance or
493
4 9 4 • S e c t i o n 5 AS S ES S M EN T OF THE WHO LE CHI LD
episodic care for the child (e.g., immunization delays, pain, but not injury, for the purpose of correction or
failure to follow prescribed health recommendations). control of the child’s behavior.” The most common
Educational neglect is the failure to ensure that a child types of corporal punishment used are spanking, slap-
attends school each day or to adhere to any special ping, roughly shoving, and hitting, often with objects
education needs set forth by the teacher or school (i.e., hair brush, belt, paddle) (Straus, 2001).
district. Supervisory neglect often results from paren- Munchausen syndrome by proxy (MSP) is a form of
tal substance abuse, mental illness, or depression; for physical abuse in which one person, most often the
example, a young child is left with a person who is child’s mother, purposely causes the child to be ill;
unable to care for small children. Supervisory neglect this is also a form of emotional abuse (Stirling, Jenny,
also involves failure to provide age-appropriate super- Christian, Hibbard, Kellogg, & Spivak, 2007). Most
vision to infants or young children (e.g., letting them victims of MSP are between 15 months and 6 years of
play alone near the street or a swimming pool; leaving age (Mason & Poirier, 2009). Often, the perpetrator has
young children unattended in a bathtub, in the home, a medical background, which facilitates making the
or in a vehicle). In older children, supervisory neglect false history sound credible. The signs and symptoms
may entail leaving a child alone with guns, allow- demonstrated by the child are only witnessed by the
ing underage alcohol or drug use, and allowing long perpetrator, who appears quite concerned about the
periods of unsupervised time on the Internet or at the child’s illness. Signs and symptoms disappear when
mall (Hymel, Block, Hibbard, Jenny, Kellogg, Spivak, the child is separated from the perpetrator. Children
et al., 2006). who are made intentionally ill by their mothers may
Another form of neglect is exposure to known hazards. be subjected to needless laboratory and diagnostic
Examples include in utero drug exposure; exposure to studies, hospitalizations, and even surgery (Stirling et
hazards in the home, such a lead or other poisons; al., 2007). Historical and physical findings of MSP are
smoking around children; allowing children to ride in listed in Table 23-1.
a vehicle without a car seat or seatbelt; allowing chil-
dren to ride a bicycle without a helmet; and exposure
to domestic violence (Dubowitz, 2004). VERBAL ABUSE
The most extreme form of child neglect is child Verbal abuse involves a deliberate attempt on the part
abandonment. This occurs when a parent does not re- of the perpetrator to belittle a child or destroy his or
trieve a child who has been left in the care of friends her self-esteem. This can include aggressive scolding,
or relatives or abandons a child outside the parameters screaming, swearing, blaming, criticizing, threatening,
of safe relinquishment provided by law. In the last de- name-calling, insulting, mocking, excessive teasing, rid-
cade, safe-haven relinquishment procedures have been iculing, shaming, humiliation, or harassment (Teicher,
developed in all 50 states to prevent unsafe infant Samson, Polcari, & McGreenery, 2006). It is important
abandonment and infanticide; under these laws, new for the pediatric health care provider to watch for clues
mothers can anonymously abandon their newborn that a child is being verbally abused, even though this
without fear of prosecution. However, the abandon- abuse may be difficult to quantify. Children who are ver-
ment must take place at locations to which the safe- bally abused are more likely to suffer from anxiety and
haven laws apply, such as police stations, hospitals, or depression as adults (Sachs-Ericsson, Verona, Joiner, &
fire houses (USDHHSACF, 2008). Preacher, 2006). Verbal and emotional abuse are similar,
and overlap is common.
PHYSICAL ABUSE
Physical abuse is the nonaccidental injury of a child by EMOTIONAL ABUSE
an older child (e.g., sibling) or an adult (e.g., a parent, Emotional abuse can be even more harmful to a child
relative, babysitter). Physical injuries include, but are than other forms of abuse because of the way in which
not limited to, punching, beating, kicking, biting, hair- it damages self-esteem. This type of abuse involves a
pulling, burning, shaking, throwing, stabbing, chok- pattern of behavior, usually perpetrated by a parent,
ing, and hitting (e.g., with a hand, belt, or stick). Any caregiver, or peer that aims to belittle, berate, humili-
injury to a child is considered abuse whether or not ate, or criticize. Exposing a child to domestic violence
there was an intent to harm before the injury occurred can also be considered emotional abuse (Teicher et al.,
(Paulk, 2004). 2006). While emotional abuse always accompanies
In some families, corporal punishment is used to dis- other forms of abuse, it can occur alone. Examples of
cipline children, raising questions for the health care emotional abuse are listed in Box 23-1.
provider about what constitutes physical abuse as de- Bullying, another form of emotional abuse, is seen
fined by societal and cultural norms. Straus (2001, p.4) when a child or adolescent is targeted by another person
defines corporal punishment as “the use of physical and teased, tormented, criticized, humiliated, or even
force with the intention of causing a child to experience physically bullied (e.g., tripped, hit, pushed) (Governo
C H A P T E R 23 A s s e s s m e n t o f Ch ild A bus e and Neglec t • 495
TABLE 23-1
Findings in Munchausen Syndrome by Proxy
HISTORICAL FINDINGS POSSIBLE PHYSICAL FINDINGS
• Symptoms are unusual, rare, or inconsistent with • Inconsistencies between history and physical findings
clinical, laboratory, and diagnostic study findings.
• Symptoms disappear when caretaker is absent. • Seizures witnessed only by parent
• Parent has medical knowledge or background. • Poisonings with medication, salt, or hydrocarbons
• Parent requests many diagnostic tests to be done. • Recurrent apparent life-threatening events or apnea (because
of suffocations)
• Child does not tolerate tests or treatments well. • Vomiting (caused by poisonings)
• Child is unresponsive to treatment. • Recurrent diarrhea (induced by laxatives)
• Child has numerous past hospitalizations. • Multiple infections with unusual pathogens in unusual sites
• Parents are extremely concerned for child. • Hypoglycemia (from receiving insulin or oral
hypoglycemics)
• Hematuria or guaiac-positive stools without renal or

gastrointestinal abnormality
• CNS depression produced by drugs
CNS, central nervous system.

Source: Mason, J. D., & Poirier, M. P. (2007). Munchausen syndrome by proxy. Retrieved November 30, 2008, from
http://www.emedicine.com/emerg/topic830.htm.
& Siewers, 2008). This can be perpetrated by a parent, via the Internet through chat room talk, blogs, and
stepparent, sibling, extended family member, teacher, e-mail messages (Governo & Siewers, 2008; McColgan
or peer. Bullying can also be perpetrated by more than & Giardino, 2005). All types of emotional abuse impair
one person, as for example, when a child is shunned a child’s self-esteem and often have lifelong negative
from a friendship or clique. Children and adolescents consequences (Sachs-Ericsson, et al., 2006).
can also be harassed, bullied, threatened, and demeaned
SEXUAL ABUSE
Sexual abuse occurs when a child is forced to engage
BOX 23-1
in sexual activity by someone who knows the child,
Examples of Emotional Abuse such as a parent, stepparent, sibling, or other relative.
• Isolating Because the offender is known, the child is coerced
• Ignoring into secrecy. Sexual abuse of a child typically occurs
• Use of the silent treatment over a period of time and can include exhibitionism,
fondling a child’s genitals, penetration, rape, incest,
• Threatening
sodomy, sexual innuendo, exposure to pornography in
• Rejecting
print or via the Internet, or prostitution (Paulk, 2004).
• Excessive criticism
• Betraying
• Belittling
• Taunting
EPIDEMIOLOGY OF CHILD
• Having developmentally inappropriate expectations ABUSE AND NEGLECT
• Excessive control
Child abuse and neglect occur in all races and socio-
• Withholding love, friendship, support, or affection
economic groups, with African American, American
• Corrupting
Indian, Alaska native, and multiracial children having
• Terrorizing
the highest rates of victimization. Neglect is the most
• Pressuring common form of child maltreatment. The highest rates
of child maltreatment occur in girls (51.5%) and young
children from birth until age 7 (USDHHSACF, 2008).

BOX 23-2
Risk factors for child abuse involve the interaction of
Parent/Caregiver Risk Factors
the parent, child, and their social environment.
for Abuse or Neglect
• Substance abuse
PARENTAL CHARACTERISTICS • Poverty
Certain characteristics of the parent increase the risk • Poor parenting skills
for abuse or neglect of a child. In the United States in
• Lack of knowledge of normal growth and
2006, of the parents who abused their children, 57.9% development; unrealistic expectations
were women, 42.1% were men, and 60% of these par-
• Low level of education
ents had a history of neglecting their children. In addi-
• Low intelligence
tion, single parents are at highest risk for abusing their
• Parental/caregiver developmental delay
children (USDHHSACF, 2008).
Providers must assess emotional unavailability on • Single parent
the part of the parents, as a poor parent–child relation- • Adolescent mother
ship can lead to poor socio-emotional development in • Parent of many children
the child. Parental substance abuse is another major • Parent of premature or sick infant with history of
risk factor strongly associated with child maltreatment prolonged hospitalization
(Paulk, 2004), and parents who abuse their children • Domestic violence
were likely abused themselves as children (Lutenbacher, • Depression
Cohen, & Conner, 2004). Also, these parents may look • Mental illness
to the child to fill their emotional needs, a type of role- • Anger management issues; poor impulse control
reversal that constitutes emotional abuse of the child. • Low self-esteem
Maternal depression is another risk factor of great con- • Social isolation/poor social supports
cern, particularly postpartum depression. Women who • Unemployment
are depressed are more likely to abuse or neglect their
• Homelessness
children; in the first year of life, a woman may still
• History of child abuse or neglect as a child
be suffering from postpartum depression ( Johnson &
Flake, 2007). This is significant because injuries to neo- • Previous involvement with CPS
nates or infants, especially shaking injuries, are more
likely to be fatal (Nakagawa & Conway, 2004). A sum- Source: Block, R. W., & Krebs, N. F., & the Committees on Child Abuse
mary of other risk factors that increase the potential for and Neglect and Nutrition. Failure to thrive as a manifestation of child
neglect. Pediatrics, 116(5), 1234–1237; Moore, D. R., & Florsheim,
the parent to abuse the child are listed in Box 23-2. P. (2008). Interpartner conflict and child abuse risk among African-
American and Latino adolescent parenting couples. Child Abuse and
Neglect, 32(4), 463–475; Paulk, D. (2004). How to recognize child abuse
CHARACTERISTICS OF THE CHILD and neglect. The Clinical Advisor, 10, 43-49.
Certain characteristics of the child may place him or

her at risk for maltreatment or neglect. Infants and tod- a child often lives in a single-parent home with poor
dlers, for example, are at high risk for serious physi- social supports and few financial resources, increas-
cal abuse because of their complete dependence on the ing the chance of abuse or neglect. Households where
parent, communicating through crying, the challenges domestic violence takes place put the children at risk
of toilet training, and temper tantrums. Physical or for physical and emotional abuse or injury (Berkowitz,
mental disability, such as mental retardation, mental 2005; Horner, 2005). The chronic stress related to un-
illness, vision or hearing impairment, learning or phys- employment or poverty, including substandard hous-
ical disability, behavior problems, or chronic medical ing, crowded living conditions, and hunger, can lead
problems also predispose a child to abuse or neglect parents to lash out at their children impulsively.
(USDHHSACF, 2008). In addition, children who have
a history of prematurity or perinatal illness requiring
a prolonged hospital stay have a higher risk for abuse
and neglect because of impaired parent–infant bonding CULTURAL AND RELIGIOUS
(USDHHSACF, 2008; Block, Krebs, and the Committees CONSIDERATIONS
on Child Abuse and Neglect and Nutrition, 2005). When evaluating a child for suspected child abuse, it
is imperative to consider the family’s cultural and reli-
gious beliefs. Certain folk remedies, for example, coin
ENVIRONMENTAL STRESSORS rubbing (“cao gio”) and cupping, may mimic physical
Adverse living conditions can predispose a child to abuse abuse. Coin rubbing, a traditional Southeast Asian,
or neglect; for example, after a separation or divorce, nonabusive healing practice, involves the vigorous
rubbing of the edge of a coin on the child’s anterior history of past injuries; the social history, the family’s
and posterior chest to treat fever, fatigue, or cough. discipline practices, and an assessment of the child’s
This leaves a pattern of linear bruises in the shape of behavior.
a fir tree. Cupping, which is primarily used to treat
respiratory complaints, involves placing a glass cup Past Medical History
on the skin on the child’s forehead or trunk; a can- The child’s past medical history is a necessary compo-
dle is then lit, creating suction that leaves an area of nent of the assessment to identify risk factors and red
ecchymosis and petechiae in the shape of a circle. flags for abuse and neglect and to diagnose diseases that
Moxibustion is a traditional Chinese healing practice may mimic abusive injuries. The child’s birth and neo-
often performed with acupuncture; it involves burn- natal histories are reviewed, noting any history of pre-
ing the skin, which may produce scars after the burn maturity or perinatal asphyxia. Children with special
is healed. Azarcon, or Greta, both Mexican folk reme- needs, such as those who have postnatal complications
dies, contain lead and may lead to unintentional lead or chronic illnesses, are at high risk for abuse or neglect
poisoning of the child. Religious traditions regarding (USDHHSACF, 2008). Chronic respiratory illnesses such
fasting during religious holidays may be the cause of as asthma, allergies, ear infections, and sinusitis, must
temporary dehydration, a factor to consider when ex- be noted, especially if the parents or anyone else smoke
amining the child. in the home. Secondhand smoke exposure exacerbates
Cultural beliefs about corporal punishment are diverse. chronic respiratory conditions in children (USDHHS,
Corporal punishment is a common practice in African Office of the Surgeon General, 2007). In some states,
American (Ibanez, Borrego, Pemberton, & Terao, 2006) exposing a child to secondhand smoke constitutes
and Caribbean cultures (Westby, 2007). Religious beliefs child neglect ( Jarvie & Malone, 2008).
may also influence the practice of corporal punishment, Any medical conditions associated with clinical
as parents who believe in Biblical inerrancy or literalism manifestations that could be mistaken for child mal-
are more likely to use corporal punishment and physi- treatment are noted, such as hemophilia A (factor VII
cally abuse their children (Socolar, Cabinum-Foeller, & deficiency) or hemophilia B (factor IX deficiency), both
Sinal, 2008). Providers must respect a family’s religious of which can lead to spontaneous bruising, pain, bleed-
beliefs but must always remember that the child’s phys- ing, stiffness of the joints, intracranial bleeding, hemor-
ical and psychologic well-being are paramount in all rhage, spontaneous hematuria, and intramuscular hem-
circumstances. orrhage (Furlong & Furlong, 2008; Furlong & Furlong,
2008a). Von Willebrand disease is another inherited
bleeding disorder that can cause easy bruising, pro-
ASSESSMENT OF CHILD longed bleeding from wounds, and recurrent epistaxis
(Geil, 2007). Osteogenesis imperfecta, also known as
MALTREATMENT AND NEGLECT “brittle bone disease,” is an autosomal recessive condi-
tion of abnormal collagen formation that results in frac-
The pediatric health care provider may incidentally tures after minor trauma (Plotkin & Pattekar, 2008).
find signs of abuse or neglect when children come for A history of past injuries focuses on the child’s age
health maintenance or episodic visits. The child may at the time of injury, the mechanism of injury, and
present with an acute physical injury or psychoso- whether medical care was sought. A history of repeated
cial complaints that result from long-standing verbal injuries is a red flag for abuse. The dates and reasons
or emotional abuse. To ensure that an accurate diag- for any hospitalizations are also assessed, with attention
nosis is made and to avoid false allegations, some of to whether the hospitalization was a result of injury
the child’s past and current history must be reviewed. or neglect. A history of any psychosocial illnesses is as-
When obtaining any part of the history with suspected sessed, such as depression, anxiety disorders, phobias,
child abuse or neglect, it is essential for the health care or substance abuse, which may or may not be the re-
provider to do so in a sensitive, nonjudgmental man- sult of child maltreatment. The child’s immunization
ner. This approach enhances provider–caregiver trust status is evaluated, noting any delays and determining
and conveys to the child and parent that the health if the delays are a result of medical neglect. The pro-
care provider is there to help. vider must note the reasons for any frequent emergency
room use, as this may indicate injuries resulting from
lack of supervision, intentional injuries, or medical
OBTAINING A HISTORY neglect. The child’s medications are reviewed, with the
General History indications and side effects for each drug considered.
Numerous portions of the child’s medical and social Medications ordered for hyperactivity, anxiety, depres-
history are extremely important when determining if sion, or other psychosocial illnesses may be the cause
a child has been neglected or abused. These factors or result of abuse. Side effects of certain drugs can
include the child’s past medical history including any cause irritability, hyperactivity, or restlessness, which
may precipitate physical abuse in parents or caregivers The presence of a gun in the home greatly increases
with poor coping skills. a child’s risk for harm, especially in homes where do-
mestic violence takes place (Barrier, 2004). A child’s
Social History school performance and relationships with friends at
Many aspects of the child’s family life and interactions school are evaluated; difficulties in these areas can be a
at school are important when evaluating a child for result of abuse or neglect.
emotional or physical abuse. The child’s living situa- Children who have lacked a consistent primary
tion is assessed for any predisposing factors for abuse caregiver, such as those in foster care or orphanages,
(see Epidemiology of Child Abuse and Neglect), such those who have a primary caregiver who is incarcer-
as parental mental illness or depression, social isola- ated, or those who have been abandoned, are at risk
tion, economic difficulties, and lack of social supports. for reactive attachment disorder (RAD), a clinical disor-
It is important to determine who lives in the home der described in the Diagnostic and Statistical Manual of
and each person’s relationship to the child. Mental Disorders, 4th edition, revised (DSM-IV revised)
Parental substance abuse is a crucial assessment to that involves developmentally inappropriate attach-
make as this often results in child maltreatment. Chil- ments caused by either a lack of a primary caregiver
dren of parents who use drugs or alcohol to the extent (inhibited RAD) or one disrupted attachment after the
that daily functioning is impaired may assume many other (disinhibited RAD) (APA, 2000).
parental responsibilities (“parentalized child”), a form
of emotional abuse. School-aged and adolescent chil- Caregiver Discipline Practices
dren are assessed for mental illness and substance abuse The provider must elicit parental discipline practices to
as well. Parental stress is an important risk factor for get a full picture of the family dynamic to assess risk
abuse; Box 23-3 provides a list of questions the provider for physical and psychologic injury. It is imperative to
can ask to determine the level of parental stress. Chil- ask about the parents’ beliefs about corporal punishment
dren who live in families where domestic violence takes and to gain a full understanding of what the parent’s
place are at risk for being physically injured (Berkowitz, definition of corporal punishment is; this may range
2005) and also suffer emotional abuse as they witness from minor spanking to severe beating with or without
the interpersonal violence between adults. Children weapons. Reasons for and the frequency of corporal
who witness domestic violence are also at risk for PTSD punishment are determined. Questions are also asked
(Teicher et al., 2006; Horner, 2005). Mothers who are about shaking, particularly involving children younger
victims of domestic violence are also more likely than than 2. Parental and child triggers for corporal punish-
their counterparts to abuse their children physically or ment should be assessed. Inconsolable crying, toileting
emotionally, even when they are in nonabusive rela- accidents, messy or curious toddlers, temper tantrums,
tionships (Lutenbacher, Cohen, & Conner, 2004). sibling fights, running into the street, and poor school
performance are examples of parental triggers for use
of discipline or corporal punishment. Hunger and fa-
tigue are common reasons that young children cry
BOX 23-3 or have tantrums, which is normal, age-appropriate
Assessment of Parental Stress behavior; any parental knowledge deficits regarding
this behavior should be noted. Likewise, spanking a
• Does the parent have a steady source of income?
1-year-old child for soiling his or her pants reveals lack
• Does the family have a stable place to live?
of knowledge about a toddler’s ability to control the
• Does the parent have a support system? Who or
bowel and bladder. Parents should be asked what they
where?
do when their child cries inconsolably or has a temper
• Does the parent engage in self-care activities
tantrum and whether there is a “safe area” in the home
including getting enough rest and having a healthy
in which the toddler can play, away from the stove,
diet as well as soothing, restful outlets for frustration?
stairs, or electrical outlets; this obviates the need to
• Does the parent take breaks (e.g., leave the child in
“spank” to teach the child a “lesson.” Safe outside play
the care of a trusted family member or friend) for an
afternoon to destress? areas are also necessary, away from streets or alleys. The
use of verbal reprimands and scolding are explored as
• Does the parent cope with the stresses of parenting
by using tobacco, drugs, or alcohol? needed to assess whether these practices cross the line
to harsh criticism, emotional isolation, or rejection, all
• Is the mother depressed? Has she seen a health care
provider who has diagnosed her with postpartum of which constitute emotional abuse.
depression? Is she being treated for it?
• Is there community support for the parents, such as Behavioral History
parent support groups or parenting classes? The behavioral history provides critical informa-
tion in the assessment of child maltreatment. At all
developmental levels, deviations in developmentally

TABLE 23-2
normal behavior can be a sign of abuse or neglect. For
Red Flags for Possible Abuse or
example, infants who do not display stranger anxi-
ety at the expected age demonstrate a lack of secure
Neglect Seen During Routine
attachment to a primary caregiver, which is a sign Assessment
of neglect. Similarly, curiosity about the genitals is ASSESSMENT RED FLAGS FOR POSSIBLE
developmentally normal for preschoolers, but knowl- DOMAIN ABUSE OR NEGLECT
edge of adult sexual behavior in this age group sug-
gests sexual abuse. Any history of anger-based behaviors Nutrition Obesity
Malnourishment
is noted, such as repeated fights at school, destroying
Eating disorders
property, difficulty with relationships, and bullying. Poor weight gain or growth failure
Nonsuicidal self-injury in adolescents can be associ- Numerous, untreated dental caries or
ated with anger, depression, or loss, the origins of severe dental decay
which should be investigated (Peterson, Freedenthal,
Elimination Chronic constipation or encopresis
Sheldon, & Anderson, 2008). Assessments of past epi- patterns Nocturnal enuresis past age 5–6 years
sodes of suicide attempts are critical to the behavioral
history, including the precipitating factors. Safety Frequent injuries resulting from lack
A history of cruelty to animals is very concerning of age-appropriate supervision
Frequent visits to emergency room
because it shows a lack of empathy regarding pain
or urgent care center for treatment of
and suffering, and is a red flag that the child has been injuries
mistreated. Juvenile animal abuse can result when chil- Incidental finding of injuries during
dren have been exposed to violence; this can later routine health care examination
lead to violence toward human beings (Muscari, 2004; Finding of injuries in various stages
of healing
Ascione, 2001). Reports of deliberate fire setting are also
an important part of the behavioral history; this can Sleep Sleep refusal
be symptomatic of extreme stress, rage, and revenge- Difficulty falling asleep
seeking or be a sign of delinquent behavior, resulting Difficulty staying asleep
from extreme family stress (Dadds & Fraser, 2006). Nightmares
Social No stranger anxiety in an infant after

Interval History age 7 months until preschool
Alcohol or drug abuse in child, teen,
When obtaining the interval history during a routine or parent or anyone else living in the
health maintenance visit, much information can be home
gleaned about the child’s and family’s life that may Poor school performance
raise reds flags for abuse or neglect. Routine areas of Depression in child or teen
Maternal depression
health assessment, such as nutrition, elimination pat-
Suicide attempts by child, teen, or
terns, safety, sleep patterns, and the child’s social and parent
developmental history, may present red flags for abuse Child or teen runs away from home
(Table 23-2). Developmental delays, such as lags in Cruelty to animals
achieving age-appropriate motor, language, and social Homelessness
Use of corporal punishment
abilities, may result from neglect. Again, any parental
Domestic violence
knowledge deficits regarding age-appropriate behavior
must be noted. Growth and Physical growth less than fifth
development percentile of NCHS growth charts
Overweight or obesity
Delay in achieving motor, language,
ASSESSING NEGLECT and psychosocial developmental
History milestones
Sexual precocity; knowledge of sexual
Intentional neglect may be difficult to identify when matters inappropriate for age
obtaining the history because its causes are so closely
related to poverty. The provider must focus on histori-
cal factors that overlap with risk factors for neglect
and abuse. For example, it is important to determine as any history of feeding the child inconsistently. Any
whether the child’s primary caregiver suffers from history of repeated injuries is important, as this may
mental illness or substance abuse, which increases a be the result of a lack of age-appropriate supervision.
child’s risk for neglect. The child’s growth charts are Assessment of any delays in seeking necessary medical
reviewed, looking for evidence of poor growth. The or dental care, untreated medical or dental problems,
practice of bottle propping in infants is assessed, as well a lack of necessary immunizations, or smoking around
a child with respiratory problems must be included in a lack of eye contact, smiling, or vocalization, no
the history. In older children, poor school performance stranger anxiety, a disinterest in social interactions, or
may signal chronic truancy, a sign of neglect. Pro- an aversion to being touched. Physical findings may
longed amounts of unsupervised screen time can also include loss of subcutaneous tissue, loose skin folds,
constitute neglect, particularly if the television pro- dull eyes, or oral lesions secondary to malnutrition.
gramming is inappropriate for young children. Media Failure to thrive is defined as decreased growth or a
violence has been shown to have numerous negative cessation of growth over time (e.g., weight-for-age fall-
effects on children, including desensitization to vio- ing two major percentile lines on the National Cen-
lence, seeing violence as justified, viewing violence as ter for Health Statistics (NCHS) growth charts from
a way of solving problems, perceiving the world as a previously established growth patterns) or weight less
violent and scary place, increasing aggressive behav- than 80% of ideal body weight for age (Block, Krebs,
iors, and seeing violence as something entertaining and the Committees on Child Abuse and Neglect and
and funny (Christakis & Zimmerman, 2007; Muscari, Nutrition, 2005). The cause of FTT is multifactorial,
2002). Prolonged screen time can also lead to over- involving poor nutrition, most often resulting from
weight and obesity, a negative health consequence poverty and some level of altered parenting and ne-
for the child that constitutes neglect (Christakis & glect (see Box 23-1). Failure to thrive can be fatal if it
Zimmerman, 2007; Dubowitz, 2004). is not recognized and treated.
Behavioral Indicators Differential Diagnoses

When assessing children who have been neglected, cer- Developmental delays, malnutrition, and a failure
tain parent–child interactions are important to note. to gain weight can result from organic causes, such as
Impaired child–parent bonding as evidenced by poor those that cause chronic hypoxia or malabsorption.
eye contact between parent and child, lack or warmth Examples include congenital heart disease, cleft lip or
or attentiveness to the child; and reacting minimally palate, cystic fibrosis, sickle cell disease, gastroesopha-
or ignoring a child’s cries for hunger, thirst, or pain geal reflux, celiac disease, lead poisoning, or human
during the visit all are red flags for poor attachment or immunodeficiency virus (HIV)/acquired immunodefi-
bonding. During the health care visit, the health care ciency syndrome.
provider may also note deficits in parenting skills and
knowledge of age-appropriate behavior (Murry, Baker,
& Lewin, 2000). Neglected infants may appear listless ASSESSING PHYSICAL ABUSE
and respond minimally to stimulation. Children who History
have poor attachment to a primary caregiver will not
When a child presents with a suspicious injury, a
display stranger anxiety and may demonstrate affec-
complete history must be obtained from the person
tion indiscriminately. This is particularly concerning
bringing the child for medical attention. A complete
in older infants when stranger anxiety is normally at
description of the injury is necessary, along with an in-
its peak, because it shows that the child has no secure
quiry regarding who was present to witness the injury.
primary attachment.
Several critical questions must be asked to determine if
the injury is unintentional or inflicted:
Physical Examination
• Is the “historian” the child’s primary caregiver?
The physical examination of a neglected child often • Does the history match the type and degree of in-
reveals poor hygiene, diaper rash, dirty diapers, dirty jury? Inconsistencies between the history and type
or inappropriate clothing (e.g., long-sleeved shirt in and degree of injury are the most important factor to
hot weather), indications of malnutrition, dental consider when making the decision to notify CPS.
decay, or developmental delays. Infants and toddlers • Is the child developmentally capable of injuring
may appear excessively passive. Fatigue or listless- him- or herself in the manner described? Suspicion
ness may be noted. Children who have been in or- for abuse is raised when the parent or caregiver states
phanages may also have positional plagiocephaly that an injury occurred during motor activity of
with accompanying hair loss in that area of the scalp which the child is not yet capable (e.g., falling after
as a result of lying in one spot in a crib or bed for pro- climbing in a preambulatory infant).
longed periods of time. • Is the parent unable to explain fully how the injury
happened? An absent history raises a red flag for
Failure to Thrive abuse.
Failure to thrive (FTT) is demonstrated as poor weight • Do the parents give conflicting accounts of what
gain or severe weight loss, developmental delays, and happened?
abnormal behaviors, all of which can be caused by • Does the history change when told more than once
neglect. These behaviors may be accompanied by or told to different health care providers?
• Does the child, when interviewed with the parent to be able to discern intentional from unintentional
out of the room, plainly state that he or she was hit injuries in children. To do this, the provider must
or injured in some way? conduct a thorough, head-to-toe physical examina-
• Was there any delay is seeking medical attention for tion on all children in whom physical abuse is sus-
the injury? This is a red flag for abuse, presenting pected. Some injuries are readily apparent, such as
the possibility that the abusive parent or caregiver burns or bruises; others are not visible with a quick
hoped that the problem would resolve on its own. overall inspection, such as intraocular hemorrhages.
• Does the child have a history of multiple injuries While conducting the physical assessment, the exam-
or ingestions, necessitating visits to the emergency iner compares the history to the physical findings, and
room or urgent care center? At minimum, this is a evaluates the behavior and demeanor of the parent
red flag for neglect. and child, watching for behavioral signs of abuse. The
• Was the reason for seeking health care something provider must also be able to recognize conditions that
other than the injury? For example, was the chief can mimic physical abuse, such as osteogenesis imper-
complaint an upper respiratory infection, and a frac- fecta, bleeding disorders, birthmarks, or folk remedies
tured radius was found incidentally? or cultural practices that may leave marks on the skin.
• Is the parent uncomfortable, irritable, or defensive
when questioned about the injury? General Assessments. A current weight, length or
• Does the parent show concern, attention, and love to height, weight for stature, and body mass index (BMI)
the child, or is the parent preoccupied, withdrawn, are obtained to evaluate whether the child’s growth is
or annoyed? within normal limits. Overweight and obesity are prev-
• How is the child behaving toward the parent? Cling- alent in children but may also signal neglect (Dubowitz,
ing? Submissive? Afraid? Is the child trying to make 2004) or depression related to abuse, including sexual
eye contact? abuse (Gustafson & Sarwer, 2004). Physical growth be-
When the child is developmentally capable, begin- low the third to fifth percentile on the NCHS growth
ning approximately at age 3, he or she should be inter- charts may result from organic causes, such as malab-
viewed separately from the parent to allow the child sorption disorders, congenital hyperthyroidism, or FTT.
to speak without any fear of intimidation and to assess
the compatibility of the histories. Open-ended ques- Bruises. When evaluating bruises in children, it is im-
tions are used such as, “What happened to your arm?” portant to consider the location, size, shape, color, and
These types of questions do not lead the child to any pattern of the bruise (Horner, 2005a). The child’s age
specific answer. Leading questions such as, “Did your must also be considered. In healthy, ambulatory chil-
mom’s boyfriend burn your arm?” are biased, and a dren, bruises normally occur in the course of play and
young child may then answer in the affirmative in an activities of daily living and tend to be small. Bruises over
effort to please the provider, even if the answer is not bony prominences such as the extensor surfaces of the
yes. Examples of less direct questions that may pro- lower leg, knees, elbows, and forehead are the most com-
vide clues that a child is being abused include: “Are mon sites of accidental bruising in childhood (Thompson,
you afraid of anyone?” “Does anyone ever hurt you?” 2005). Bruises that occur on a child who is not yet cruis-
“Does anyone make you keep secrets?” Affirmative ing should raise a red flag for abuse unless the child has an
answers to any of these questions require further in- underlying bleeding disorder (Mudd & Findlay, 2004).
vestigation regarding the details of the abuse (Melnyk, Inflicted bruises often occur on the chest, abdo-
Brown, Jones, Kreipe, & Novak, 2003). men, back of the body, or soft tissue areas of the face,
ears, neck, upper arm, inner thigh, genital area, or but-
tocks (Fig. 23-1) (Thompson, 2005; Herendeen, 2002).
Behavioral Indicators
Bruises on the genital area or buttocks are always suspi-
While gathering the history and conducting the physical
cious because the child’s diaper or pants should afford
examination of suspected physical abuse, the behavioral
some protection to the skin over this area (Fig. 23-2).
demeanor of both the child and parents is assessed. The
Bruises to the pinna or earlobe may occur with firm
child may display excessive fearfulness of the parent,
pinching or twisting. Bruising to the entire ear area
apathy, or withdrawal, or may cry or cling to the parent.
may result from punching the child in the ears (“box-
The parent may minimize the child’s injuries or blame a
ing” the ears); this can also cause bleeding behind the
sibling for the injury. Some parents may be overly atten-
tympanic membrane (hemotympanum).
tive to the child, particularly in the case of MSP.
Previously, it was thought that the age of bruises could
be estimated based on their color, but research has shown
Physical Examination that this practice is not fully reliable (Thompson, 2005;
It is common for young children to be injured acciden- Herendeen, 2002). The color of a bruise is affected by
tally during play or as part of their activities of daily the location of the bruise, the child’s skin pigmentation,
life. It is essential for the pediatric health care provider the intensity of force that caused the bruise, whether
inflict the injury (see Pattern Injuries). If a child presents

with one or more suspicious bruises or accompanying
lacerations, the child’s entire body must be examined for
any further injuries.
Burns. When assessing burns in children, review of the

history is essential to distinguish intentional from acci-
dental burns. Important information includes the child’s
age, the consistency of the history, the pattern and lo-
cation of the burn, and if there was any delay in seek-
ing medical attention (Herendeen, 2002). Several factors
must be considered when evaluating burns in children:
(a) the age of the child to determine developmental ca-
pabilities and estimate the thickness of the skin; (b) the
length of contact with the heat source; (c) the tempera-
ture of the heat source; and (d) the blood supply to the
affected tissue (Reece & Christian, 2008). Most cases of
inflicted burns involve children younger than 3 because
of the child’s complete dependence on the caregiver, po-
tential inconsolable crying, or toilet training challenges.
Accidental burns tend to be asymmetrical, irregular (e.g.,
occur in a splash pattern), partial thickness, and reflect
the child’s motor capabilities; thus, accidental burns most
often occur on the the face, neck, trunk, or upper extrem-
Common nonaccidental injury sites ities (Thompson, 2005). Accidental burns are worse at
the top of the body and form an inverted triangle, as the
FIGURE 23-1. Injury sites on a child’s body that raise suspicion liquid flows downward, as when a toddler pulls a pot of
for abuse.
boiling water down from the stove (Herendeen, 2002).
Intentional burns are often symmetric, full-thickness
the child is on any anticoagulants, or whether the child with uniform depth, and may be older than the his-
has an underlying bleeding disorder (Thompson, 2005; torian indicates, dirty, or infected. Immersion burns
Mudd & Findlay, 2004). Bruises usually begin as red and are those that occur when a child is forcibly placed in
progress to purple, gradually becoming blue, green, and scalding hot water; these are the most common type
then yellow. Most bruises last 2 to 4 weeks (Herendeen, of inflicted burns in children (Thompson, 2005). These
2002). Multiple bruises in different places usually indi- burns have a clear line of demarcation in a “stocking”
cate repeated intentional injury. The shape and pattern or “glove” pattern. Another type of immersion burn
of the bruise are also an essential part of the assessment, occurs when a child is submerged into a bathtub of
as these can provide clues to the type of weapon used to scalding water. When the child is placed in the wa-
ter, he or she instinctively draws up his or her hands
and feet while the perpetrator forcibly holds the child
down, causing a distinctive burn pattern known as
the “doughnut”; the outer buttocks, upper thighs, and
genital area are burned with the central area of the but-
tocks less burned as a result of being held against the
comparatively cooler bottom of the tub (Fig. 23-3).
Contact burns are the second most common type of
inflicted burns in children (Thompson, 2005). These
burns include cigarette or cigar burns that characteristi-
cally result in small, crater-like, deep, indurated, circu-
lar burns (Fig. 23-4). These burns are approximately 8
to 10 mm in diameter and are typically found on areas
of the body that are concealed by clothing, the palms
of the hands, soles of the feet, torso, and buttocks.
Branding injuries from a hot object often reflect the
shape of the item used to burn the child, such as a light-
FIGURE 23-2. Bruises in the diaper area and on the lower
back raise a red flag for abuse. For a full-color example, please er, an iron, or the hot grill of a hair dryer (Fig. 23-5)
refer to Figure 23-2 on page C4. (Thompson, 2005).
FIGURE 23-3. Immersion burn in

“doughnut” pattern. Note the sparing
of the buttocks that were forcibly held
against the comparatively cooler surface of
the tub.
FIGURE 23-5. Branding injury. This child was held up against

FIGURE 23-4. Cigarette burn. For a full-color example, a radiator cover and burned. For a full-color example, please
please refer to Figure 23-4 on page C4. refer to Figure 23-5 on page C4.
Oral Injuries. Injuries to the mouth can manifest as

oral bruises, lacerations, or a torn frenulum. Lacerations
and bruising to the lips can occur with a firm blow
to the mouth. Bruising around the mouth or lips can
result when an adult places a hand firmly over an in-
fant or child’s mouth to silence crying. Oral lacera-
tions occur when sharp objects are firmly pushed into
the child’s mouth. For example, a torn frenulum can
also be caused by vigorously pushing a child’s mouth
closed or by forcibly placing a pacifier or bottle in an
infant’s mouth.
Pattern Injuries. Pattern injuries are bruises, lacera-

tions, abrasions, or other soft tissue injuries that form FIGURE 23-7. Ligature marks from being tied down. For a
recognizable marks on the child’s body in the shape full-color example, please refer to Figure 23-7 on page C4.
of the weapon used to inflict the injury. For example,
oval-shaped bruises on the upper arms of infants can abuse, will state during the history that the child was
result from the perpetrator’s firm grip during shaking bitten by an animal. However, humans have four in-
or forcible restraint. Facial bruises may reflect a pattern cisors and short canines while dogs have six incisors
of the perpetrator’s fingers after a forceful slapping. and long canines (Fischer & Hammel, 2003). Human
Bruises in the shape of a loop or parallel lines, most bite marks occur in a circular, oval, or crescent-shaped
often on the child’s back or buttocks, may have been pattern with visible teeth marks within these areas.
inflicted by a coat hanger, rope, or looped electrical The severity of a human bite depends on the loca-
cord (Fig. 23-6). Other pattern injuries include bruis- tion of the bite and the amount of force used to bite
es in the shape of the heel of a shoe, spoon handles, the child. It is important to distinguish a child’s bite
paddles, belts, or chains. Strangulation or restraint from that of an adult. Bites by children who still have
marks may manifest as circular abrasions around the their deciduous teeth are more superficial and have a
neck, ankles, or wrists if a child has been choked or distance of less than 3 cm between the canines. Adult
tied down (Fig. 23-7). In some instances, the item used bites tend to be deeper and have a space of more than
to restrain the child may be tied so tightly that circula- 3 cm between the canines (Shah & Lucchesi, 2006).
tion may be compromised to the distal portion of the Preverbal toddlers often bite as a way of expressing
extremity. frustration. There is never a plausible reason for a
child to present with an adult bite. Once an injury
Bite Marks. The ability to recognize human bites is is determined to be an adult human bite, the wound
essential for all pediatric health care providers. Some is swabbed for DNA; this assists forensic and law en-
parents or caregivers, in an attempt to cover the forcement personnel in identifying the perpetrator.
The bite is then measured and photographed for anal-
ysis by a forensic dentist for identification of the per-
petrator. The bite should then be cleaned and dressed
to prevent infection.
Eye Injuries. Intentional injuries to the eye can present

with or without external evidence of injury. For this rea-
son, all children with signs of physical abuse should have
a funduscopic examination. Possible external injuries of
the eye include corneal abrasions, bruises beneath one or
both eyes (“black eye”), orbital fracture, subconjunctival
hemorrhage, or hyphema. These injuries can occur when
a child is struck with a closed fist or weapon. Internal
injuries of the eye include retinal hemorrhages, which oc-
cur with shaking injuries (shaken baby syndrome [SBS])
or head injuries. Retinal detachment can also occur after
trauma to the eye.
Abdominal Trauma. Blunt abdominal trauma is

FIGURE 23-6. Bruises caused by the loops made by an
electrical cord. For a full-color example, please refer to the second-leading cause of death in children from
Figure 23-6 on page C4. abusive injury (Thompson, 2005). Most victims
of intentional abdominal trauma are children are

aged 6 months to 3 years. These children are often
more seriously injured than older children because
the weapon used or the adult hand or foot causing
the injury covers such a large portion of the abdo-
men. Young children also have less fat and weaker
abdominal muscles, which fail to absorb the force of
the blow to the abdomen, transmitting the force to
the internal organs, causing intra-abdominal hemor-
rhage and hypovolemic shock (Thompson, 2005).
Young children may have very few objective signs
of injury, so a delay in seeking medical attention is
common. Presenting signs of acute abdominal injury
can include abdominal guarding, rigidity, vomiting,
lethargy, abdominal distention, decreased bowel
sounds, anemia, or shock and fever caused by peri-
tonitis. Older children may complain of abdominal
FIGURE 23-8. Spiral fracture.
pain. There may be associated findings, including
fractures, head trauma, or soft tissue injury, such as
bruising to the abdominal wall. To determine the ex- to the child’s age, developmental level, and physical
tent and severity of the abdominal trauma, a com- findings (Thompson, 2005).
puted tomography (CT) scan of the abdomen, liver
enzymes, and urinalysis must be obtained. A CT scan Head Trauma. Central nervous system injuries,
of the head and a skeletal survey are ordered to assess such as asphyxia , direct blows to the head, or shak-
for other injuries (Herendeen, 2002). ing, are the leading cause of death resulting from
inflicted injury (Hymel & Hall, 2005). Depending
Skeletal Trauma. Skeletal injuries may occur in chil- on the type and extent of injury, children with
dren during the course of active play or as sports neurologic injuries may present with nonspecific
injuries. The key in evaluating skeletal injuries in signs, such as irritability, sleepiness, and poor ap-
children is to consider the child’s age, developmental petite, or more specific signs of altered neurolog-
capabilities, and the mechanism of injury as stated ic status, such as vomiting, lethargy, seizures, or
in the history. For example, subluxation of the ra- coma. Children who have been choked or asphyxi-
dial head can occur as the result of suddenly pull- ated may have strangulation marks or bruising on
ing or yanking a young child’s arm to protect him or the neck. Any tenderness, deformity, or swelling
her from running in the street, or it can occur when of the head or scalp may indicate inflicted head
swinging a child during play. This injury can also be trauma. Any soft tissue injuries of the scalp, skull
the result of the caregiver deliberately pulling the fractures in pre-ambulatory infants, injuries to the
child roughly. head that are over soft tissue, fractures or soft tissue
Any fractures that occur in the pre-ambulatory in- injuries in multiple stages of healing, pattern in-
fant, fractures in multiple stages of healing, old frac- juries, or any head injuries associated with mouth
tures that are incidental findings, and fractures in or eye injuries raise suspicion for abuse (Hymel &
children younger than 2 are suspicious for abuse. In Hall, 2005).
children who do not yet walk, a spiral fracture of the SBS is a severe form of whiplash where the infant or
long bone is also suspect, as a strong, twisting motion toddler is held by the upper body and shaken violently.
is necessary to create the injury (Fig. 23-8). Fractured Retinal hemorrhages, subdural hematomas, and damage
ribs are highly suspect because the percentage of car- to the spinal cord and neck often occur as the result of
tilage in the ribs is high, making the ribs more flex- violent shaking. Children under 4 are more susceptible
ible and pliant, thus more difficult to break. “Bucket to this type of injury because of their large heads, fri-
handle” or “metaphyseal chip” fractures are considered able intracranial vasculature, and weak neck muscles.
pathognomonic for abuse. This type of fracture in- If the infant is thrown after shaking, skull fracture may
volves fragmentation of the distal end of the metaphy- occur. These infants may also sustain rib fractures if
sis, often in the leg, close to the knee. The mechanism the perpetrator squeezes the child’s rib cage with sig-
of injury is violent yanking or shaking, or using the nificant force. Rib fractures associated with SBS tend to
child’s limb as a handle (Chapman, 2007). Radio- be lateral and posterior rib fractures, most often on the
graphic skeletal surveys should be done on any child infant’s left posterior chest because right-hand domi-
younger than 2 who presents with a femur fracture nance is more prevalent than left-hand dominance
and on older children based on the history compared (Nakagawa & Conway, 2004). Clinical manifestations
of SBS may include poor feeding, vomiting, listlessness, metastasized to the bone and may be confused with
and irritability. Signs of injury are not usually visible. intentional fracture injury.
Intracranial edema causes an infant to have a full an-
terior fontanelle. In some instances, the infant is so
severely shaken that significant alterations in level of ASSESSING EMOTIONAL AND VERBAL
consciousness, changes in muscle tone, seizures, bra- ABUSE
dycardia, or apnea occur. This degree of shaking injury Both verbal and emotional abuse are difficult to sub-
often results in death or long-term neurologic impair- stantiate, especially because there are no visible mani-
ment (Nakagawa & Conway, 2004). festations. Although physical signs are lacking, there
are several possible behavioral, emotional, and even
Differential Diagnoses cognitive signs that may indicate that a child is being
The pediatric health care provider must be aware of emotionally or verbally abused.
medical conditions that the child may have that may
be confused with physical abuse. Most of these condi- History
tions are readily diagnosed by conducting a thorough If emotional or verbal abuse is suspected, the provider
history and physical examination and by using rele- should review the child’s past medical history, social
vant diagnostic studies. Examples include hemophilia, history, and behavioral history, focusing on any previ-
von Willebrand disease, idiopathic thrombocytopenic pur- ously diagnosed mental health disorders, a history of
pura, leukemia, erythema multiforme, or Henoch-Schönlein poor school performance, bullying, violent behavior,
purpura, all of which can be mistaken for intentional or regression to make accurate assessments.
bruising. Bullous impetigo (Fig. 23-9), allergic reactions,
staphylococcal scalded skin syndrome, or moxibustion Behavioral Indicators
may mimic burns. Mongolian spots (see Chapter 12), Children often demonstrate a change in behavior as a
which typically appear over the sacral area, may be result of emotional or verbal abuse. Some children may
confused with bruises inflicted during spanking; how- become excessively shy, fearful, or clingy. They may have
ever, bruises fade in about a week, but Mongolian spots difficulty forming relationships, have an inability to re-
take years to fade (Mudd & Findlay, 2004). Coining and late to other children, and lack self-confidence. Teachers
cupping may also be confused with bruising. Allergic may report that the child is intensely afraid of making
shiners and raccoon eyes that occur with allergies and any mistakes or that their school performance is poor
accidental head trauma, respectively, are also included (Berkowitz, 2005). Some children may become “paren-
in the differential diagnosis with bruising. Fractures talized”; that is, they become overly responsible as they
may occur with osteogenesis imperfecta, Ehlers-Danlos may be expected to assume an adult role at home. Other
syndrome, rickets, osteomyelitis, or malignancy that has children have sleep problems, developmentally regress in
response to the stress of emotional abuse, or demonstrate
attention-seeking behaviors. More serious behavioral in-
dicators of emotional or verbal abuse are substance abuse,
depression, suicide attempts (Teicher et al., 2006), running
away from home, self-mutilation, and problems with the
law (Hutchinson & Mueller, 2008). Bullying may begin,
which may be the cause or result of being emotionally
abused. Depending on a child’s temperament, children
who are emotionally abused at home may become hostile
and aggressive and cruelly bully other children or animals.
Conduct disorders may develop (Finch, Nelson, & Hart,
2006). Other children may react to the emotional abuse
at home by becoming shy, helpless, and hopeless, thus
becoming easy targets for bullies (Hutchinson & Mueller,
2008). Children who have been traumatized may also
experience developmental delays, and difficulties with
reading, comprehension, and abstract thinking. PTSD
may even occur as a result of chronic emotional or ver-
bal abuse, sexual abuse, or exposure to domestic violence
(Brown, 2005). Behavioral indicators are also evident in
the parent when a child is being emotionally or verbally
FIGURE 23-9. The impetigo lesion on the child’s nose may
be mistaken for a burn. For a full-color example, please refer abused. These include the parent having unreasonable
to Figure 23-9 on page C4. age-inappropriate behavioral expectations or being harsh
or critical of the child in front of the health care provider. • What, if anything, the adult witnessed or heard
Conversely, the parent or caregiver may be completely • Any changes in the child’s behavior and what these
behaviorally appropriate. changes are
• Specific chief complaints for the visit (e.g., genital
Physical Examination discharge or bleeding; pelvic or genital pain)
Children who are emotionally or verbally abused should • Who lives in the home with the child and the child’s
be evaluated for signs of FTT, developmental delays, relationship to each person
enuresis, sleep disorders, self-injury, eating disorders, • If the adult accompanying the child is not the par-
depression, and suicidal ideation. ent, where the parents are and what role, if any, they
play in the child’s life
Differential Diagnoses It is also important to know the child’s past medical
Previously diagnosed emotional or mental health illness- history in the event the child has any conditions that
es must be considered when evaluating emotional abuse may mimic sexual abuse (see Differential Diagnoses).
in a child. PTSD can occur in the child, resulting from Children who have been sexually abused may present
causes other than emotional abuse or exposure to domes- with nonspecific anogenital complaints such as pain,
tic violence, such as witnessing traumatic events, includ- itching, erythema, or burning on urination. More spe-
ing natural disasters, suffering the chronic stress of living cific complaints may include rectal or genital bleeding,
in high-crime areas, or experiencing war and terrorism difficulty walking or sitting, the development of sexu-
(Brown, 2005). Depression, bipolar disorder, generalized ally inappropriate behavior for the child’s age, genital
anxiety disorder, separation anxiety disorder, social pho- discharge, or genital lesions (Kellogg & the Committee
bias, obsessive-compulsive disorder, and oppositional- on Child Abuse and Neglect, 2005; Paulk, 2004). When
defiant disorder are all diagnoses to consider when a evaluating the presence of genital discharge or lesions
child has been verbally or emotionally abused. in children, the provider must keep in mind that not
all sexually transmitted infections (STIs) require oral-
to-genital or genital-to-genital contact to infect the
ASSESSING SEXUAL ABUSE
child. Some STIs can be transmitted through fondling
Children who have been sexually abused may have if the perpetrator has infected secretions on his or her
many different presentations to the health care provider. hand (Giardino & Finkel, 2005). Transmission of ano-
The child may be in the provider’s care for a routine genital warts, for example, can occur through sexual
health maintenance visit, and because of certain his- contact but also via autoinoculation, direct contact
torical or physical findings, sexual abuse becomes part with an infected caregiver who is shedding the virus,
of the differential diagnosis. The child may be brought and through direct contact with nonporous surfaces
to the health care provider by the parent specifically for contaminated with human papillomavirus fomites
suspected sexual abuse, or the child may be brought to (Horner, 2004). Vertical transmission of STIs must be
the health care provider by social service or law enforce- considered in children younger than 1 (Giardino &
ment personnel for evaluation of sexual abuse. In in- Finkel, 2005). STIs that are considered diagnostic for
stances of acute sexual abuse, the child may be brought sexual abuse in children are gonorrhea, syphilis, and
to the emergency department for evaluation, collec- Chlamydia (if not perinatally acquired), and HIV (if
tion of evidence, and crisis management (Kellogg & the not perinatally or transfusion acquired) (Kellogg & the
Committee on Child Abuse and Neglect, 2005). Committee on Child Abuse and Neglect, 2005).
When sexual abuse is suspected, the child should be
History interviewed alone, beginning at age 3 (Kellogg & the
When sexual abuse is suspected in a child, the parent Committee on Child Abuse and Neglect, 2005). Obtain-
and child should be interviewed separately. Before begin- ing the history from the child must be done in the most
ning the assessment, the pediatric health care provider nonthreatening, nonjudgmental, caring manner pos-
must remember that sexual abuse of a child involves a sible. Trust must first be established between the child
range of sexually inappropriate activities, such as expo- and health care provider; this involves a slow pace, a
sure to pornography, being photographed for pornogra- developmentally appropriate approach, and allowing
phy, being exposed to adult sexual activity, and sexual the child or adolescent as much control over the pro-
contact with an adult (Giardino & Finkel, 2005). First, cess as possible (Giardino, 2006). In young children, it
the provider must elicit certain information from the is necessary for the examiner to determine what termi-
adult who accompanyies the child. This information in- nology the child uses when referring to his or her geni-
cludes determining (Giardino & Finkel, 2005): tals and to avoid using medical terminology. Simple,
• Why the adult suspects sexual abuse open-ended questions are necessary (e.g., “What hap-
• To whom the child made any disclosures and what pened?”) versus leading questions (e.g., “What did your
the child said mom’s boyfriend do to you?”), which may influence
the child’s answer. Brief answers should be followed delay (Kellogg & the Committee on Child Abuse and
with encouraging statements, such as, “Tell me more” Neglect, 2005).
or “then what happened” until the provider is satisfied When conducting the physical examination to de-
that the child has completed his or her story (Giardino termine if any sexual abuse has taken place, the utmost
& Finkel, 2005). Approaches to interviewing the young care and sensitivity is required. The child must have a
child may include the use of anatomically correct dolls, caring adult with them at all times (one not involved
the use of puppets, or encouraging the child to draw a in the abuse) and, if age-appropriate, the examination
picture about what happened. should be explained to the child. The child must be
In adolescent girls, a gynecologic history must be ob- reassured that he or she has done nothing wrong.
tained, including the date of the last menstrual period, With recent anogenital trauma, instruments may
number of pregnancies, past surgery, or trauma to the need to be used to illuminate and magnify the relevant
anogenital region, STI history, date of last consensual structures; this may include colposcopy, a noninvasive
intercourse, and contraception use (Botash, 2008). method to light and magnify anogenital structures for
examination. Still and video photography of anogenital
Behavioral Indicators injuries may also be necessary (Giardino & Finkel, 2005).
Digital and speculum examinations are not performed
A child who is sexually abused may demonstrate cer-
on a prepubertal child (Kellogg & the Committee on
tain nonspecific behaviors as a result of the abuse,
Child Abuse and Neglect, 2005).
some of which may immediately raise the suspicions of
If a child who is unable to cooperate with the physi-
the provider. Some nonspecific behaviors include sleep
cal examination presents with blunt force penetrating
disturbances, abdominal pain, enuresis, encopresis, or
trauma or if the examiner senses that the child will
phobias (Kellogg & the Committee on Child Abuse and
suffer psychologically because of the nature of the
Neglect, 2005); poor school performance, acting out,
examination, conscious sedation may be used for the
regression, and the development of eating disorders,
examination with the child’s vital signs closely moni-
anxiety, depression, or suicidal ideation. Behaviors
tored according to protocol (Kellogg & the Committee
that should raise a red flag include knowledge of and
on Child Abuse and Neglect, 2005; Giardino & Finkel,
preoccupation with any type of sexual act (e.g., inter-
2005). Older children may be allowed to participate in
course, oral sex, inserting objects into the vagina or
the examination to give them a sense of control over
anus, masturbation), sexualized behaviors, use of sexu-
the situation (Giardino & Finkel, 2005).
ally explicit language, sexually explicit drawings made
In children of both sexes, the focus of the physical
by the child, acting out sexually with siblings or peers,
examination is on areas involved in sexual activity: the
or compulsive cleanliness of the perineal area (Botash,
mouth, genitals, perineal region, buttocks, and anus;
2008; Giardino & Giardino, 2008; Gustafson & Sarwer,
however, there may also be bruises on the face, neck,
2004). Some children may deny the sexual abuse while
breasts, or buttocks.
others make outright statements that they are being
In female children, the genital examination includes
sexually abused. All children who are suspected of hav-
inspection of the inner thighs, labia majora and minora,
ing been sexually abused must have an overall assess-
clitoris, urethra and surrounding area, hymen, hymenal
ment of behavioral, mental, and emotional status to
opening, fossa navicularis, and posterior fourchette
identify any urgent psychosocial needs. Children who
(Kellogg & the Committee on Child Abuse and Neglect,
have been sexually abused commonly demonstrate
2005). Certain factors affect the examiner’s ability to in-
PTSD (Botash, 2008).
spect the child’s inner anatomic structures: (a) the child’s
degree of relaxation, (b) the amount of traction that the
Physical Examination examiner places on the labia majora, and (c) the position
Physical indicators of sexual abuse vary, according to the child is in for the examination (i.e., supine, lateral,
the type and nature of abuse and when the last incident knee to chest). Concerning (not diagnostic) findings in-
occurred. The physical examination alone is not specific clude bruising of the inner thighs or genitals, tearing or
enough to confirm sexual abuse in a child; corroborat- scarring of the labia minora, or enlargement of the hy-
ing statements and laboratory findings are necessary to menal opening. Findings that are suggestive of sexual
complete the picture. If the alleged incident occurred abuse include scarring, loss of integrity of the hymen,
within 72 hours or less or if there is acute injury or scarring of the fossa navicularis, and tears or scarring of
visible bleeding, a full examination of the anogenital re- the posterior fourchette (Kellogg & the Committee on
gion is required. The health care provider must take care Child Abuse and Neglect, 2005). Genital discharge or
to collect any evidence of the abuse according to “chain lesions may also be seen, which may suggest STI. Any
of evidence” protocols (see Collection of Evidence). If objective signs of pregnancy must be noted.
more than 72 hours have passed since the alleged abuse In male children, the thighs, penis, and scrotum
occurred or there are no acute injuries, the physical ex- are examined for acute injury such as bruising, bleed-
amination can be deferred if circumstances warrant a ing, burns, bite marks, abrasions, or other soft tissue
injuries (Kellogg & the Committee on Child Abuse and conduct an investigation of the scene where the injury
Neglect, 2005). Any penile discharge or lesions, sug- took place and to interview any witnesses to determine
gesting STIs, must be noted. Evidence of past injuries, the veracity of the history (Giardino & Finkel, 2005).
such as scarring or ligature marks, must also be noted.
In both sexes, the anus is examined, using the supine
or left side-lying position. The knee-chest position should
not be used as this is likely the position in which the
DIAGNOSTIC STUDIES
abuse took place. If the abuse was recent, the examiner
The type of diagnostic study required to clarify the type
notes any pain, signs of injury such as bruising, bleed-
and severity of physical, sexual, or psychologic injury
ing, laceration, or soft tissue tears around the anogenital
to a child depends on the history, location, and type of
region. Any evidence of STIs is noted, such as discharge
injury. The goal of obtaining these diagnostic studies
or anal lesions. If the injury was not recent, laxity of the
is to diagnose or exclude inflicted injury. Conditions
anal sphincter should be noted, keeping in mind that
that may ensue as a result of prolonged neglect also
this is a nonspecific finding and may be caused by the
need to be defined and treated. Table 23-3 lists some of
passage of large bowel movements. Also, if the perpetra-
these diagnostic studies and their indications.
tor used lubrication or penetration without force, anal
laxity will not be present (Giardino & Finkel, 2005).
Differential Diagnoses DOCUMENTING AND

Some conditions or injuries involving the anogenital area REPORTING ABUSE AND
may mimic sexual abuse. It is vitally important for the NEGLECT
health care provider to be familiar with these conditions
to avoid any false allegations, which can have catastrophic All pediatric nurse practitioners, nurses, physicians,
sequelae for the child, family, and the accused. Common and physician assistants are mandated by law to report
conditions in this category include diaper dermatitis, hy- any suspected or confirmed child abuse or neglect to
menal tags, labial adhesions, vulvovaginitis, anal fissures, the CPS agency in the state in which they practice. The
and perianal skin tags that can result from chronic consti- provider must also determine if the child needs to be
pation. Less common conditions are congenital malfor- hospitalized because of the severity of his or her inju-
mations, poor hygeine, physical abuse, accidental strad- ries or for protection.
dle or impaling injuries of the anogenital region (Kellogg It is extremely important for the health care provider
& the Committee on Child Abuse and Neglect, 2005), to document all historical and physical findings in a
foreign bodies in the vagina or anus, pinworm infestation clear, objective manner, as these notes will likely be
(Brady & Dunn, 2009), and anal or rectal skin tags associ- used to assist law enforcement personnel in prosecut-
ated with Crohn’s disease or cystic fibrosis. ing any crime. Body diagrams and color photographs
may be necessary to augment written documentation
Collection of Evidence of physical findings. All physical injuries must be de-
scribed in terms of location, distribution, size, depth,
A board-certified sexual assault nurse examiner-pediatric
color, and pattern (Horner, 2005). The child’s emo-
(SANE-P) should be used for the collection of evidence of
tional and physical demeanor, overall hygiene, and
sexual abuse. The SANE-P is a registered nurse who is spe-
the nature of the interaction with the parent are also
cially trained to conduct forensic examinations, provide
documented. With sexual abuse, it is important to doc-
emotional support to the child and family, ensure a chain
ument who was present when the child disclosed the
of evidence, and provide expertise for effective courtroom
abuse and what prompted the disclosure and to docu-
testimony if needed (Bechtel, Ryan, & Gallagher, 2008). If
ment the child’s words in direct quotes (Botash, 2008).
the sexual abuse took place within the last 72 hours or if
there is evidence of acute injury, collection of biologic ev-
idence (e.g., hair, blood, semen) should proceed (Kellogg
& the Committee on Child Abuse and Neglect, 2005). Be-
SAMPLE WRITE-UP: NEGLECT
fore obtaining cultures to determine the presence of STIs, Subjective Findings
the provider must consider the type of sexual contact. If A 12-month-old girl is seen for annual health main-
the history indicates fondling only, cultures may not be tenance visit accompanied by mother. Mother and
necessary. If the history indicates oral, genital, or rectal child currently living in homeless shelter. Child has
contact or the child is symptomatic, cultures are obtained had one set of immunizations that mom “knows of.”
to diagnose STIs (Kellogg & the Committee on Child Child drinks 8 to 10 bottles a day of milk, and ap-
Abuse and Neglect, 2005). If the child presents with acute proximately 16–24 ounces of apple juice a day. Mother
genital or anal trauma attributed to accidental straddle or reports that she is eager to toilet train child who has no
impaling injuries, it is necessary for law enforcement to interest. Mother smokes in presence of child.
TABLE 23-3
Diagnostic Studies to Evaluate Child Abuse
CONDITION TYPE OF STUDY COMMENTS
Bruising PT, PTT, CBC with platelet count Coagulation studies obtained to confirm or
exclude bleeding disorders
Altered neurologic status; signs of Radiographic skull series; CT and Determines presence of skull fractures;
acute head trauma MRI studies intracranial bleeding
Abdominal trauma CBC with platelet count; serum Anemia points to hemorrhage; hematuria
chemistry, urinalysis, liver function suggests renal injury; elevated amylase can
tests, serum amylase; CT of the indicate pancreatic trauma; liver trauma
abdomen causes elevated hepatic transaminases; CT
of the abdomen will show major organ
trauma
Skeletal trauma Radiographic skeletal survey To determine type and extent of fracture;
also determines if child has clinically
undetected fractures, or multiple fractures
in various stages of healing
Sexual abuse Culture for gonorrhea, syphilis, To confirm sexual abuse

Chlamydia, condyloma acuminata,
trichomonas vaginalis, bacterial
vaginosis; obtain HIV and serum
pregnancy test
CBC, complete blood count; CT, computed tomography; MRI, magnetic resonance imaging; PT, prothrombin time; PTT, partial
thromboplastin time.
Source: Hymel, K. P., & Hall, C. A. (2005). Diagnosing pediatric head trauma. Pediatric Annals, 34(5), 358–370; Kellogg, N., & the
Committee on Child Abuse and Neglect (2005). The evaluation of sexual abuse in children. Pediatrics, 116(2), 506–512.
Objective Findings mediately immersed arm in cold water. PMH non-

Measurements: weight: 95th percentile; height: contributory.
25th percentile; head circumference: 25th percen-
tile; BMI: ⬎95th percentile Objective Findings
General: Alert, obese female walks over to provider Left hand noted to have full-thickness burn in a glove
and puts arms up to be held pattern, with a clear line of demarcation at the wrist.
Integument: Poor hygiene, extensive excoriation No splash burn marks noted on arm. Hand edematous
noted in diaper area with skin peeling. Child crying during examination
Oral: Poor dentition, multiple brown and black areas Assessment: Inflicted burn
over maxillary and mandibular central incisors
Neurologic: Hearing, vision grossly normal
Developmental: Walks well, does not use spoon SAMPLE WRITE-UP: SEXUAL ABUSE
well, does not drink from cup, cannot build tower Subjective Findings
of two cubes, briefly scribbles with crayon; says, A 4-year-old girl being seen for annual health main-
“Mama,” “Baba,” and “Dada,” cannot point to any tenance visit. Mother mentions that child frequently
named body part complains of “itching on her privates.” Mother
Assessment: Neglect appears tentative and fearful about mentioning this
complaint.
SAMPLE WRITE-UP: PHYSICAL ABUSE Objective Findings

Subjective Findings Child became combative during examination and re-
A 2-year-old boy presents to Urgent Care Clinic ac- fused inspection of perineal area, stating that “He puts
companied by mother. Mother states that 2 days his finger there, and it hurts.” Refuses to say who “he”
ago, she was holding the child while drinking a cup is while mother is in the room. SANE-P called to con-
of hot coffee, and the child reached for the cup, tinue examination.
spilling the coffee on his hand and arm. Mother im- Assessment: Presumptive sexual abuse
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Stirling, J., Jenny, C., Christian, C., Hibbard, R. A., Kellogg,
N. D., & Spivak, B. S. (2007). Beyond Munchausen syndrome U.S. Department of Health and Human Services Agency
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ishment in American families. San Francisco, CA: Jossey-Bass http://www.ahrq.gov/clinic/3rduspstf/famviolence/famvio/rs.htm
Publishers Inc. Parent Support Groups
Teicher, M. H., Samson, J. A., Polcari, A., & McGreenery, C. E.
(2006). Sticks, stones, and hurtful words: relative effects of Parents Anonymous
various forms of childhood maltreatment. The American Jour- http://www.parentsanonymous.org/
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Thompson, S. (2005). Accidental or inflicted? Evaluating cuta- parenting challenges in the safety of a confidential peer support
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U.S. Department of Health and Human Services, Office of the Postpartum Depression
Surgeon General. (2007). Children and Secondhand Smoke PSI: Postpartum Support International
Exposure: Excerpts from the health consequences of invol- http://postpartum.net/
untary exposure to tobacco smoke: A report of the Surgeon 1-800-994-4PPD
General. Retrieved January 29, 2009, from http://www.cdc Provides information and support to mothers suffering from
.gov/tobacco. postpartum depression. Web site has directory for local support
U.S. Department of Health and Human Services, Administration groups, resources, and events.
on Children, Youth and Families. (2008). Child maltreatment The Edinburgh Postnatal Depression Scale (EPDS)
2006. Washington, DC: U.S. Government Printing Office. http://www.dbpeds.org/media/edinburghscale.pdf
Westby, C. E. (2007). Child maltreatment—a global issue. Lan- A scale designed for use in the outpatient area to screen women
guage, Speech, and Hearing Services in Schools, 38(20), 140–148. for postpartum depression.
Position Statements Opposing Corporal Punishment in
Children
RESOURCES
Center for the Human Rights of Children American Academy of Pediatrics (AAP)
http://www.luc.edu/chrc/
A Child Advocacy Center that aims to protect the human rights Committee on Psychosocial Aspects of Child and Family
of children through research, education, and service. A guiding Health
tenet for this Center is the United Nations Convention on the Guidance for Effective Discipline
Rights of the Child: http://www2.ohchr.org/english/bodies/crc/. http://aappolicy.aappublications.org/cgi/content/full/
pediatrics;101/4/723
Bright Futures
http://www.brightfutures.aap.org American College of Emergency Physicians
Hagan, J. F., Shaw, J. S., & Duncan, P. M. (Eds). (2008). Bright http://www.acep.org/practres.aspx?id⫽29154
futures: Guidelines for health supervision of infants, children and PolicyStatements/peds/CorporalPunishmentChildren.htm
adolescents. (3rd ed.). Elk Grove Village, IL: American Academy
of Pediatrics.
National Association of Pediatric Nurse Practitioners
Published by the American Academy of Pediatrics, this set of
(NAPNAP)
health supervision guidelines can aid the pediatric health care pro-
http://download.journals.elsevierhealth.com/pdfs/journals/
vider in providing family support and teaching the parents about
0891⫽5245/PIIS089152450600410X.pdf
normal physical and psychosocial developmental milestones.
Fussy Baby Network The United Nations Committee on the Rights of the Child
http://www.fussybabynetwork.org/ (CRC) recommends that States Parties to the Convention on
A network of services to which the provider can refer parents the Rights of the Child (1989) prohibit corporal punishment
of fussy babies. Offers parent support groups, home visits by in institutions, in schools, and in the home.
infant behavior specialists, pediatrician services for fussy babies, http://www2.ohchr.org/english/bodies/crc/
CHAPTER
Assessment of Mental
24 Disorders in Children
and Adolescents
SHIRLEY A. BUTLER AND ELLEN M. CHIOCCA
According to the MECA Study (Methodology for Epi-

demiology of Mental Disorders in Children and Ado- PHYSICAL ASSESSMENT OF
lescents), almost 21% of children and adolescents in CHILDREN WITH SUSPECTED
the United States aged 9–17 years had a diagnosable MENTAL DISORDERS
mental or addictive disorder (Shaffer, Fisher, Dulcan,
Davies, Piacentini, Schwab-Stone, et al., 1996). Not Knowledge of normal growth and development is cru-
all mental disorders diagnosed in children and ado- cial when assessing children and adolescents for men-
lescents continue into adulthood, even though the tal health disorders. A thorough evaluation includes
incidence of mental disorders is about the same as interviews with the children or adolescents, parents or
that for adults. It is not uncommon for a child or an caregivers, and siblings, as well as the collection of data
adolescent to have more than one mental disorder. about the child’s school performance, such as data from
For example, Garzon (2007) reported that depressed standardized tests, checklists, and questionnaires.
children may also have a conduct disorder, opposi-
tional defiant disorder, or anxiety disorder.
Mental disorders in children and adolescents can SUCCESSFUL COMMUNICATION
cause significant emotional distress and interfere with
According to Morrison and Anders (1999), listening
their abilities to study, work, or interact with family
carefully, directing conversation, establishing rapport,
and peers. The Surgeon General’s Report on Children and
and following up important cues are the general
Mental Health (U.S. Department of Health and Human
guidelines to a successful interview. The provider
Services [USDHHS], 1999) discussed risk factors for de-
must observe interactions between the child or ado-
veloping a mental disorder or experiencing difficulties
lescent and the parent or caregiver. Young children
in psychosocial development. The following risk fac-
often express themselves through play activities (e.g.,
tors were identified:
drawings, puppets, storytelling, therapeutic games),
• Prenatal damage from exposure to alcohol, illegal while older children and adolescents are able to
drugs, and tobacco respond directly. The provider should exhibit a warm,
• Low birth weight calm, and pleasant demeanor. If possible, the setting
• Difficult temperament or an inherited predisposition should reflect the age-group being served (e.g., bright,
to a mental disorder colorful, small furniture for young children). Mental
• External risk factors such as poverty, deprivation, health brochures and teaching materials should also
abuse, and neglect represent the patient population (Cottrell, Nield, &
• Unsatisfactory relationships Perkins, 2006).
• Parental mental health disorder When interviewing the child, adolescent, or par-
• Exposure to traumatic events ents, the provider should begin with less sensitive
Knowledge of these risk factors, as well as care- topics, progressing to emotionally intense subjects
ful screening and a comprehensive assessment, can once trust and rapport have been established (Cottrell,
help a health care provider identify mental disorders, Nield, & Perkins, 2006). Confidentiality and safety are
allowing effective treatment for affected children and also discussed. The child or adolescent should be told
adolescents. what kind of information must be shared with the
513
parents. Any information regarding situations that are is currently taking or has taken within the last week,
potentially harmful to the child or adolescent’s health focusing not only on medications that cause central
have to be communicated to the parents or caregivers nervous system and behavioral side effects, but drug
(Cottrell, Nield, & Perkins, 2006). interactions that could cause these side effects as well.
The provider should also inquire about the use of ana-
bolic steroids in the adolescent client. Side effects of
MEDICAL HISTORY anabolic steroids may include aggression, paranoia,
When obtaining the health history in children and confusion, sleeping disorders, anxiety, hallucinations,
adolescents, the provider should listen carefully for any euphoria, depression, suicidal ideation, and severe
physical complaints that may indicate a need for fur- psychosis (Nanda & Konnur, 2006).
ther investigation for possible mental health concerns.
For example, chronic headaches, recurrent abdominal Family and Social Histories
pain, or episodes of shortness of breath may have a psy-
The child or adolescent’s family life and social situ-
chologic etiology. Likewise, poor school performance
ation contribute greatly to his or her mental health.
may not be the manifestation of behavioral problems
Table 24-1 summarizes the relevant assessments to
but rather chronic hearing loss in the child.
make in this area.
A child’s past medical history (PMH) is relevant to his Review of Systems
or her current mental health status. The PMH also The pediatric review of systems specific to mental
includes an assessment of prenatal, birth, and neonatal health assessment in children focuses on determining
histories, acute and chronic illnesses, childhood infec- if there is a history of any past acute illnesses or cur-
tious diseases, medications, immunizations, allergies, rent chronic illnesses that may have behavioral mani-
hospitalizations, and surgeries. festations. This assessment also illuminates whether
any mental illnesses cause physical symptoms such as
Prenatal, Birth, and Neonatal Histories. Prenatal substance abuse, eating disorders, mood disorders, or
exposure to drugs or maternal infections; prematurity; conduct disorders (Box 24-1).
perinatal hypoxia; congenital defects or chromosomal
abnormalities; and central nervous system infections History of Present Illness
or injuries are some examples of problems that can af-
When a child or adolescent presents with a men-
fect the child’s behavior or mental health.
tal health complaint, the provider should inquire
about the onset of symptoms, the development and
Allergies. In addition to inquiring about allergies to
duration of problems, the severity and impact of
medications, food, animal dander, or environmental tox-
the problem, and what, if any, help has been sought
ins, it is especially important for the provider to ask about
and tried (e.g., medication, counseling, hospitaliza-
seasonal allergies. To treat the allergy symptoms, the par-
tion). The provider should also determine if the
ent or caregiver may administer over-the-counter anti-
problem has had an effect on life at home or school
histamines such as diphenhydramine. This drug causes
or on the family or siblings. Certain significant
drowsiness and sedation, but in some children it may
events that occur before or concurrently with the
have a paradoxical effect and result in hyperactivity.
problem (e.g., illness, hospitalization, separation,
divorce, death) may have an effect on the child’s
Hospitalizations. The date, length, and reason for each
behavior.
hospitalization should be determined, with notation
Table 24-1 identifies the historical assessment data
of any hospitalizations for abdominal pain, mental or
that should be gathered for each child or adoles-
emotional disorders, substance abuse, depression, sui-
cent.
cide attempts, seizures, head injuries, or other neuro-
logic problems.
Surgeries. The provider should also note the date and
reason for all surgeries, assessing whether the surgery A complete, head-to-toe physical examination should
was related to a mental health disorder (e.g., surgery to be conducted, focusing on hearing, vision, neurologic
repair a self-inflicted injury). assessments, and neurologic soft signs. A mental sta-
tus exam should also be done, as well as an assess-
ment of the child or adolescent’s general appearance,
Current Medications behavior, and manner of relating (see Table 24-1).
The provider should conduct a thorough, detailed A developmental assessment should also be included
inventory of all medications the child or adolescent in the examination (see Chapter 2).
C H A P T E R 24 A s s e s s m e n t o f M e n tal Dis o rde rs in C hildr en • 515
TABLE 24-1
Categories of Assessment Data
ASSESSMENT DATA TO COLLECT POSSIBLE FINDINGS
History of present illness Chief complaint
Development and duration of problems
Help sought and tried (e.g., medication, counseling,
hospitalization)
Effect of problem on child or adolescent’s life at home
and school
Effect of problem on family and siblings
Medical history Review of systems Neurologic or

Trauma, hospitalizations, surgeries, and child’s response developmental
Illnesses of injuries affecting the central nervous system problems, fetal alcohol
Medications syndrome, chromosomal
Allergies abnormalities, and
congenital defects
Neurologic assessment Cerebral functions Neurologic/developmental

Cerebellar functions problems
Sensory functions
Reflexes
Cranial nerves
Functions can be observed in developmental assessment
and while playing games involving a specific ability
(e.g., “Simon says, touch your nose”)
Coordination or motor Posture Cerebral palsy

function Gait
Balance
Gross motor movement
Fine motor movement
Writing and drawing skills
Unusual characteristics (e.g., bizarre postures, tiptoe
walking, hand flapping, head banging, hand biting)
Child or adolescent mental General Appearance:

status assessment Size (height and weight)
General health and nutrition
Dress and grooming
Distinguishing characteristics
Gestures and mannerisms
Looks or acts younger or older than chronologic age
Speech:
Rate, rhythm, and intonation
Pitch and modulation
Vocabulary and grammar appropriate to age
Mute, hesitant, or talkative
Articulation problems
Other expressive problems
Unusual characteristics (e.g., pronoun reversal, echolalia,
gender confusion, neologisms)
Intellectual Functions:
Fund of general information
Ability to communicate (e.g., follow directions, answer
questions)
Memory
Creativity
Sense of humor
Social awareness
Learning and problem-solving
Conscience (e.g., sense of right and wrong, accepts guilt
and limits)
(continued)
TABLE 24-1
Categories of Assessment Data (Continued)
Developmental history Pregnancy, birth, neonatal data, developmental Developmental delay
milestones, possible traumatic events, description of
eating, sleeping, elimination habits, and routines
Attachment behaviors
Types of play
Social skills and friendships
Sexual history (e.g., patient’s age at puberty, if
adolescent, dating, sexual activity)
Development assessment Psychomotor Developmental delay

Language
Cognitive
Interpersonal and social
Behavior (e.g., response to stress, changes in the
environment)
Problem-solving and coping skills (e.g., impulse control,
delay of gratification)
Energy level and motivation
Characteristics of child’s play Age-appropriate use of toys Depression, grief, loss,

Themes of play anxiety
Imagination and pretend play
Role and gender play
Age appropriate play with peers
Relationship with peers (e.g., empathy, sharing, waiting
for turns, best friends)
Activity level Hyperactivity/hypoactivity ADHD, Tourette’s

Tics, other body movements syndrome,
Autoerotic and self-comforting movements (e.g., thumb trichotillomania, and
sucking, ear or hair pulling, masturbation) autistic spectrum disorders
Thought processes and content Orientation Drug or alcohol abuse,

Attention span neurologic problems,
Self concept and body image ADHD, loss, and grief
Sex role, gender identity
Ego-defense mechanisms
Perceptual distortions (e.g., hallucinations, illusions)
Preoccupations, concerns, and unusual ideas
Fantasies and dreams
Personal, familial, and social Child’s birthplace, number of siblings, and sibship position Loss, grief, separation,
background Present family constellation and patient’s present behavior problems, school
residence refusal, conduct disorder,
Family ethnic background, religious preferences, and oppositional/defiant
cultural values; parental discipline styles; parental disorder, and child abuse/
knowledge of normal child development; child’s neglect
temperament and parent’s perception of same
Parents’ relationship: length/stability of marriage,
separation or divorce, remarriages, and relationships
within reconstituted families
Physical/verbal violence or substance misuse in home
Is child adopted? If so, intra- or extra-familially at what
ages? Facts (if known) about natural parents; what does
patient know?
Extended family involvement in caregiving, foster care,
other alternative care
Degree of family closeness
Social supports for family
Education: current or most recent grade, scholastic
problems, school refusal behavioral problems, truancy,
and suspensions/expulsions

Hobbies/interests, participation in sports/other activities,
and any changes resulting from illness
Strengths, positive qualities, or outcomes, sources of
satisfaction, and self-esteem
Manner of relating Eye contact Shy temperament, PTSD,

Ability to separate from caregiver and be independent and separation anxiety
Attitude toward interviewer
Behavior during interview (e.g., ability to have fun/play,
low frustration tolerance, impulsive, aggressive)
Sensitive subjects Substance use by adolescent: type of substance, duration Drug or alcohol use,
of use, quantity, effects, and consequences (i.e., medical, depression, eating
personal or interpersonal, school or job, legal, financial) disorders, and conduct
Suicide ideas/attempts: seriousness, methods, and drug- disorder
or alcohol-associated, consequences
Violence/delinquency: nature or history; legal system
involvement (e.g., arrests, incarcerations), illegal
behaviors for which adolescent was apprehended
Physical or sexual abuse: exact nature of events,
perpetrator, and legal system involvement, and effects
on adolescent and family
ADHD, attention deficit hyperactivity disorder; PTSD, posttraumatic stress disorder.

Source: Goodman, J. D., & Sours, J. (1987). The child mental status examination. (2nd ed.). New York: Basic Books; Varcarolis, E. (2006). Manual
of psychiatric nursing care plans, diagnoses, clinical tools, and psychopharmacology. (3rd ed.). Philadelphia: Saunders-Elsevier; and Morrison, J., &
Anders, T. (2001). Interviewing children and adolescents. Skills and strategies for effective DSM-IV diagnosis. New York: Guilford, with permission.
DIAGNOSTIC STUDIES Autistic Disorder

Some physical health problems have behavioral mani- According to the DSM IV-TR criteria, autism affects three
festations in children. Specific laboratory or radiology major areas: (a) qualitative impairment in social interac-
studies can determine whether a physical problem is tions, (b) qualitative impairment in communication, and
causing behavioral changes in the child or adolescent (c) restricted stereotypical patterns of behavior, activities,
(Table 24-2). or interests. In many cases, mental retardation is an asso-
ciated diagnosis, which can range from mild to profound.
The onset of autistic disorder is before 3 years of age.
SELECTED MENTAL HEALTH The parents or caregivers first notice the autistic behav-
DISORDERS IN CHILDREN ior. The infant often does not appear to be interested in
others or socially responsive through facial gestures and
eye contact. Common behavior problems include head
PERVASIVE DEVELOPMENTAL
banging, biting, aggression, and hair pulling.
DISORDERS Developmental gains can occur in school-aged chil-
Pervasive developmental disorders are characterized dren and adolescents; however, some children deteriorate
by severe and pervasive impairment in several areas during adolescence. Approximately one third of individu-
of development, such as reciprocal social interaction als are able to attain partial independence (APA, 2004).
skills, communication skills, or the presence of stereo-
typical behavior, interests, and activities (American Asperger’s Disorder
Psychiatric Association [APA], 2004). These disorders Asperger’s disorder is characterized by severe impair-
affect many areas of development, are exhibited early ment in two areas: (a) reciprocal social interactions
in life, and cause significant impairments in function- and (b) repertoire of activities and interests (APA,
ing. The APA’s Diagnostic and Statistical Manual of Men- 2004). Language, cognitive development, and age-
tal Disorders, 4th ed., revised text (DSM-IV-TR) includes appropriate self-help skills are generally within normal
five pervasive developmental disorders: autistic disor- ranges (APA, 2004). The onset of the disorder occurs
der, Rett’s disorder, childhood disintegrative disorder, after 2 years of age. Social problems may not be appar-
Asperger’s disorder, and pervasive developmental dis- ent until the child goes to school and must interact
order not otherwise specified. The most common per- with same-age peers. These individuals are capable of
vasive developmental disorders are discussed below. working and leading normal adult lives (Box 24-2).
BOX 24-1
Pediatric Review of Systems as It Relates to Mental Disorders
GENERAL
Congenital defects (e.g., fetal alcohol syndrome), overall state of health, chronic fatigue, mood, recent significant weight
gain or loss, exercise tolerance, increased or decreased need for sleep, attachment to primary caregiver (young children),
drug or alcohol use; human immunodeficiency virus infection (needle sharing, sexual practices)
SKIN, HAIR, AND NAILS

Changes in skin: dry, yellowish skin seen in seen in anorexia nervosa and acanthosis nigricans obesity; scars on knuckles
(“Russell’s sign”), which indicates repeated self-induced vomiting; cuts, burns, or bruises (self-injury), burns or picking at
the skin (methamphetamine use), severe acne (anabolic steroid use); dry, thin, brittle hair, or lanugo (anorexia nervosa);
hirsutism (anabolic steroid use; habits such as hair-twisting or hair-pulling (trichotillomania), premature balding (anabolic
steroid use), or nail-biting
HEAD
Chronic headaches; microcephaly (fetal alcohol syndrome); macrocephaly (hydrocephalus)
EYES
Conjunctival injection (marijuana use); watery eyes (narcotics); dilated pupils (cocaine or hallucinogens)
EARS
Frequent ear infections (otitis media); evidence of hearing loss or delayed speech
NOSE
Chronic rhinorrhea (inhalant use), snoring, or obstructive sleep apnea (obesity)
MOUTH/THROAT
Tooth decay and sore throat (chronic vomiting); gum recession (chewing tobacco); dry mouth (drug use)
CHEST
Chest pain (cocaine use); gynecomastia in boys, small breast size in girls (steroid use)
RESPIRATORY
Chronic cough (nicotine, inhalant use); dyspnea (obesity, cigarette smoking); shortness of breath (anxiety, respiratory
disorders)
CARDIAC
Hypotension, bradycardia, cardiac arrhythmia (eating disorders, inhalant or amphetamine use); hypertension (obesity);
tachycardia (drug use)
GASTROINTESTINAL
Diarrhea (laxative use), constipation (opioid use), vomiting (purging, alcohol or drug overdose, nicotine toxicity);
gastritis, peptic ulcer disease, and heartburn (chronic alcohol use, purging); liver disorders (drug or alcohol use; anabolic
steroids); recurrent abdominal pain
ENDOCRINE
Obesity; intolerance to cold (anorexia nervosa, hypothyroidism), excessive sweating (drug use); precocious puberty
(anabolic steroid use)
GENITOURINARY
Testicular atrophy (anabolic steroid use)
GYNECOLOGIC
Pregnancy; irregular menses (abnormally low body weight, anabolic steroid use)
MUSCULOSKELETAL
Stunted growth, increased muscle mass (anabolic steroid use)
NEUROLOGIC
Impaired coordination, tremors, seizures, nystagmus, memory loss (drug or alcohol use); cerebral palsy
LYMPHATIC
History of frequent infections (chronic malnutrition secondary to eating disorders, infection after intravenous drug use)
DEVELOPMENTAL
Developmental delays, impaired cognition, speech or language delays, slurred speech, impaired gross or fine motor
development, reduced attention span
BEHAVIOR
School truancy, poor school performance, poor school attendance, difficulty with concentration, dropping out of school,
apathy, change in attention span, mood swings, emotional lability, paranoia, aggressiveness, cruelty to animals, violent
behavior, difficult relationships at home and school (depression, drug or alcohol abuse)
PSYCHOSOCIAL
Family history of mental health disorders; attention deficit hyperactivity disorder, conduct disorder, bipolar disorder,
eating disorders, anxiety disorders, panic attacks, hallucinations, flashbacks, depression, suicidal ideation, and suicide
attempts
TABLE 24-2
Specific Laboratory or Radiology Studies That Determine Which Physical
Problems Cause Behavioral Changes
POSSIBLE BEHAVIORAL
STUDY POSSIBLE DIAGNOSES MANIFESTATIONS
CBC Anemia Lethargy, irritability, restlessness, anorexia,
developmental delays, or pica
Thyroid function tests Hypothyroidism or Hypothyroidism: delayed mental responsiveness

hyperthyroidism in neonates, lethargy, poor school performance
Hyperthyroidism: emotional instability, weight
loss, insomnia, behavioral problems, difficulty
concentrating, or poor school performance
Lead level Lead poisoning Learning disabilities, hearing impairment,

developmental delays, hyperactivity, behavioral
problems, chronic headache, or pica
Urine toxicology screen Substance abuse Behavior changes, personality disorders,

depression, paranoia, hallucinations, mood
swings, aggression, insomnia, anxiety, loss
of concentration, memory loss, personality
changes, flashbacks, decreased motivation, or
antisocial behavior to support habit
Electroencephalogram Seizures Partial seizures, resulting in staring spells and

alteration in behavior
CT scan or MRI of the brain Intracranial mass Behavior changes, irritability, lethargy, staring, or
automatisms (partial seizures)
Chromosomal analysis Fragile X syndrome Mental retardation, developmental and language

delays, short attention span, hyperactivity,
intolerance to change in routine, autistic-like
behaviors, aggressive behavior, comorbidities of
depression, obsessive-compulsive disorder, and
sensory integration disorder ( Jewell, 2005).
CBC, complete blood count; CT, computed tomography; MRI, magnetic resonance imaging.
BOX 24-2 BOX 24-4

Pertinent Assessment Data: Pertinent Assessment Data:
Pervasive Developmental Disruptive Behavior Disorders
Disorder
• Assess the seriousness of the aggressive behavior
• Assess the quality of attachment (bonding) between toward others.
the child and parents or caregivers. • Assess the impact of the child’s aggressive behavior
• Observe the child’s quality of eye contact, facial on family life, school performance, and social life.
gestures, and body movements. • Assess the degree of empathy for others and the
• Assess developmental levels. Note developmental ability to learn from mistakes.
lags in cognition, language, behavior, and social • Determine the child’s willingness to take responsibility
skills. for his or her own behavior.
• Observe for uneven development and loss of acquired • Explore the child’s image of self and others.
skills.
ATTENTION-DEFICIT HYPERACTIVITY Conduct Disorder

DISORDER Conduct disorder is characterized by aggressive behav-
Attention-deficit hyperactivity disorder (ADHD) is ior toward others and the serious violation of societal
characterized by a persistent and marked pattern of in- norms or rules (APA, 2004). Children or adolescents
attention or hyperactive and impulsive behavior (APA, with this disorder may exhibit threatening, bullying,
2004). It is difficult to diagnose in children younger or intimidating behaviors toward others. They also
than 5 years because of developmental variations. may be cruel to animals (Muscari, 2004). The DSM
These children experience difficulties in social, aca- IV-TR categorizes conduct disorder into four areas: (a)
demic, and extracurricular functioning (Box 24-3). aggression to people and animals, (b) destruction of
property, (c) deceitfulness or theft, and (d) serious vio-
lations of rules (APA, 2004). Conduct disorder is one
DISRUPTIVE BEHAVIORAL DISORDERS of the most common mental disorders diagnosed in
children (Box 24-4).
Oppositional Defiant Disorder
Children with oppositional defiant disorder exhibit a
recurrent pattern of negativistic, defiant, disobedient, EATING DISORDERS
and hostile behavior toward authority figures. These Eating disorders are characterized by a marked distur-
children generally do not exhibit serious physical ag- bance in eating patterns. They are chronic, serious,
gression against others (APA, 2004). life-threatening conditions (Bernstein, 2008; Moreno
& Judd, 2008). The onset of eating disorders can be
seen in children as young as 10 years of age. These dis-
BOX 24-3 orders can cause severe physical problems, unlike most
Pertinent Assessment Data: mental disorders. Anorexia nervosa, bulimia nervosa,
Attention-Deficit Hyperactivity and obesity are briefly discussed.
Disorder
Anorexia Nervosa
• Assess the attention span, verbal activity, and physical Anorexia nervosa is characterized by low body weight
activity of the child. (85% of expected weight), a distorted perception of
• Observe the child’s ability to follow directions. body shape or weight, and an intense fear of weight
• Assess the impact of the child’s behavior on gain (APA, 2004). The mortality rate in anorexia ner-
relationships at school and home. vosa ranges from 10%–20% (Bernstein, 2008). Death is
• Determine the parent or caregiver’s responses to the from suicide, starvation, or electrolyte imbalance (APA,
child’s behavior. 2004). The DSM-IV-TR describes two types of anorexia
• Assess parental skills and their abilities to cope with nervosa: restricting types and binge-eating/purging
the child’s behavior. types (APA, 2004) (Box 24-5).
• Administer an ADHD checklist to parents, teachers, or Significant findings on physical examination include
caregivers. the following:
• Thin physical appearance
BOX 24-5 BOX 24-6

Anorexia Nervosa Bulimia Nervosa
• Assess body mass index, height, weight, vital signs, • Perform a physical examination and order blood work
and average daily calorie intake. (e.g., complete blood count).
• Perform a physical examination, and order blood • Assess eating patterns, body mass index, height,
work. weight, vital signs, and menstrual history.
• Determine whether the child or adolescent requires • Complete the mental status examination by assessing
hospitalization (i.e., medical or psychiatric). mood, suicidal potential, and other self-destructive
• Assess for suicidal ideation and other self-destructive behaviors (e.g., cutting).
behaviors. • Determine whether the adolescent requires
• Determine eating patterns and activity level. hospitalization (i.e., medical or psychiatric).
• Assess perception of body image and self-esteem. • Assess the adolescent and parent or caregiver’s
• Explore fears and concerns about weight. perceptions of family functioning.
• Record last normal menstrual period. • Refer the adolescent for a psychiatric or psychologic
evaluation.
• Assess family functioning and the child or adolescent’s
perception of autonomy and independence. • Assess perception of body image and self-esteem.
• Lanugo (fine body hair over body) • Alteration in elimination patterns (e.g., diarrhea,
• Dull, thin, brittle hair constipation, indigestion, heartburn)
• Dry, yellowish skin Typical laboratory or other tests include the following:
• Hypotension
• Complete blood count, which may show abnormali-
• Bradycardia
ties in serum electrolytes, magnesium, and increased
• Use of laxatives and diuretics
blood urea nitrogen
Bulimia Nervosa • Electrocardiogram, which may show cardiac
arrhythmias
Bulimia nervosa is characterized by periods of binge eat-
• Thyroid function tests, which may show abnormal
ing (2000 to 10,000 calories) followed by self-induced
T3 levels
vomiting, purging, and exercise to prevent weight
gain. The incidence of bulimia nervosa in adolescence
is 1%–3%; the age of onset is usually 16 to 18 years, Childhood Obesity
and the condition is more common in girls. These ado- According to the American Obesity Association, about
lescents report feeling “out of control” and are often 15.3% of children (ages 6 to 11) and 15.5% of adoles-
reluctant to discuss their eating patterns. Shame and cents (ages 12 to 19) are obese. This prevalence has
secrets often prevent these adolescents from getting almost tripled for adolescents in the past two decades
treatment (APA, 2004). (American Obesity Association, 2005). A measure-
Physical complications are a result of diuretic ment called body mass index (BMI) is used to identify
and laxative abuse and purging behaviors. Adoles- overweight and obesity in children and adolescents.
cents may also experience other mental disorders, The Centers for Disease Control (CDC) suggests two
such as substance abuse, depression, and anxiety levels of overweight: (a) the 85th percentile, an “at
(Box 24-6). risk” level and (b) the 95th percentile, the more severe
Significant findings on physical examination in- level (USDHHS, 2007).
clude the following: Compared to children with a healthy weight,
• Puffy cheeks (enlarged parotid glands) overweight children and adolescents have risk fac-
• Scars on the knuckles (Russell’s sign) tors for heart disease such as high cholesterol and
• Decay of the front teeth high blood pressure. The incidence of type 2 diabe-
• Irregular menses tes has increased in children and adolescents (USD-
• Dehydration or fluid retention HHS, 2007). Obese children or adolescents are often
• Hypotension, decreased heart rate, or irregular ridiculed and teased, which can cause depression,
heart rate anxiety, and low self-esteem. Childhood obesity can
• Sores around cheeks and mouth lead to long-term physical, emotional, and social
• Sore throat or hoarseness consequences, which can persist through adulthood
• Low energy (Box 24-7).
According to the DSM IV-TR criteria, this disorder

BOX 24-7
affects several domains of functioning: personal, aca-
Pertinent Assessment Data:
demic, social, and familial (APA, 2004). Children with
Childhood Obesity social phobia have low self-esteem. They often feel as
• Assess body mass index, height, weight, average daily though people are viewing them negatively and often
calorie intake, and vital signs. use avoidance behaviors as coping mechanisms. They
• Determine eating patterns and activity level. generally avoid school and social activities and, in ado-
• Perform a physical examination and order blood lescence, dating. Ginsburg and Grover (2005) reported
work. that social withdrawal impedes the development of
• Ask parents or caregivers about the child or appropriate social skills.
adolescent’s sleeping pattern, specifically noting Academically, children with social phobia have prob-
snoring, irregular breathing episodes, or difficulty lems in the classroom. For example, speaking in class
breathing. or working in a group activity can cause severe anxiety
• Assess perception of body image and self-esteem. or emotional distress. At home, the children are reluc-
• Assess family, social, and school functioning. tant to attend family gatherings and often prefer solitary
activities (e.g., computer games, reading a book). These
children may also exhibit physical symptoms, such as
stomachaches, headaches, and panic attack symptoms
Significant findings on physical examination in- (Ginsburg & Grover, 2005). Assessment of social phobia
clude the following: in children and adolescents (Box 24-8) should include
data from teachers, parents, clinical interviews, and
• Body mass index of 25 or greater
rating scales (e.g., MASC Multidimensional Anxiety
• Elevated blood pressure
Scale for Children, SPA1-C Social Phobia and Anxiety
• Dyspnea, snoring, or stridor
Inventory for Children, SAS Social Anxiety Scales for
Typical results of laboratory tests may include high Children and Adolescents).
cholesterol levels.
Separation Anxiety Disorder
ANXIETY DISORDERS Separation anxiety disorder is characterized by a child’s
excessive worry about being separated from the home
Anxiety disorders are the most common mental dis- or from parents. This anxiety exceeds that which is ex-
orders of childhood and adolescence (Bothe & Ol- pected for the child’s developmental level (APA, 2004).
ness, 2007, 2007a). Children and adolescents may also The prevalence rate in children and young adolescents
exhibit symptoms of depression. Parents of children is 4%. The incidence decreases as the child reaches
or adolescents with anxiety disorders often report de- adolescence.
pressive episodes and anxiety. Other anxiety disorders In separation anxiety disorder, physical symptoms
that are diagnosed in children or adolescents include are generally worse on evenings and mornings before
social and school phobias, generalized anxiety disor- school and are absent on weekends and holidays, ex-
der (Hudson, Deveney, & Taylor, 2005), panic disor- cept the night before school starts. School absences
der, and obsessive-compulsive disorder (Lewin, Storch,
Adkins, Murphy, & Geffken, 2005). Social phobias,
separation anxiety disorder, and posttraumatic stress
(PTSD) are discussed. BOX 24-8
Pertinent Assessment Data:
Social Phobia Social Phobia
Social phobia (also called social anxiety disorder) is
the most common childhood mental disorder, af- • Assess the level of the child’s anxiety and the child’s
fecting 5%–15% of youth at some time during their ability to function at school and at home.
adolescent years (Ginsburg & Grover, 2005). In the • Determine the level of involvement in social activities
past, social phobia was often dismissed as “childhood at home and school.
shyness,” and the disorder was therefore underidenti- • Administer standardized assessment tools (e.g.,
fied and undertreated. The average age of onset is 11 rating scales) to the child or adolescent, parents or
caregivers, and teachers.
to 12 years of age. Children as young as 6 have been
reported (Ginsburg & Grover, 2005; Bothe & Olness, • Assess academic performance and school attendance.
2007). According to Ginsburg and Grover (2005), so- • Recommend supportive counseling for the child or
cial phobia is chronic and often continues into young adolescent and for the parents or caregivers.
adulthood.
BOX 24-9 BOX 24-10

Separation Anxiety Disorder Posttraumatic Stress Disorder
• Assess the level of the child’s anxiety and the child’s • Determine the traumatic event.
ability to function at school (e.g., absenteeism). • Assess the child’s or adolescent’s emotional, social,
• Collect data about school attendance. If the child physical, and cognitive responses to the traumatic
missed more than a week of school, immediate event.
referral for a psychiatric evaluation is recommended. • Assess the social supports and the family’s responses
The longer the child is out of school, the more to the traumatic event.
difficult it is to re-enter school.
• Determine the child’s current and past ability to
separate from the parent or caregiver.
• Remember normal separation anxiety is often seen in SUBSTANCE USE DISORDERS
toddlers.
According to the DSM IV-TR criteria, substance use dis-
• Gather data about the family life (e.g., death of a pet,
orders include substance abuse and substance depen-
parent, sibling; illness of a parent; recent moves).
dency (APA, 2004). Substance abuse is characterized
by a maladaptive pattern of substance use manifested
by significant and recurrent consequences related to
the persistent use of substances (APA, 2004). In com-
parison, substance dependence is a combination of
can affect a child’s academic performance ( Jurbergs
physiologic, cognitive, and behavioral symptoms, in-
& Ledley, 2005). These children also are often preoc-
dicating that the adolescent continues to use the sub-
cupied with death, dying, and illnesses (APA, 2004)
stance despite significant substance-related problems
(Box 24-9).
(APA, 2004).
Adolescent substance use can have deleterious ef-
Posttraumatic Stress Disorder
fects on family and peer relationships, cognitive pro-
PTSD is characterized by the development of emo- cesses, school functioning, and physical and mental
tional and behavioral symptoms following a traumat- health. Adolescent violence (e.g., assaults, rapes) and
ic, unexpected event that is outside the range of usual adolescent substance use are also correlated. The sub-
human experience and during which the individual stance most commonly abused by adolescents is al-
feels intense fear and hopelessness. Children may re- cohol (CDC, 2009). According to Kulig (2005), about
spond with agitated or disorganized behavior (APA, 50% of adolescents have used an illicit drug by the
2004). For children and adolescents, the traumatic time of high school graduation (Box 24-11).
events are the same as for adults: rape, kidnapping,
violence, disruption caused by environmental dis-
asters (e.g., fires, floods, hurricanes, tornadoes). The MOOD (AFFECTIVE) DISORDERS
child or adolescent may experience the event directly
The most commonly diagnosed mood disorders in
or indirectly (Brown, 2005).
children and adolescents are major depressive disorder,
Symptoms of PTSD in children differ from the
dysthymic disorder, and bipolar disorder. The symp-
symptoms exhibited by adults. Initial effects include
toms of mood disorders are similar to adults; howev-
fear of death and fear of separation from parents, es-
er, the developmental stage of a child or adolescent
pecially in young children. Children withdraw from
may modify the expression of these symptoms. Chil-
new experiences. Re-experiencing the event may occur
dren and adolescents sometimes have trouble talking
in the form of nightmares, daydreams, or repetitive,
about their emotions and so they may resort to acting
potentially dangerous reenactments in symbolic play
out behaviors. Mood disorders are briefly discussed
or in actual behavior (APA, 2004). Children may de-
(APA, 2004).
velop physical symptoms, such as stomach problems
and headaches. Sleep disturbances may interfere with
activities of daily living. Children frequently exhibit Major Depressive Disorder
regressive behaviors (i.e., show behaviors characteristic Major depressive disorder is characterized by the fol-
of a previous developmental stage). According to the lowing symptoms: sadness, irritability, hopelessness,
DSM IV-TR criteria, the symptoms of PTSD must occur feelings of worthlessness, changes in weight and
for 30 days or longer; if the symptoms last for less than sleep patterns, loss of interest in activities, low en-
30 days, the diagnosis is called acute stress disorder ergy level, fatigue, low self-esteem, poor concentra-
(APA, 2004) (Box 24-10). tion, restlessness, and thoughts of death or suicide.
BOX 24-11 BOX 24-12

Substance Use Disorders Affective Disorder
• Assess family, social, and school functioning. • Perform a mental status examination.
• Perform a physical examination, and order urine and • Assess sleeping and eating patterns.
blood tests (e.g., toxicology screens). • Assess social, school, and family functioning.
• Complete the mental status examination by assessing • Inquire about recent losses (e.g., death, relationship
mood, suicidal potential, and other self-destructive difficulties, recent move).
behaviors. • Administer self-report mood disorder checklists.
• Determine if the adolescent requires hospitalization • Assess suicidal potential (see Appendix F for SAD
(i.e., medical, psychiatric). Persons Scale).
• Administer drug screening tests (e.g., Michigan • Establish a “no harm or no suicide” contract if
Alcohol Screening Test [MAST]; Brief Drug Abuse needed.
Screening Test [B-DAST]) see Appendix D).
• Determine whether the child or adolescent requires
• Assess substance use (i.e., type of substances used; hospitalization.
frequency and amount of use; methods of use such
as oral, inhalation, or injection); contexts of use; and
history of use (see Appendix E for substance-specific
criteria for substance intoxication).
• Assess the adolescent’s self-esteem. Point prevalence rates of dysthymic disorder have
• Use multiple assessment methods from a variety of been reported that range from 0.6%–1.7% in children
sources (i.e., adolescent, parent or caregiver, siblings) and 1.6%–8.0% in adolescents (Rogers & Spalding,
• Refer adolescent or family for a psychiatric or 2008). Major depressive disorder and dysthymic dis-
psychologic evaluation. order are equally common in boys and girls before
puberty (Rogers & Spalding, 2008). However, after age
15, depression is twice as common in girls as in boys
(Rogers & Spalding, 2008).
Children and adolescents often have school prob-
lems, including school refusal, reluctance to attend Bipolar Disorder
school, or poor academic performance (APA, 2004). According to the DSM IV-TR, the diagnostic criteria in
Depressed children and adolescents generally have children and adolescents are the same as for adults.
at least one other mental disorder, such as anxiety dis- Symptoms include extreme mood swings, intermittent
order, substance abuse disorder, disruptive disorder, or aggressive behavior, impulsivity, high levels of distract-
an eating disorder. Somatic symptoms, such as stom- ibility, periods of irritability, and sleep disturbances.
achaches and headaches, are also common in chil- These adolescents may have difficulty with normal
dren and adolescents (Garzon, 2007). These depressive day-to-day functioning and may require hospitaliza-
symptoms can last 7 to 9 months. tion. Other mental disorders or conditions may be
Depression affects 2% of preteen children and 5% present such as ADHD, disruptive disorders, substance
to 8% of adolescents (Sung & Kirchner, 2000). The in- abuse disorders, or psychotic features (e.g., hallucina-
cidence of the diagnosis of major depressive disorder tions, delusions) (Schapiro, 2005).
among all children aged 9 to 17 is approximately 5% Adolescents are also at risk for sexually transmit-
(Shaffer et al., 1996). ted diseases because of unsafe sex practices and pro-
miscuous behavior. The prevalence rate of bipolar
Dysthymic Disorder disorder increases with age. Bipolar disorder is rare
Dysthymic disorder is a chronic mood disorder simi- in children. The disorder generally begins in adoles-
lar to major depressive disorder. The symptoms of cence (Box 24-12).
dysthymic disorder are less severe and debilitating
than major depressive disorder but last at least 1 year
or more in children or adolescents. These children are SUICIDE
depressed for most of the day and on most days, and Suicide is not considered a mental disorder; however,
symptoms persist for several years. According to Rog- the presence of a mood disorder increases the likeli-
ers & Spalding (2008), the average duration of a dys- hood of suicide. The incidence of suicide attempts
thymic period in children and adolescents is about 4 reaches a peak during the midadolescent years, and
years. Approximately 70% of these depressed children mortality from suicide increases steadily through the
or adolescents are diagnosed with a major depressive teen years. Suicide is the third leading cause of death
disorder. in these teens (CDC, 2009a).
BOX 24-13 BOX 24-14

Suicide Self-injury
• Determine the presence of mental disorders (e.g., • Address self-esteem issues (e.g., low self-esteem).
depression, anxiety, conduct disorder or substance • Identify school, social, and family problems.
abuse). • Discuss relationship difficulties.
• Include a history of previous suicidal attempts. • Assess physical or sexual abuse.
• Identify all stressful life events (school and legal • Identify any mental disorder (e.g., depression,
problems, relationship problems). substance abuse, eating disorder, anxiety disorder).
• Address the lack of supportive family members • Assess the difficulty expressing or managing emotions.
(chaotic, unpredictable, home environment, marital
conflict).
• Identify parents with mental disorders (substance Source: Aguirre, B., & Smith, B. D. (2007). Handling young patients
who cut themselves. The Clinical Advisor, 10(8), 64–69.
abuse, affective disorders).
• Identify parents, relatives, friends, or role models who
have attempted suicide or completed suicide.
• Assess access to highly lethal methods (e.g., guns). Silverman, 2006). The incidence of self-injury among
adolescents is increasing.
These adolescents generally have low self-esteem, a
Source: Goodman, R. & Scott, S. (2005). Child psychiatry. (2nd ed.). history of physical or sexual abuse, and have difficulty
Malden, MA: Blackwell, with permission.
expressing their emotions. The act of mutilation be-
comes a way for the adolescents to show or express
psychologic pain.
According to the Surgeon General’s Report on Chil-
Self-injury behaviors may be present with other men-
dren and Mental Health, in 1996 the age-specific mor-
tal disorders such as affective disorders, anxiety disor-
tality rate from suicide was 1.6 per 100,000 for 10- to
ders, eating disorders, and substance abuse disorders.
14-year-olds and 9.5 per 100,000 for 15- to 19-year-olds
The self-injurious behavior is more common in girls than
(USDHHS, 1999). Boys are about four times more likely
boys. These adolescents often stir up emotions in health
to commit suicide than girls, whereas girls are twice
care providers, which is called countertransference.
as likely to attempt suicide (CDC, 2009a). Minorities
D’Onofrio (2007) defined countertransference as the
at risk for suicide include the following ethnic groups:
projection of a health care provider’s experiences, val-
Hispanic, African American, and Native American male
ues, and emotions onto the patient. Strong emotions
adolescents (CDC, 2008), though completed suicides
either positive or negative may indicate countertransfer-
are more common among white male adolescents.
ence in the provider. Education about the dynamics of
The availability of firearms and the increased sub-
self-injury decreases negative emotions toward these ad-
stance abuse by adolescents has contributed to the rise
olescents and ensures an accurate assessment and proper
in suicidal behavior among adolescent boys (CDC,
treatment (Box 24-14).
2009a, Karch, Crosby, & Simon, 2006, Nakagawara,
Howard, Thiersch, & Harruff, 2005). Suicide by fire-
arm is the most common method used by adolescents SUMMARY
(Nakagawara, et al., 2005).
Suicidal gestures should always be taken seriously Accurate assessment of mental disorders in children
by parents, teachers, and health care providers. A thor- and adolescents plays an important role in the diag-
ough suicide assessment should be done. A variety of nosis and treatment of mental disorders. Many of the
suicide assessment tools or checklists are available. mental disorders are treatable if detected early. The
(Refer to Appendix F for suicide assessment tools.) Psy- provider must use a variety of resources to complete a
chiatric consultation and evaluation is highly recom- comprehensive assessment.
mended (Box 24-13).
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SELF-INJURY American Obesity Association. (2005). Childhood obesity. Re-
Self-injury (also called self-mutilation) is the “inten- trieved July 28, 2006, from http://www.obesity.org/subs/
childhood/prevalence.shtml.
tional infliction of bodily harm or disfigurement that American Psychiatric Association. (2004). Diagnostic and statisti-
is performed during a state of emotional crisis” (Glenn cal manual of mental disorders. (4th ed., text rev.) Washington,
& De Nisco, 2006, p. 64). The most common forms DC: American Psychiatric Publishing, Inc.
Bernstein, B. E. (2008). Eating disorder: Anorexia. Retrieved
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(Glenn & DeNisco, 2006; Whitlock, Eckenrode, & article/912187-overview.
Bothe, D., & Olness, K. (2007). Worried sick: Anxiety among role of pediatrician in prevention, identification, and man-
youth. Part I. Contemporary Pediatrics, 24(7), 58–63. agement of substance abuse. Pediatrics, 115(3), 816–821.
Bothe, D., & Olness, K. (2007a). Worried sick: Anxiety among Lewin, A., Storch, E., Adkins, J., Murphy, T., & Geffken, G. (2005).
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Brown, E. (2005). Clinical characteristics and efficacious treat- Pediatric Annals, 34(2), 128–134.
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cents. Pediatric Annals, 34(2), 138–146. trieved December 2, 2009, from http://emedicine.medscape
Centers for Disease Control and Prevention. (2008). Youth risk .com/article/913721-overview.
behavior surveillance—United States, 2007. Surveillance Morrison, J., & Anders, T. F. (2001). Interviewing children and ado-
Summaries, June 6. MMWR, 57(SS-4), 1–131. lescents: Skills and strategies for effective DSM-IV diagnosis. New
Centers for Disease Control and Prevention. (2009). Alcohol & York: Guilford Press.
drug use. National Center for Chronic Disease Prevention Muscari, M. (2004). Juvenile animal abuse: Practice and policy
and Health Promotion, Division of Adolescent and School implications for PNPs. Journal of Pediatric Health Care, 18(1),
Health. Retrieved December 1, 2009, from http://www.cdc. 15–21.
gov/HealthyYouth/alcoholdrug/index.htm. Nakagawara, J., Howard, J., Thiersch, N., & Harruff, R. (2005).
Centers for Disease Control and Prevention, National Center for Gun storage practices and risk of youth suicide and uninten-
Injury Prevention and Control. (2009a). Web-based Injury tional firearm injuries. Journal of the American Medical Associa-
Statistics Query and Reporting System (WISQARS). Retrieved tion, 293(6), 707–714.
December 2, 2009, from http://webappa.cdc.gov/sasweb/ Nanda, S., & Konnur, N. (2006). Adolescent drug & alcohol use in
ncipc/mortrate10_sy.html. the 21st century. Pediatric Annals, 35(3), 193–199.
Cottrell, L., Nield, L., & Perkins, K. C. (2006). Effective interview- Schapiro, N. A. (2005). Bipolar disorders in children and adoles-
ing and counseling of the adolescent patient. Pediatric Annals, cents. Journal of Pediatric Health Care, 19(3), 131–141
35(3), 164–172. Rogers, E. S., & Spalding, S. L. (2008). Dysthymic disorder. Re-
D’Onofrio, A. A. (2007). Introduction: Self-injury on the front trieved December 2, 2009, from http://emedicine.medscape.
lines. In D’Onofrio, A. A. Adolescent self-injury: A comprehensive com/article/913941-overview.
guide for counselors and health professionals. (pp. 3–18). New Shaffer, D., Fisher, P., Dulcan, M. K., Davies, M. Piacentini J.,
York: Springer. Schwab-Stone, M. E., et al. (1996). The NIMH diagnostic in-
Garzon, D. L. (2007). Childhood depression: Diagnosis and man- terview schedule for children version 2.3 (DISC-2.3): Descrip-
agement in an era of black box warnings. Advance for Nurse tion, acceptability, prevalence rates, and performance in the
Practitioners, 15(2), 35–44. MECA study. Methods for the epidemiology of child and ado-
Ginsburg, G., & Grover, R. (2005). Assessing and treating social lescent mental disorders study. Journal of the American Acad-
phobia in children and adolescents. Pediatric Annals, 34(2), emy of Child and Adolescent Psychiatry, 35, 865–877.
119–127. Sung, S. E., & Kirchner, J. T. (2000). Depression in children
Glenn, C. H., & DeNisco, S. (2006). Self-mutilation in adoles- and adolescents. American Family Physician, 62, 2297–2308,
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Nurse Practitioners, 10(11/12), 63–76. U.S. Department of Health and Human Services. (1999). Mental
Goodman, R., & Scott, S. (2005). Child psychiatry. (2nd ed.). Mal- health; A report of the Surgeon General. Children and mental
den, MA: Blackwell. health (Chap. 3). Rockville, MD: U.S. Department of Health and
Goodman, J. D., & Sours, J. (1987) The child mental status exami- Human Services, Center for Mental Health Services, National
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Hudson, J., Deveney, C., & Taylor, L. (2005). Nature, assessment, www.surgeongeneral.gov/library/mentalhealth/chapter3/
and treatment of generalized anxiety disorder in children. sec1.html.
Pediatric Annals, 34(2), 97–106. U.S. Department of Health and Human Services. (2007). The Sur-
Jewell, J. (2007). Fragile X syndrome. Retrieved November 12, geon General’s call to action to prevent and decrease overweight
2007, from http://www.emedicine.com/ped/topic800.htm. and obesity: Overweight in children and adolescents. Rockville,
Jurbergs, N., & Ledley, D. (2005). Separation anxiety. Pediatric MD: USDHHS, Public Health Service, Office of the Surgeon
Annals, 34(2), 108–115. General.
Karch, D., Crosby, A., & Simon, T. (2006). Toxicology testing Weissman, M. M., & Klerman, G. L. (1977). Sex differences and
and results for suicide victims—13 States, 2004. MMWR, 55, the epidemiology of depression. Archives of General Psychiatry,
1245–1248. 34, 98–111.
Kulig, J. W. (2005). American Academy of Pediatrics Committee Whitlock, J., Eckenrode, J., & Silverman, D. (2006). Self-injurious
on Substance Abuse. Tobacco, alcohol, and other drugs: the behaviors in a college population. Pediatrics, 117(6), 1939–1948.
APPENDIX A
Normal Vital Signs in Infants, Children, and Adolescents
Normal Heart Rate and Respiratory Rate Ranges

HEART RATE, NORMAL RANGE RESPIRATORY RATE, NORMAL
AGE (BEATS PER MINUTE) RANGE (BREATHS PER MINUTE)
Preterm 141–171, depending on 40–70, depending on
chronologic age chronologic age
Neonate 95–170 30–50
1–11 months 90–170 30–45
1–2 years 90–150 20–30
3–4 years 70–130 20–30
5–7 years 65–130 20–25
8–11 years 70–110 14–22
12–15 years Female: 70–110 12–20

Male: 65–105
⬎15 years Female 55–95 12–20

Male: 50–90
Normal Temperature Ranges*

AGE FAHRENHEIT CELSIUS
Preterm infant 97.7–98.6 36.5–37
Term infant 97.2–99.9 36.2–37.7
0–6 months 97.2–99.4 36.2–37.4
6–12 months 96–99.7 35.6–37.6
1–13 years 95.9–99 35.5–37.2
⬎13 years 96.4–99.6 35.8–37.6
*Measurement method and circadian rhythm must be considered in evaluating normal.
527
5 2 8 • Ap pe ndi c e s
Blood Pressure Levels for Boys by Age and Height Percentile

SYSTOLIC BP (mm Hg) DIASTOLIC BP (mm Hg)
BP
PERCENTILE ← PERCENTILE OF HEIGHT → ← PERCENTILE OF HEIGHT →
AGE (YEAR) ↓ 5th 10th 25th 50th 75th 90th 95th 5th 10th 25th 50th 75th 90th 95th
1 50th 80 81 83 85 87 88 89 34 35 36 37 38 39 39
90th 94 95 97 99 100 102 103 49 50 51 52 53 53 54
95th 98 99 101 103 104 106 106 54 54 55 56 57 58 58
99th 105 106 108 110 112 113 114 61 62 63 64 65 66 66
2 50th 84 85 87 88 90 92 92 39 40 41 42 43 44 44
90th 97 99 100 102 104 105 106 54 55 56 57 58 58 59
95th 101 102 104 106 108 109 110 59 59 60 61 62 63 63
99th 109 110 111 113 115 117 117 66 67 68 69 70 71 71
3 50th 86 87 89 91 93 94 95 44 44 45 46 47 48 48
90th 100 101 103 105 107 108 109 59 59 60 61 62 63 63
95th 104 105 107 109 110 112 113 63 63 64 65 66 67 67
99th 111 112 114 116 118 119 120 71 71 72 73 74 75 75
4 50th 88 89 91 93 95 96 97 47 48 49 50 51 51 52
90th 102 103 105 107 109 110 111 62 63 64 65 66 66 67
95th 106 107 109 111 112 114 115 66 67 68 69 70 71 71
99th 113 114 116 118 120 121 122 74 75 76 77 78 78 79
5 50th 90 91 93 95 96 98 98 50 51 52 53 54 55 55
90th 104 105 106 108 110 111 112 65 66 67 68 69 69 70
95th 108 109 110 112 114 115 116 69 70 71 72 73 74 74
99th 115 116 118 120 121 123 123 77 78 79 80 81 81 82
6 50th 91 92 94 96 98 99 100 53 53 54 55 56 57 57
90th 105 106 108 110 111 113 113 68 68 69 70 71 72 72
95th 109 110 112 114 115 117 117 72 72 73 74 75 76 76
99th 116 117 119 121 123 124 125 80 80 81 82 83 84 84
7 50th 92 94 95 97 99 100 101 55 55 56 57 58 59 59
90th 106 107 109 111 113 114 115 70 70 71 72 73 74 74
95th 110 111 113 115 117 118 119 74 74 75 76 77 78 78
99th 117 118 120 122 124 125 126 82 82 83 84 85 86 86
8 50th 94 95 97 99 100 102 102 56 57 58 59 60 60 61
90th 107 109 110 112 114 115 116 71 72 72 73 74 75 76
95th 111 112 114 116 118 119 120 75 76 77 78 79 79 80
99th 119 120 122 123 125 127 127 83 84 85 86 87 87 88
9 50th 95 96 98 100 102 103 104 57 58 59 60 61 61 62
90th 109 110 112 114 115 117 118 72 73 74 75 76 76 77
95th 113 114 116 118 119 121 121 76 77 78 79 80 81 81
99th 120 121 123 125 127 128 129 84 85 86 87 88 88 89
10 50th 97 98 100 102 103 105 106 58 59 60 61 61 62 63
90th 111 112 114 115 117 119 119 73 73 74 75 76 77 78
95th 115 116 117 119 121 122 123 77 78 79 80 81 81 82
99th 122 123 125 127 128 130 130 85 86 86 88 88 89 90
(continued)
AP P E ND I X A No rm al Vital Sign s in I n f an ts , Ch ildre n , an d Adolesc ents • 529
Blood Pressure Levels for Boys by Age and Height Percentile (Continued)
BP
11 50th 99 100 102 104 105 107 107 59 59 60 61 62 63 63
90th 113 114 115 117 119 120 121 74 74 75 76 77 78 78
95th 117 118 119 121 123 124 125 78 78 79 80 81 82 82
99th 124 125 127 129 130 132 132 86 86 87 88 89 90 90
12 50th 101 102 104 106 108 109 110 59 60 61 62 63 63 64
90th 115 116 118 120 121 123 123 74 75 75 76 77 78 79
95th 119 120 122 123 125 127 127 78 79 80 81 82 82 83
99th 126 127 129 131 133 134 135 86 87 88 89 90 90 91
13 50th 104 105 106 108 110 111 112 60 60 61 62 63 64 64
90th 117 118 120 122 124 125 126 75 75 76 77 78 79 79
95th 121 122 124 126 128 129 130 79 79 80 81 82 83 83
99th 128 130 131 133 135 136 137 87 87 88 89 90 91 91
14 50th 106 107 109 111 113 114 115 60 61 62 63 64 65 65
90th 120 121 123 125 126 128 128 75 76 77 78 79 79 80
95th 124 125 127 128 130 132 132 80 80 81 82 83 84 84
99th 131 132 134 136 138 139 140 87 88 89 90 91 92 92
15 50th 109 110 112 113 115 117 117 61 62 63 64 65 66 66
90th 122 124 125 127 129 130 131 76 77 78 79 80 80 81
95th 126 127 129 131 133 134 135 81 81 82 83 84 85 85
99th 134 135 136 138 140 142 142 88 89 90 91 92 93 93
16 50th 111 112 114 116 118 119 120 63 63 64 65 66 67 67
90th 125 126 128 130 131 133 134 78 78 79 80 81 82 82
95th 129 130 132 134 135 137 137 82 83 83 84 85 86 87
99th 136 137 139 141 143 144 145 90 90 91 92 93 94 94
17 50th 114 115 116 118 120 121 122 65 66 66 67 68 69 70
90th 127 128 130 132 134 135 136 80 80 81 82 83 84 84
95th 131 132 134 136 138 139 140 84 85 86 87 87 88 89
99th 139 140 141 143 145 146 147 92 93 93 94 95 96 97
BP, blood pressure.

*The 90th percentile is 1.28 SD, 95th percentile is 1.645 SD, and the 99th percentile is 2.326 SD over the mean.
From National Heart, Lung, and Blood Institute, National Institutes of Health, U.S. Department of Health and Human Services. (2005).
Fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. NIH Publication No. 05-5267.
Retrieved May 25, 2008 from http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.pdf. Used with permission.
Blood Pressure Levels for Girls by Age and Height Percentile

BP
1 50th 83 84 85 86 88 89 90 38 39 39 40 41 41 42
90th 97 97 98 100 101 102 103 52 53 53 54 55 55 56
95th 100 101 102 104 105 106 107 56 57 57 58 59 59 60
99th 108 108 109 111 112 113 114 64 64 65 65 66 67 67
2 50th 85 85 87 88 89 91 91 43 44 44 45 46 46 47
90th 98 99 100 101 103 104 105 57 58 58 59 60 61 61
95th 102 103 104 105 107 108 109 61 62 62 63 64 65 65
99th 109 110 111 112 114 115 116 69 69 70 70 71 72 72
3 50th 86 87 88 89 91 92 93 47 48 48 49 50 50 51
90th 100 100 102 103 104 106 106 61 62 62 63 64 64 65
95th 104 104 105 107 108 109 110 65 66 66 67 68 68 69
99th 111 111 113 114 115 116 117 73 73 74 74 75 76 76
4 50th 88 88 90 91 92 94 94 50 50 51 52 52 53 54
90th 101 102 103 104 106 107 108 64 64 65 66 67 67 68
95th 105 106 107 108 110 111 112 68 68 69 70 71 71 72
99th 112 113 114 115 117 118 119 76 76 76 77 78 79 79
5 50th 89 90 91 93 94 95 96 52 53 53 54 55 55 56
90th 103 103 105 106 107 109 109 66 67 67 68 69 69 70
95th 107 107 108 110 111 112 113 70 71 71 72 73 73 74
99th 114 114 116 117 118 120 120 78 78 79 79 80 81 81
6 50th 91 92 93 94 96 97 98 54 54 55 56 56 57 58
90th 104 105 106 108 109 110 111 68 68 69 70 70 71 72
95th 108 109 110 111 113 114 115 72 72 73 74 74 75 76
99th 115 116 117 119 120 121 122 80 80 80 81 82 83 83
7 50th 93 93 95 96 97 99 99 55 56 56 57 58 58 59
90th 106 107 108 109 111 112 113 69 70 70 71 72 72 73
95th 110 111 112 113 115 116 116 73 74 74 75 76 76 77
99th 117 118 119 120 122 123 124 81 81 82 82 83 84 84
8 50th 95 95 96 98 99 100 101 57 57 57 58 59 60 60
90th 108 109 110 111 113 114 114 71 71 71 72 73 74 74
95th 112 112 114 115 116 118 118 75 75 75 76 77 78 78
99th 119 120 121 122 123 125 125 82 82 83 83 84 85 86
9 50th 96 97 98 100 101 102 103 58 58 58 59 60 61 61
90th 110 110 112 113 114 116 116 72 72 72 73 74 75 75
95th 114 114 115 117 118 119 120 76 76 76 77 78 79 79
99th 121 121 123 124 125 127 127 83 83 84 84 85 86 87
10 50th 98 99 100 102 103 104 105 59 59 59 60 61 62 62
90th 112 112 114 115 116 118 118 73 73 73 74 75 76 76
95th 116 116 117 119 120 121 122 77 77 77 78 79 80 80
99th 123 123 125 126 127 129 129 84 84 85 86 86 87 88
(continued)
AP P E ND I X A No rm al Vital Sign s in I n f an ts , Ch ildre n , an d Adolesc ents • 531
Blood Pressure Levels for Girls by Age and Height Percentile (Continued)
BP
11 50th 100 101 102 103 105 106 107 60 60 60 61 62 63 63
90th 114 114 116 117 118 119 120 74 74 74 75 76 77 77
95th 118 118 119 121 122 123 124 78 78 78 79 80 81 81
99th 125 125 126 128 129 130 131 85 85 86 87 87 88 89
12 50th 102 103 104 105 107 108 109 61 61 61 62 63 64 64
90th 116 116 117 119 120 121 122 75 75 75 76 77 78 78
95th 119 120 121 123 124 125 126 79 79 79 80 81 82 82
99th 127 127 128 130 131 132 133 86 86 87 88 88 89 90
13 50th 104 105 106 107 109 110 110 62 62 62 63 64 65 65
90th 117 118 119 121 122 123 124 76 76 76 77 78 79 79
95th 121 122 123 124 126 127 128 80 80 80 81 82 83 83
99th 128 129 130 132 133 134 135 87 87 88 89 89 90 91
14 50th 106 106 107 109 110 111 112 63 63 63 64 65 66 66
90th 119 120 121 122 124 125 125 77 77 77 78 79 80 80
95th 123 123 125 126 127 129 129 81 81 81 82 83 84 84
99th 130 131 132 133 135 136 136 88 88 89 90 90 91 92
15 50th 107 108 109 110 111 113 113 64 64 64 65 66 67 67
90th 120 121 122 123 125 126 127 78 78 78 79 80 81 81
95th 124 125 126 127 129 130 131 82 82 82 83 84 85 85
99th 131 132 133 134 136 137 138 89 89 90 91 91 92 93
16 50th 108 108 110 111 112 114 114 64 64 65 66 66 67 68
90th 121 122 123 124 126 127 128 78 78 79 80 81 81 82
95th 125 126 127 128 130 131 132 82 82 83 84 85 85 86
99th 132 133 134 135 137 138 139 90 90 90 91 92 93 93
17 50th 108 109 110 111 113 114 115 64 65 65 66 67 67 68
90th 122 122 123 125 126 127 128 78 79 79 80 81 81 82
95th 125 126 127 129 130 131 132 82 83 83 84 85 85 86
99th 133 133 134 136 137 138 139 90 90 91 91 92 93 93
BP, blood pressure.

*The 90th percentile is 1.28 SD, 95th percentile is 1.645 SD, and the 99th percentile is 2.326 SD over the mean.
From National Heart, Lung, and Blood Institute, National Institutes of Health, U.S. Department of Health and Human Services. (2005).
Fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. NIH Publication No. 05-5267.
Retrieved May 25, 2008 from http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.pdf. Used with permission.
APPENDIX B
CDC Growth Charts
Birth to 36 months: Boys NAME

Length-for-age and Weight-for-age percentiles RECORD #
Birth 3 6 9 12 15 18 21 24 27 30 33 36
in cm AGE (MONTHS)
cm in
41 41 L
97
40 40 E
100 90 100 N
39 39
75 G
38 38
95 50 95 T
37 37 H
25
36 36
90 10 90
35 3 35
34
85
33 97
32 38
80 17
31
L 90 36
30
E 75 16
N
29
75
34
G 28
70 15
T 27 32
H 26 50
65 14
25 30 W
24 25 E
60 13
23 28 I
10 G
22 55 12 H
21 3 26
T
20 50 11 24
19
18 45 10 22
17
16 40 9 20
15
8 18
16 16
7 AGE (MONTHS)
kg lb
12 15 18 21 24 27 30 33 36
14
6 Mother’s Stature Gestational
W Father’s Stature Age: Weeks Comment
E 12
Date Age Weight Length Head Circ.
I 5 Birth
G 10
H
T
4
8
3
6
2
lb kg
Birth 3 6 9
532
A P P E ND I X B CDC Gr owth C har ts • 533
Birth to 36 months: Girls NAME

Length-for-age and Weight-for-age percentiles RECORD #
Birth 3 6 9 12 15 18 21 24 27 30 33 36
in cm AGE (MONTHS)
cm in
41 41 L
40 97 40 E
100 100 N
39 90 39
38 G
75 38
95 95 T
37 50 37 H
36 25 36
90 90
35 10 35
34 3
85
33 97
32 38
80 17
31
L 30 36
75 90 16
E
N
29
34
G 28
70 75
15
T 27 32
H 26 65 14
25 50 30 W
24 E
60 13
23 25 28 I
G
22 55 12 H
10 26
21 T
20 3
50 11 24
19
18 45 10 22
17
16 40 9 20
15
8 18
16 16
7 AGE (MONTHS)
kg lb
12 15 18 21 24 27 30 33 36
14
6 Mother’s Stature Gestational
W Father’s Stature Age: Weeks Comment
E 12
Date Age Weight Length Head Circ.
I 5 Birth
G 10
H
T
4
8
3
6
2
lb kg
Birth 3 6 9
Birth to 36 months: Boys

Head circumference-for-age and NAME
Weight-for-length percentiles RECORD #
Birth 3 6 9 12 15 18 21 24 27 30 33 36
in cm AGE (MONTHS) cm in H
E
97 A
52 90 52
D
20 75 20
50 50 C
50
I
25 R
H 19 19
48 48 C
E 10 U
A 3 M
D 18 46 46 18 F
E
R
C 44 44 E
I 17 17 N
R C
C 42 42 E
U 16
M 40 50
F 22 48
E
15 38 21 46
R
E 20 44
N 36 19 42
14
C 97
E 18 40
34 90
17 38
13 75
36
32 50
16
34
12 25 15
30 10 32
3 14
30 W
13 28 E
12 I
26 G
24 11 11 24 H
22 10 10 22 T
20 9 9 20
18 8 8 18
16 7 7 16
W
E 14 14
6 6
I 12
14 12
G 5 5
10 kg lb
H 4 LENGTH
T 8 cm
64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98100
6 3
26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 in
4 2
Date Age Weight Length Head Circ. Comment
2 1
lb kg
cm 46 48 50 52 54 56 58 60 62
in 18 19 20 21 22 23 24
Birth to 36 months: Girls

Head circumference-for-age and NAME
Weight-for-length percentiles RECORD #
Birth 3 6 9 12 15 18 21 24 27 30 33 36
in cm AGE (MONTHS) cm in H
E
A
52 52
97 D
20 90 20
50 50 C
75 I
50 R
H 19 19
48 48 C
E 25 U
A 10 M
D 18 46 46 18 F
3
E
R
C 44 44 E
I 17 17 N
R C
C 42 42 E
U 16
M 40 50
F 22 48
E
15 38 21 46
R
E 20 44
N 36 19 42
14 97
C
E 18 40
34 90
17 38
13 75 36
32 16
50 34
12 25
15
30 32
10 14
3 30 W
13 28 E
12 I
26 G
24 11 11 24 H
22 10 10 22 T
20 9 9 20
18 8 8 18
16 7 7 16
W
E 14 14
6 6
I 12
14 12
G 5 5
10 kg lb
H 4 LENGTH
T 8 cm
64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98100
6 3
26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 in
4 2
Date Age Weight Length Head Circ. Comment
2 1
lb kg
cm 46 48 50 52 54 56 58 60 62
in 18 19 20 21 22 23 24
2 to 20 years: Boys NAME

Stature-for-age and Weight-for-age percentiles RECORD #
12 13 14 15 16 17 18 19 20
Mother’s Stature Father’s Stature cm in
Date Age Weight Stature BMI*
AGE (YEARS) 76
97 190
74
90
185 S
75
72
180 T
50 70 A
175 T
25 68 U
170 R
10 66
165 E
in cm 3 4 5 6 7 8 9 10 11 3 64
160 160
62 62
155 155
S 60 60
T 150 150
A 58
T 145
U 56
140 105 230
R
54
E 135 97 100 220
52
130 95 210
50
125 90 200
90
48 190
120 85
46 180
115 80
75
44 170
110 75
42 160
105 50 70
150 W
40
100 65 140 E
25
38 I
95 60 130 G
10
36 90 H
3 55 120
T
34 85 50 110
32 80 45 100
30
40 90
80 35 35 80
W 70 70
30 30
E 60 60
I 25 25
G 50 50
H 20 20
40 40
T
15 15
30 30
10 10
lb kg AGE (YEARS) kg lb
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
2 to 20 years: Girls NAME

Stature-for-age and Weight-for-age percentiles RECORD #
12 13 14 15 16 17 18 19 20
Mother’s Stature Father’s Stature cm in
Date Age Weight Stature BMI*
AGE (YEARS) 76
190
74
185 S
72
180 T
70 A
97 175 T
90
68 U
170 R
75 66
165 E
in cm 3 4 5 6 7 8 9 10 11 50
64
160 25 160
62 62
155 10 155
S 60 60
T 3
150 150
A 58
T 145
U 56
140 105 230
R
54
E 135 100 220
52
130 95 210
50
125 97 90 200
48 190
120 85
46 180
115 80
44 170
110 90 75
42 160
105 70
150 W
40 75
100 65 140 E
38 I
95 60 130 G
50
36 90 H
55 120
25 T
34 85 50 110
10
32 80 3 45 100
30
40 90
80 35 35 80
W 70 70
30 30
E 60 60
I 25 25
G 50 50
H 20 20
40 40
T
15 15
30 30
10 10
lb kg AGE (YEARS) kg lb
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
2 to 20 years: Boys NAME

Body mass index-for-age percentiles RECORD #
Date Age Weight Stature BMI* Comments

BMI
35
34
33
32
97
31
30
95
29
BMI 28
90
27 27
26 85 26
25 25
75
24 24
23 23
50
22 22
21 21
25
20 20
10
19 19
3
18 18
17 17
16 16
15 15
14 14
13 13
12 12
2 2
kg/m AGE (YEARS) kg/m
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
2 to 20 years: Girls NAME

Body mass index-for-age percentiles RECORD #
Date Age Weight Stature BMI* Comments

BMI
35
97
34
33
32
95
31
30
29
BMI 28
90
27 27
26 85 26
25 25
24 75 24
23 23
22 22
50
21 21
20 20
25
19 19
10
18 18
3
17 17
16 16
15 15
14 14
13 13
12 12
2 2
kg/m AGE (YEARS) kg/m
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
NAME
Weight-for-stature percentiles: Boys RECORD #
Date Age Weight Stature Comments kg lb

76
34
33
72
32
31 68
30
29 64
28
97
95
lb kg 27 60
26 26
56 56
25 25
90
24 85 24
52 52
23 75 23
48 22 22 48
50
21 21
25
44 20 20 44
10
19 3 19
40 18 18 40
17 17
36 36
16 16
15 15
32 32
14 14
13 13
28 28
12 12
24 11 11 24
10 10
20 9 9 20
8 8
lb kg STATURE kg lb
cm 80 85 90 95 100 105 110 115 120
in 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47
NAME
Weight-for-stature percentiles: Girls RECORD #
Date Age Weight Stature Comments kg lb

76
34
33
72
32
31 68
30
29 64
97
28
lb kg 27 60
26 26
56 56
25 90 25
24 85 24
52 52
23 75 23
48 22 22 48
50
21 21
44 20 25 20 44
19 10 19
3
40 18 18 40
17 17
36 36
16 16
15 15
32 32
14 14
13 13
28 28
12 12
24 11 11 24
10 10
20 9 9 20
8 8
lb kg STATURE kg lb
cm 80 85 90 95 100 105 110 115 120
in 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47
APPENDIX C
Michigan Alcohol Screening Test: Brief Version
1. Do you feel you are a normal drinker?
2. Do friends or relatives think you are a normal drinker?
3. Have you ever attended an Alateen or Alcoholics Anonymous?
4. Have you ever gotten in trouble at school, work, or home because of drinking?
5. Have you ever lost friends or girlfriends/boyfriends because of drinking?
6. Have you ever neglected your obligations, your family, or your school/work for
2 or more days in a row because of your drinking?
7. Have you ever had delirium tremens, severe shaking, heard voices, or seen things
that were not there after heavy drinking?
8. Have you ever gone to anyone (school counselor, peer) for help about your drinking?
9. Have you ever been in a hospital because of your drinking?
10. Have you ever been arrested for driving under the influence or other drunken
behavior?
Note: Scoring “yes” to three or more indicates alcoholism.

Source: Reprinted with permission from Pokorny, A. D., Miller, B. A., & Kaplan, H. B. (1972). The brief MAST: a shortened
version of the Michigan Alcohol Screening Test. American Journal of Psychiatry, 129, 342–345.
542
APPENDIX D
Drug Abuse Screening Test
The following questions concern information about your involvement with drugs, not
including alcoholic beverages, during the past 12 months. In the statements, “drug abuse”
refers (1) to the use of prescribed or over-the-counter drugs in excess of the directions
and (2) any nonmedical use of drugs. The various classes of drugs may include cannabis,
solvents, antianxiety drugs, sedative–hypnotics, cocaine, stimulants, hallucinogens, and
narcotics. Remember that the questions do not include alcoholic beverages. These ques-
tions refer to the past 12 months.
Have you used drugs other than those required for medical purposes? Yes__ No__
Do you abuse more than one drug at a time? Yes__ No__
Are you always able to stop using drugs when you want to? Yes__ No__
Have you had “blackouts” or “flashbacks” as a result of drug use? Yes__ No__
Do you ever feel bad about your drug abuse? Yes__ No__
Do your parents/friends/relatives ever complain about

your involvement with drugs? Yes__ No__
Have you ever neglected your family/friends because of your

use of drugs? Yes__ No__
Have you engaged in illegal activities in order to obtain drugs? Yes No
Have you ever experienced withdrawal symptoms (felt sick)

when you stopped taking drugs? Yes No
Have you had medical problems as a result of your drug use

(e.g., memory loss, hepatitis, convulsions, bleeding)? Yes No
Note: Scoring: one positive response warrants further evaluation.

From: Skinner, H. A. (1982). Drug Abuse Screening Test (DAST). Addictive Behavior, 7, 363.
543
APPENDIX E
Substance-specific Criteria for Substance Intoxication
A. The development of a reversible substance-specific syndrome due to recent ingestion

of (or exposure to) a substance. Note: Different substances may produce similar or
identical syndromes.
B. Clinically significant maladaptive behavioral or psychologic changes that are due to

the effect of the substance on the central nervous system (e.g., belligerence, mood
lability, cognitive impairment, impaired judgment, impaired social or occupational
functioning) and develop during or shortly after use of the substance.
C. The symptoms are not due to a general medical condition and are not better
accounted for by another mental disorder.
From: American Psychiatric Association. Diagnostic and statistical manual of mental disorders, text revision. (4th ed.).
Washington, DC: American Psychiatric Association.
544
APPENDIX F
SAD PERSONS Scale
S Sex 1 if male
A Age 1 if 25 to 44 or 65⫹ years
D Depression 1 if present
P Previous attempt 1 if present
E Ethanol use 1 if present
R Rational thinking loss 1 if present
S Social supports lacking 1 if lacking, especially recent loss
O Organized plan 1 if plan with lethal method
N No spouse 1 if single male, divorced, widowed, or separated
S Sickness 1 if severe or chronic
Guidelines for Action
Points Clinical Action
0–2 Send home with follow-up

3–4 Close follow-up; consider hospitalization
5–6 Strongly consider hospitalization
7–10 Hospitalize or commit
Source: Patterson, W. M. (1983). Evaluation of suicidal patients: The sad persons scale. Psychosomatics, 24(4), 343.
545
INDEX
Page records followed by f, b, or t indicate material in figures, boxes, or tables, respectively.
A African/African American lungs in, 4t–6t, 349, 350f

child-rearing differences with, 63t lymphatic system in, 9t–10t, 260–261, 260f
AAP. See American Academy of Pediatrics folk healing practices of, 67t male genitalia in, 414–416, 415f, 416f
Abdomen, 391–411 health conditions related to, 58t metabolic system in, 13t
anatomy/physiology of, 7t–8t, 391–394, Ages and Stages Questionnaires, 37t mouth in, 3t–4t, 326–328, 327f, 328f
392f–394f, 393t Albumin, 185t musculoskeletal system in, 11t–12f,
auscultation in assessment of, 402–403 Alcoholism, 58t 436–441, 437f–441f, 437t, 438t
cultural/racial variations with, 396 Alcohol screening test, 542 joints, 436–437, 438f, 438t
developmental considerations for, Allergic dermatitis, 240t muscles, 441
394–396, 395f Allergy history skeletal system, 436–441, 437f–441f,
diagnostic studies on, 406, 407t–410t abdomen assessment with, 397 437t, 438t
documenting finding on, 406, 411 eyes assessment with, 308 tendons, 441
child with abdominal pain face assessment with, 332 nails in, 232, 232f
example of, 406 lung assessment with, 353 nasopharynx in, 325–326
child with dysuria example of, 406, 411 mouth assessment with, 332 neck in, 2t–3t, 258–259, 259f, 260f
well child example of, 406 neurologic system assessment with, 470 neurologic system in, 12f–13t, 458–465,
history in assessment of, 396–398 nose assessment with, 332 459f–461f, 462t, 463f
allergies, 397 pediatric health history with, 93, 105t nose in, 3t–4t, 325, 326f
family, 397 thorax assessment with, 353 paranasal sinuses in, 326, 327f
hospitalizations, 397 All-terrain vehicles, morbidity/mortality penis in, 414, 415f, 416f
immunizations, 397 statistics for, 113 peripheral nervous system in, 463–464, 464f
injuries, 397 Alopecia areata, 30 pharynx in, 328–329
medications, 397 Alternative medicine, 69t–70t reproductive system in, 413–417, 414f–417f
nutritional, 398 acupuncture, 69t scrotum in, 414–416, 415f, 416f
present illness, 398, 399t–400t aromatherapy, 69t sebaceous glands in, 2t
review of systems, 396–397 biofeedback, 69t sinuses in, 3t–4t
social, 397–398 dietary supplements, 69t skin appendages in, 232, 232f
surgical, 397 massage, 69t skin in, 230–231, 231f
inspection in assessment of, 401–402, 402f religious, 69t small intestine in, 8t
newborns assessment with, 218–219 therapeutic touch, 70t somatic nervous system in, 463
palpation in assessment of, 404–405, American Academy of Pediatrics (AAP), spinal cord in, 461–463, 463f
404f, 405f developmental examination spine in, 11t
percussion in assessment of, 403, 403f recommended by, 31 spleen in, 10t
physical examination in assessment of, developmental evaluation, 36 stomach in, 8t
398–401 developmental screening, 31–36 subcutaneous glands in, 232
equipment for, 140b, 400 developmental surveillance, 31, 36 subcutaneous tissue in, 231, 231f
growth parameters with, 400–401 Anatomy, child, 1, 2t–14t sweat glands in, 232
vital signs with, 400, 401b abdomen in, 7t–8t, 391–394, 392f–394f, 393t teeth in, 3t
special techniques for, 405–406 apocrine glands in, 2t testicles in, 414–416, 415f, 416f
iliopsoas test, 405 autonomic nervous system in, thermoregulation in, 13t
obturator test, 405, 405f 463–464, 464f thorax in, 4t–6t, 348–349, 349f, 350t
pelvic exam, 406 blood-brain barrier in, 461 pleural cavity, 349
rectal exam, 405–406 brain in, 2t–3t, 458–461, 459f–461f, 462t thoracic cage, 348, 349f, 350t
ABR. See Auditory brainstem response breast, 416, 416f, 417f thoracic cavity, 348
Abuse. See Child abuse/neglect cardiovascular system in, 6t–7t, throat in, 3t–4t
Acanthosis nigricans, C2 366–368, 367f Animal safety, 118b, 122
Acculturation, 57t central nervous system in, 458–463, Anorexia nervosa, 520–521, 521b
Acne, 240t 459f–461f, 462t, 463f Anthropometric measurements, 153–158
Acrocyanosis, 210 central nervous system pathways in, 463 arm span, 157–158
Active listening, 46 cerebral blood supply in, 461 body mass index, 156, 156t, 170
Acupuncture, 69t dermis, 231, 231f breast- v. formula-fed infants with, 154
ADHD. See Attention deficit hyperactivity ears in, 3t, 278–280, 279f, 280f chest circumference, 158
disorder external ear, 278–279, 279f children with chronic conditions, 155
Adolescents inner ear, 279f, 280, 280f ethnic/racial variations with, 154–155
abdomen of, 8t middle ear, 279–280, 279f growth charts for, 154, 183, 183t
communication with, 53t, 54 eccrine glands in, 2t head circumference, 158, 158f, 170
dietary evaluation of, 192t endocrine system in, 14t height, 157, 157t, 170
dietary intake information for, 196 epidermis in, 230–231, 231f length, 156–157, 157f, 170
endocrine system of, 14t eyes in, 3t, 302–305, 303f, 304f, 305f mid-upper arm circumference, 156
Erikson child development theory on, 22t external eye, 302–303, 303f nutrition assessment with, 182–183, 183t
Freud child development theory on, 22t internal eye, 303–305, 303f, 304f premature infants with, 154
Gilligan child development theory on, 22t vision, 305, 305f skinfold thickness, 156
growth/development of, 14 face in, 325, 326f weight, 155–156, 155f, 170
integument of, 2t female genitalia in, 413–414, 414f, 415f weight-for-length, 157, 170
Kohlberg child development theory on, 22t fluid balance in, 11t weight-for-stature, 157
musculoskeletal system of, 12t gastrointestinal system in, 391–393, 393f Anus, physical examination of, 432
nutrition history for, 97 genitourinary system in, 10t–11t Anxiety disorders, 522–523, 522b, 523b
pediatric health interview with, 90 hair in, 232 APGAR score, 201, 204, 204t
Piaget child development theory on, 22t head in, 2t–3t, 258, 259f APIB. See Assessment of Preterm Infants’
safety assessment for, 130, 132t–133t, hematologic system in, 10t Behavior
133–134 hepatic system in, 8t–9t Apocrine glands, child anatomy for, 2t
sequence of physical examination, 148t immunity in, 10t Arab American, child-rearing differences
sinuses of, 4t integumentary system in, 230–232 with, 63t
sleep patterns for, 100t integument in, 2t Argininosuccinic acidemia, 226t
social history assessments for, 103, 104t large intestine in, 8t Arm recoil, 206f, 207, 207t
wellness history assessment for, 166t larynx in, 5t Arm span, 157–158
Adoptive families, 78–79 liver in, 8t–9t Aromatherapy, 69t
547
5 4 8 • I nde x
Ash leaf spots, 30 Breasts, 216 cyanosis in, 376

Asian/Asian American anatomy/physiology of, 416, 416f, 417f diaphoresis in, 376
child-rearing differences with, 63t physical examination of, 432–434, 433f diastolic murmurs in, 383–384, 383f, 384t
folk healing practices of, 67t physical maturity assessment with, 206f, 208 edema in, 376
health conditions related to, 58t Brigance Screens, 38t equipment for, 140b
Asperger’s disorder, 517 Bruises, C4 growth pattern in, 375
Assessment of Preterm Infants’ Behavior Brushfield’s spots, 214 heart sounds in, 377–380, 377f, 378f, 380f
(APIB), 225 Bulimia nervosa, 521, 521b innocent murmurs in, 384–385
Assimilation, 57t Burns palpation in, 376–377, 377f
Asymmetric tonic neck reflex, 223t, 224f cigarette, C4 pathologic murmurs in, 384, 385t
Atopic dermatitis, 240t morbidity/mortality statistics for child, 111 point of maximal impulse in, 377, 377f
Attention deficit hyperactivity disorder prevention safety, 118b, 122 pulmonary ejection murmur in, 385
(ADHD), 20, 520, 520b pulmonary flow murmur in, 385
Auditory brainstem response (ABR), 214 Still’s murmur in, 385
C
Auscultation, 143 systolic murmurs in, 380–383, 380f, 381f,
abdomen assessment with, 218, 402–403 Café-au-lait spots, 30, 211b, 234f, C1 381t–383t
cardiovascular assessment with, 217 Caida de la mollera (Fallen fontanel), 66t venous hum in, 385
cardiovascular examination with, 377–385, Calgary Family Assessment Model (CFAM), preparticipation sports examination
377f, 378f, 380f, 381f, 381t–385t, 85–88, 85b, 86b, 86f, 87f with, 173b
383f, 384f developmental assessment in, 86 respiratory complaints with, 372–373
chest assessment with, 216 functional assessment in, 86–87 review of systems, 25
lung assessment with, 216 genogram in, 85–86, 86f, 87f syncope with, 373–374
thorax assessment with, 360–362, 361f, structural assessment in, 85, 85b, 86b The Carey Temperament Scales, 38t
361t, 362t context, 85, 86b Carotid arteries, physical examination of, 272
Autism spectrum disorder, language acquisition external structure, 85, 85b Carotid bruit, 385
affected by, 23b internal structure, 85, 85b CAT-CLAMS. See Cognitive-Adaptive Test/
Autistic disorder, 517 Cambodian, child-rearing differences with, 63t Clinical Linguistic and Auditory
Autonomic nervous system, anatomy/physiology Cancer, hot/cold theory regarding, 65t Milestone Scale
of, 463–464, 464f Candidiasis, 241t Caucasian/European ancestry, health
Awake states, 225 Caput succedaneum, 212, 213f conditions related to, 58t
Cardiovascular system, 366–389 Cavernous hemangiomas, 211b
anatomy/physiology of, 6t–7t, CDC. See Centers for Disease Control
B
366–368, 367f Ceeb. See Fright illness
Babinski reflex, 224t cardiac cycle, 367–368 Celiac disease, Caucasian/European ancestry
Barlow maneuver, 221 electrical conduction pathway, 368 related to, 58t
Battelle Developmental Inventory (BDI), 37t normal, 366–367, 367f Cellulitis, 240t
Bayley Infant Neurodevelopmental Screen chest pain with, 373 Centers for Disease Control (CDC), growth
(BINS), 37t congestive heart failure with, 374, 374t chart of, 183–184, 532–541
BBB. See Blood-brain barrier cyanosis with, 374 body mass index, 183–184, 538–539
BDI. See Battelle Developmental Inventory developmental considerations for, head circumference-for-age, 184, 534–535
Behavioral stages, child development with, 14 368–369, 369f stature-for-age, 184, 536–537
Biceps reflex, 222 closure of fetal shunts, 369 weight-for-age, 184, 532–533, 536–537
Bicultural state, 57t embryologic heart development, 368 weight-for-length, 184, 534–535
Bicycle safety, 118b, 121–122, 121f fetal circulation, 368–369, 369f weight-for-stature, 184, 540–541
morbidity/mortality statistics for child, 113 diagnostic tests on, 386–388, 387f Central nervous system
Bimanual examination, 428–429, 429f cardiac catheterization in, 388 anatomy/physiology of, 458–463, 459f–461f,
BINS. See Bayley Infant Neurodevelopmental chest radiograph in, 388 462t, 463f
Screen echocardiogram in, 388 pathways, 463
Biochemical markers, 185–187, 185t, 187t electrocardiogram in, 387–388, 387f Cephalhematoma, 212, 213f
cholesterol/triglycerides/lipid levels, documenting finding on, 388–389 Cephalocaudal development, 17, 18f, 19f
186–187, 187t health child example of, 388–389 Cerebral blood supply, anatomy/physiology
disease-specific, 187 ill child example of, 389 of, 461
glucose, 187 exercise intolerance with, 372 Cerebral palsy, language acquisition affected
iron, 186 history in assessment of, 369–374, 374t by, 23b
serum proteins, 185–186, 185t family, 371–372 Cervical dysplasia, health screening for, 172
Biofeedback, 69t immunizations, 371 CFAM. See Calgary Family Assessment Model
Biomedical theory, 64 medications, 371 CHAT. See Checklist for Autism in Toddlers
Bipolar disorder, 524, 524b present illness, 372–374, 374t Checklist for Autism in Toddlers (CHAT), 39t
Birth history, 201–203, 204t review of systems, 370–371 Chest
Bladder exstrophy, 218 social, 372 newborns assessment with, 215–216
Blocked intestine. See Empacho surgical, 371 pediatric health history with, 92t
Blood-brain barrier (BBB) joint symptoms with, 374 Chest circumference, 158
anatomy/physiology of, 461 liver with, 386 Chief complaint, 91, 106
neonates, 12t lungs with, 386 Child. See also Adolescents; Infants; Neonates;
Blood pressure neurologic symptoms with, 374 Preschoolers; School-aged children;
cardiovascular assessment with, 218 newborns assessment with, 216–218 Toddlers
newborns assessment with, 209 auscultation, 217 anatomic/physiologic differences in, 1,
normal child levels of, 528–531 blood pressure in, 218 2t–14t
physical examination with, 152–153, heart rate in, 217 abdomen, 7t–8t
154b, 170 heart sounds in, 217 apocrine glands, 2t
Body language, 49–50 inspection, 216 brain, 2t–3t
arms/legs open or crossed, 49 murmurs in, 217 cardiovascular system, 6t–7t
eye contact, 49, 61 palpation, 216 ears, 3t
gestures, 49 pediatric health history with, 92t eccrine glands, 2t
head tilt, 49 peripheral pulses with, 386 endocrine system, 14t
repetitive movement of extremities, 49 physical examination in assessment of, eyes, 3t
sitting behind desk, 49 375–385, 377f, 378f, 380f, 381f, fluid balance, 11t
Body mass index, 156, 156t, 170, 183–184 381t–385t, 383f, 384f genitourinary system, 10t–11t
Brachial cleft cysts, 215 apical impulse in, 377 head, 2t–3t
Brain appearance in, 375 hematologic system, 10t
anatomy/physiology of, 2t–3t, 458–461, auscultation in, 377–385, 377f, 378f, hepatic system, 8t–9t
459f–461f, 462t 380f, 381f, 381t–385t, 383f, 384f immunity, 10t
traumatic injury to, 23b carotid bruit in, 385 integument, 2t
Breast-fed infants chest deformity in, 376 large intestine, 8t
anthropometric measurements with, 154 clubbing in, 376 larynx, 5t
dietary evaluation of, 191t continuous murmurs in, 384, 384f, 385t liver, 8t–9t
Index • 549
lungs, 4t–6t present history, 28 head tilt, 49

lymphatic system, 9t–10t primary caregiver, 26 repetitive movement of extremities, 49
metabolic system, 13t refugee status, 27 sitting behind desk, 49
mouth, 3t–4t review of systems, 24–25 cadence in, 62
musculoskeletal system, 11t–12f school progress, 27 caregiver and children, 45–46
neck, 2t–3t social, 25–28 confidentiality with, 44–45
neurologic system, 12f–13t social environment, 27 cross-cultural, 60–62
nose, 3t–4t influences on, 17–22, 18f–20f, 21t–23t nonverbal, 61
sebaceous glands, 2t laboratory/imaging assessment in evaluation tone, pitch, and cadence in, 62
sinuses, 3t–4t of, 40, 40t verbal, 61–62
small intestine, 8t language/communication skills, 14, 20, 23, 23b family/children, 14, 44–54
spine, 11t locomotion, 17, 19f parent-child relationship with, 44–52,
spleen, 10t motor skills, 14 47t, 52t
stomach, 8t pediatric health history with, 103, 105t through interpreter, 50–51
teeth of, 3t physical examination in evaluation of, 28–31 language in, 61–62
thermoregulation, 13t ears in, 30–31 listening with, 46–47
thorax, 4t–6t eyes in, 30–31 active, 46
throat, 3t–4t face in, 30–31, 31f ignoring, 46
caregiver’s relationship with, 15 general, 28 pretend, 46
communication skills required to work head in, 30–31, 31f selective, 46
with, 14 hearing in, 31 mental health assessment with, 513–514
growth/development of, 14 integument in, 30, 30f pediatric health history interview, 89–90
health care provider’s role with, 15–16 measurements in, 29–30 pitch in, 62
obtaining heath history of, 14–15 neuromuscular system in, 31 through play, 51
physical examination of, 15 vision in, 31 privacy with, 44–45
sleep needs for, 99t predictable sequence of, 18 process of, 44
sleep patterns for, 100t principles of, 17–20, 18f–20f techniques for, 46–52, 47t, 52t
sleep problems for, 101t proximal to distal, 17, 20f body language in, 49–50
Child abuse/neglect, 493–510 psychosocial stages, 14 building rapport, 46
assessment of, 497–509, 498b, 499t, red flags for, 29b empathy, 47
502f–505f risk factors for delays in, 28b encouraging conversation, 47–48, 47t
emotional abuse, 506 simple to complex, 17 listening, 46–47
history in, 497–499, 498b, 499t temperament in, 20, 23t nonjudgmental, 47t
neglect, 499–500 theories of, 20–22, 21t–23t open-ended questions, 47t
physical abuse, 500–506, 502f–505f Erikson, 21t–22t parent/child problem solving, 47t
sexual abuse, 506–509 Freud, 21t–22t parent/child self-esteem, 47t
verbal abuse, 506 Gilligan, 21t–22t verbal/nonverbal, 48–50
diagnostic studies on, 509, 509t Kohlberg, 21t–22t tone in, 62
documenting finding on, 509–510 Piaget, 21t–22t verbal/nonverbal, 48–50
epidemiology of, 495–497, 496b variable growth rate of, 18 body language in, 49–50
language acquisition affected by, 23b Child Development Inventories, 37t cross-cultural, 61–62
pictures of, C4 Childhood infectious diseases, pediatric health paralanguage with, 48
types of, 493–495, 495b, 495t history with, 93, 105t physical appearance in, 49
emotional abuse, 494–495, 495b Childhood obesity, 521–522, 522b physical environment in, 48–49
neglect, 493–494 Child-rearing practices, cross-cultural differ- Complementary and alternative medicine. See
physical abuse, 494, 495t ences with, 62, 63t–64t Alternative medicine
sexual abuse, 495 Chinese Complete blood count, 40t
verbal abuse, 494 child-rearing differences with, 63t Conduct disorder, 520, 520b
Child Behavior Checklist, 39t folk healing practices of, 67t Conduction tests, 296
Child development, 14 Choanal atresia, 214 Confidentiality, family/children
assessment of, 17–41 Choking communication with, 44–45
behavioral stages, 14 Haddon’s matrix example of, 114t Congenital nevi, 234–235
cephalocaudal, 17, 18f, 19f morbidity/mortality statistics for child, 111 Congestive heart failure, 374, 374t
cognitive abilities, 14 Cholesterol, 186–187, 187t Constipation, hot/cold theory regarding, 65t
critical sensitive periods of, 18–20 Chromosome analysis, 40t Contact dermatitis, 240t
culture in, 20 Cigarette burn, C4 Continuous murmurs, 384, 384f, 385t
developmental examination in evaluation Citrullinemia, 226t Corneal reflex, 214, 224t
of, 31–38, 32t–35t, 37t–39t Cleft lip, Asian/Asian American related to, 58t Coxsackie virus, 241t
assessment tools for, 37t–39t CLIENT OUTCOMES mnemonic, 106b Crackles, 216
developmental evaluation in, 36 Clubfoot, 221 Craniosynostosis, 212
developmental screening in, 31–36 Cognitive abilities Crawling, development of, 17, 19f
developmental surveillance in, 31, 36 child development of, 14 Crohn’s disease, Caucasian/European ancestry
milestones for, 32t–35t developmental milestones for, 32t–35t related to, 58t
preparation for, 36 Cognitive-Adaptive Test/Clinical Linguistic and Cultural awareness, 60
documentation of findings with assessment Auditory Milestone Scale Cultural bias, 57t
of, 40–41 (CAT-CLAMS), 38t Cultural competence, 59–60
child with concerns write-up, 41 Cognitive development, 22 developing, 59–60
normal child write-up, 40–41 Communication. See also Language/ altering worldview in, 60
domains in, 22–23, 23b communication skills cultural awareness in, 60
cognitive development, 22 age/developmental considerations with, cultural belief familiarity in, 60
fine motor skills, 22 52–54, 53t cultural desire in, 60
gross motor skills, 22 adolescents, 53t, 54 cultural encounters in, 60
language development, 23, 23b infants, 52, 53t cultural knowledge in, 60
socioemotional development, 23 preschoolers, 52–53, 53t cultural skill in, 60
evaluation of, 23–41 school-aged children, 53–54, 53t health care goals in, 60
head-to-toe, 17, 18f toddlers, 52, 53t increasing knowledge of cultural group
history in evaluation of, 23–28 blocks to, 51–52, 52t in, 60
family, 25 blame, 52t trust in, 60
home environment, 26–27 false reassurance, 52t health/health care disparities, 59
immigrant status, 27 inappropriate use of authority, 52t Institute of Medicine reported health care
injuries, 25 leading questions, 52t disparities, 59
institutionalization, 28 unwanted advice, 52t Cultural desire, 60
medical, 23–25 body language in, 49–50 Cultural encounters, 60
medications, 25 arms/legs open or crossed, 49 Cultural knowledge, 60
neonatal, 24 eye contact, 49, 61 Cultural skill, 60
prenatal, 23–24 gestures, 49 Culture, 56–72
5 5 0 • I nde x
abdomen, variations with, 396 Cognitive-Adaptive Test/Clinical hearing acuity assessment for, 293–297,
characteristics of, 56–59 Linguistic and Auditory Milestone 293b, 294b, 295t, 296f, 297f
child development with, 20 Scale, 38t hearing loss types in, 293, 293b
communication between, 60–62 Denver II, 38t history in, 294
nonverbal, 61 Early Language and Milestones Scale-2, 38t physical examination in, 294–296, 295t
verbal, 61–62 Eyberg Child Behavior Inventory, 39t risk factors in, 293b, 294b
defined, 56, 57t–58t M-CHAT, 39t hearing screening tests for, 296–297,
Giger & Davidhizar, 57t Parent Evaluation of Developmental 296f, 297f
Leininger, 57t Status, 37t conduction tests, 296
Purnell & Paulanka, 57t Peabody Developmental Motor Scales, 38t Rinne test, 296–297, 297f
Spector, 57t Pediatric Symptom Checklist, 39t Weber test, 296, 296f
dermatologic assessment with considerations Pervasive Developmental Disorders whisper test, 296
for, 252–255, 253f, 255t Screening Test-II, 39t history in assessment of, 281–285, 282t,
cutaneous reaction patterns with, Primary Care Screener, 39t 284t, 285t
252–253, 255t Social Communication Questionnaire, 39t family, 284
dark skin children in, 252–253, 255t developmental evaluation in, 36 hearing acuity, 294
hair in, 253 developmental screening in, 31–36 medications, 283–284, 284t
impact from practices of, 253 developmental surveillance in, 31, 36 past medical, 281–283, 282t
differences between, 62–64, 63t–64t document findings for, 36 present illness, 285, 286t–289f
child-rearing practices, 62, 63t–64t elicit parental concerns for, 36 review of systems, 25, 282–283
family relationships, 62 identify risk and protective factors for, 36 social, 284, 285t
modesty, 62, 64 obtain developmental history for, 36 surgical, 283
dynamic/ever-changing, 56 preform accurate objective assessments newborns assessment with, 213–214
folk illnesses, 65, 66t for, 36 pediatric health history with, 92t
caida de la mollera, 66t milestones for, 32t–35t physical examination in assessment of,
empacho, 66t preparation for, 36 30–31, 285–293, 289f, 291f, 292f, 292t
falling out, 66t Developmental history equipment for, 140b
fright illness, 66t eyes assessment with, 308 external auditory canal, 290–293,
mal de ojo, 66t head assessment with, 265 291f, 292f
susto, 66t musculoskeletal assessment with, 445 external ear, 289–290, 289f
Voodoo illness, 66t neck assessment with, 265 general appearance, 289
health beliefs with, 64–65, 65t neurologic system assessment with, 468–470 hearing acuity, 294–296, 295t
biomedical theory, 64 Diabetes tympanic membrane, 291–292, 292t
holistic or naturalistic perspective, 64, 65t African/African American related to, 58t physical maturity assessment with, 206f,
hot/cold theory, 64, 65t Hispanic/Latino related to, 58t 208–209
magico-religious perspective, 64–65 Native American/Alaskan related to, 58t railroad track, 31
scientific theory, 64 Diaper dermatitis, 240t Eating disorders, 520–522, 521b, 522b
yin/yang theory, 64 Diaphoresis, 376 Eccrine glands, child anatomy for, 2t
health conditions related to, 58t Diarrhea, hot/cold theory regarding, 65t Edema, 249–250, 250f, 250t, 376
health practices with, 64–70, 67t–70t Diastasis, 218 Electroencephalogram, 40t
complementary/alternative practices, Diastolic murmurs, 383–384, 383f, 384t Elimination, pediatric health history with,
69t–70t Dietary evaluation, 190–193, 191t–192t 97–98, 98f, 105t
folk healing practices, 67t–68t dietary questionnaire in, 190–191, 191t–192t ELM. See Early Language and Milestones Scale-2
religious, 70 adolescents, 192t Emergency pediatric health history, 91, 107
immigrant/refugee children assessment, breast-fed infants, 191t Emotional abuse, 494–495, 495b
70–72, 71b, 71t, 72t formula-fed infants, 191t assessing, 506
cultural assessment for, 72, 72t infants, 191t differential diagnoses in, 506
culture shock with, 71–72 school-aged children, 192t history in, 506
history/physical examination for, 70–71 food records/diaries in, 192–193 Empacho (blocked intestine), 66t
violence/torture with, 71b twenty-four-hour recall in, 191–192 Encephalocele, 213
integrated, 56 Dietary supplements, 69t Endocrine system
learned, 56 Diphtheria, 95 child anatomy for, 14t
musculoskeletal system with, 442 Disruptive behavioral disorders, 520, 520b pediatric health history with, 93t
poverty as, 59 Divorce, family assessment with, 81–82, 83b review of systems, 25
reproductive system with, 418–419 Down syndrome Environmental tobacco smoke (ETS), 167
shared, 56 facial features seen in, 30, 31f EOAE. See Evoked otoacoustic emissions
shock, 71–72 palmar crease in, 30, 30f Epidermis, anatomy/physiology of, 230–231, 231f
terms related to, 57t–58t Drowning, morbidity/mortality statistics for Erb’s palsy, 220
thorax development with, 352 child, 111 Erikson child development theory, 21t–22t
wellness care influenced by, 162 Drug abuse screening test, 543 adolescents in, 22t
Cutis aplasia, 211b Drug eruptions, 240t infant in, 21t
Cyanosis, 374, 376 Dyslipidemia, health screening for, preschoolers in, 21t
Cystic fibrosis, Caucasian/European ancestry 171–172, 172b school-aged children in, 22t
related to, 58t Dysmorphic facial features, 30 toddlers in, 21t
Cystic hygromas, 215 Dysthymic disorder, 524 Erythema toxicum, 211b, 212f, 241t, C1
Esotropia, 214
Ethnicity, 58
D E
anthropometric measurement variations
Dental/oral history Early Language and Milestones Scale-2 with, 154–155
face assessment with, 332–333, 333b (ELM), 38t child development with, 20
mouth assessment with, 332–333, 333b Ears child-rearing differences between, 62,
nose assessment with, 332–333, 333b anatomy/physiology of, 3t, 278–280, 63t–64t
Denver II, 38t 279f, 280f culture/race as different from, 56
Dermis, anatomy/physiology of, 231, 231f external ear, 278–279, 279f defined, 57t
Developmental examination, 31–38, 32t–35t, inner ear, 279f, 280, 280f dermatologic assessment with considerations
37t–39t middle ear, 279–280, 279f for, 252–255, 253f, 255t
assessment tools for, 37t–39t developmental considerations for, cutaneous reaction patterns with,
Ages and Stages Questionnaires, 37t 280–281, 281f 252–253, 255t
Battelle Developmental Inventory, 37t external ear, 280–281 dark skin children in, 252–253, 255t
Bayley Infant Neurodevelopmental inner ear, 281 hair in, 253
Screen, 37t middle ear, 281, 281f impact from practices of, 253
Brigance Screens, 38t diagnostic testing for, 297, 298t–300t health conditions related to, 58t
The Carey Temperament Scales, 38t documenting finding on, 297, 300 Ethnocentrism, 57t
Checklist for Autism in Toddlers, 39t healthy child sample, 297 ETS. See Environmental tobacco smoke
Child Behavior Checklist, 39t healthy neonate sample, 297 Evil eye. See Mal de ojo
Child Development Inventories, 37t ill child sample, 300 Evoked otoacoustic emissions (EOAE), 214
Index • 551
Exotropia, 214 Falls, morbidity/mortality statistics for child, history of present illness in,
Extrusion reflex, 224t 112–113 106–107, 106b
Eyberg Child Behavior Inventory, 39t Family assessment, 76–88 OPPQRST mnemonic for, 106b
Eye contact, 49, 61 brief, 84–85 Folk healing practices, 67t–68t
Eye exams, 170–171 Calgary model of, 85–88, 85b, 86b, 86f, 87f Folk illnesses, 65, 66t
Eyes developmental assessment in, 86 caida de la mollera, 66t
anatomy/physiology of, 3t, 302–305, 303f, functional assessment in, 86–87 empacho, 66t
304f, 305f genogram in, 85–86, 86f, 87f falling out, 66t
external eye, 302–303, 303f structural assessment in, 85, 85b, 86b fright illness, 66t
internal eye, 303–305, 303f, 304f characteristics of healthy, 77, 77t mal de ojo, 66t
vision, 305, 305f demographics in, 77–78 susto, 66t
developmental considerations for, development stages in, 80–81 Voodoo illness, 66t
305–306, 306t families in later life, 81 Folliculitis, 240t
diagnostic studies on, 322–323, 489, families with young adolescents, 81 Follow-up pediatric health history, 91, 107
490b, 490t families with young children, 80–81 Formula-fed infants
documenting finding on, 323, 489–491 joining families through marriage, 80 anthropometric measurements with, 154
ill child sample, 491 launching children and moving on, 81 dietary evaluation of, 191t
injured child sample, 323 launching single young adult, 80 Foster families, 79
normal newborn sample, 489–490 divorce in, 81–82, 83b Fragile X karyotype, 40t
well child sample, 323, 490–491 guidelines for, 82–83 Freckling, 30
history in assessment of, 92t, 306–310, 309t, importance of, 76 Freud child development theory, 21t–22t
311t–312t indications for comprehensive, 84 adolescents in, 22t
allergies, 308 purpose of, 76–78 infant in, 21t
developmental, 308 sensitive issues with, 84 preschoolers in, 21t
family, 308 strength-based, 76–77 school-aged children in, 22t
hospitalizations, 308 types of, 84 toddlers in, 21t
immunizations, 308 Family history, 25 Fright illness (Ceeb), 66t
injuries, 308 abdomen assessment with, 397
medications, 309, 309t cardiovascular assessment with, 371–372
G
ocular history, 309 ear assessment with, 284
past medical, 306–307 eyes assessment with, 308 Gait
present illness, 310, 311t–312t face assessment with, 331 physical examination in assessment of,
review of systems, 307–308 integumentary system assessment with, 447, 447f
social, 308 235–236 physical survey of, 144
surgical, 308 lung assessment with, 353–354 Galeazzi maneuver, 221, 221f
newborns assessment with, 214 mouth assessment with, 331 Gastrointestinal system, 391–411
nutrition problems related to, 188t musculoskeletal assessment with, 444 anatomy/physiology of, 391–393, 393f
physical examination in assessment of, neurologic system assessment with, 468 cultural/racial variations with, 396
30–31, 310–322, 313f–322f, 321b, 322t newborn assessment with, 199 developmental considerations for,
color vision in, 314 nose assessment with, 331 394–395, 395f
equipment for, 140b pediatric health history with, 95, 105t nutrition problems related to, 189t
extraocular eye structure in, 316–319, preparticipation sports examination with, 173b pediatric health history with, 92t
318f, 319f reproductive system assessment with, review of systems, 25
extraocular muscle function in, 421, 421b Gastroschisis, 218
314f–317f, 315–316 thorax assessment with, 353–354 Gay/lesbian parent families, 79
internal eye structure in, 319–320, 320f Family relationships General health practices safety, 118b,
ophthalmoscopic examination in, cross-cultural differences with, 62 123–124
320–322, 321b, 321f, 322f healthy, 77, 77t Genitourinary system, 391–411
palpation in, 320 Family structure, 78–80 anatomy/physiology of, 10t–11t,
peripheral visual fields in, 314–316, adoptive families, 78–79 393–394, 394f
314f–317f chronic illness in, 79 cultural/racial variations with, 396
visual acuity in, 310–313, 313f, 314f foster families, 79 developmental considerations for,
physical maturity assessment with, 206f, gay/lesbian parent families, 79 395–396
208–209 grandparent-led families, 79 newborns assessment with, 219
review of systems, 25 homeless parent families, 79 pediatric health history with, 92t
older first-time parent families, 80 review of systems, 25
single-parent families, 78 Genogram
F
stepfamilies, 78 blank, 86f
Face, 325–346 teen parent families, 79–80 family assessment with, 85–86, 86f, 87f
anatomy/physiology of, 325, 326f two-parent families, 78 sample, 87f
cultural/ethnic considerations for, 329–330 Female genitalia, 219 symbols used in, 87f
developmental considerations for, 329 anatomy/physiology of, 413–414, 414f, 415f Geographic tongue, C3
diagnostic studies on, 345, 346t physical examination equipment for, 140b Gilligan child development theory, 21t–22t
documenting finding on, 345–346 physical examination of, 422–429, 424f, adolescents in, 22t
child with sore throat example of, 425t, 427f–429f infant in, 21t
345–346 physical maturity assessment with, 206f, 209 preschoolers in, 21t
well child sample of, 345 Female genital mutilation (FGM), 71 school-aged children in, 22t
history in assessment of, 330–333, 333b, Fetal drug/alcohol exposure, language toddlers in, 21t
334t–335t acquisition affected by, 23b Glucose, 187
allergies, 332 Fetal risk assessment, 200t Grandparent-led families, 79
dental/oral history, 332–333, 333b Fever, hot/cold theory regarding, 65t Gross motor skills, 22
family, 331 FGM. See Female genital mutilation developmental milestones for, 32t–35t
hospitalizations, 331 Filipino, child-rearing differences with, 63t Growth and development. See Child
immunizations, 331 Fine motor skills, 22 development
injuries, 331 developmental milestones for, 32t–35t Growth chart, 154, 183–184, 183t, 532–541
medications, 331–332 Firearms safety, 118b, 123 body mass index, 183–184, 538–539
past medical, 330 morbidity/mortality statistics for child, head circumference-for-age, 184, 534–535
present illness, 333, 334t–335t 111–112 nutrition assessment with, 183–184
review of systems, 330 Fires stature-for-age, 184, 536–537
social, 331 morbidity/mortality statistics for child, 111 weight-for-age, 184, 532–533, 536–537
surgical, 331 safety, 118b, 122 weight-for-length, 184, 534–535
newborns assessment with, 213 Fluid balance, child anatomy for, 11t weight-for-stature, 184, 540–541
physical examination in assessment of, Focused pediatric health history, 91, 106–107, Gums, nutrition problems related to,
30–31, 31f, 333–337, 335f, 336t 106b, 107b 188t–189t
Fallen fontanel. See Caida de la mollera chief complaint in, 91, 106 Gynecologic system, pediatric health history
Falling out, 66t client outcomes in, 106b with, 93t
5 5 2 • I nde x
H Hispanic/Latino social, 25–28, 237, 265, 284, 285t, 308, 331,

children, 20 354, 372, 397–398, 421–422, 421b,
Haddon’s matrix, choking example using, 114t folk healing practices of, 67t, 68t 444–445, 468
Hair, 30 health conditions related to, 58t social environment, 27
anatomy/physiology of, 232 History. See also Pediatric health history surgical, 265, 283, 308, 331, 353, 371, 397,
cultural/ethnic considerations in assessment abdomen assessment with, 396–398 421, 444, 468
of, 253 allergy, 308, 332, 353, 397, 470 thorax assessment with, 352–354, 355t–357t
developmental considerations for, 233 birth, 201–203, 204t verbal abuse assessment with, 506
inspection for assessment of, 250–251 cardiovascular assessment with, 369–374, 374t wellness care with assessment of, 162–167,
newborns assessment with, 212–213, 213f child abuse/neglect, 497–499, 498b, 499t 164t–166t, 167b
nutrition problems related to, 188t child development, 23–28 HIV. See Human immunodeficiency virus
palpation for assessment of, 251 dental/oral, 332–333, 333b Holistic or naturalistic perspective, 64, 65t
Hair whorls, 30, 213 developmental, 265, 308, 445, 468–470 Home environment history, 26–27
Harlequin change, 210 ear assessment with, 281–285, 282t, 284t, 285t Home environment safety, 117–119, 118b, 119b
Head, 258–276 emotional abuse assessment with, 506 rural homes, 119, 120b
anatomy/physiology of, 2t–3t, 258, 259f eyes assessment with, 306–310, 309t urban homes, 117–119, 119b
developmental considerations for, 261, 261f face assessment with, 330–333, 333b, Homeless parent families, 79
diagnostic studies on, 274–275, 275t 334t–335t Homicide, morbidity/mortality statistics for
documenting finding on, 276 family, 25, 199, 235–236, 284, 308, 331, child, 112
history in assessment of, 262–267, 263t, 353–354, 371–372, 397, 421, 421b, Homocystinuria, 226t
264f, 265t–267f 444, 468 Hospitalizations
developmental, 265 head assessment, 262–267, 263t, 264f, abdomen assessment with, 397
medications, 265 265t–267f eyes assessment with, 308
past medical, 262–265 hearing acuity, 294 face assessment with, 331
present illness, 267 home environment, 26–27 lung assessment with, 353
review of systems, 262–264 hospitalization, 308, 331, 353, 397, 444, 468 mouth assessment with, 331
social, 265 immigrant/refugee children assessment, musculoskeletal assessment with, 444
surgical, 265 70–71 neurologic system assessment with, 468
newborns assessment with, 210–215, immigrant status, 27 nose assessment with, 331
212f, 213f immunization, 308, 331, 353, 371, 397, pediatric health history with, 93–94, 105t
pediatric health history with, 92t 419–420, 467 thorax assessment with, 353
physical examination in assessment of, injuries, 25, 308, 331, 353, 397, 444, 468 Hot/cold theory of health and illness, 64, 65t
30–31, 31f, 267–271, 268f, 269f, 269t, institutionalization, 28 Human immunodeficiency virus (HIV), 40t
446–447 integumentary system assessment, 233–239, Hygiene, physical survey of, 144
equipment for, 140b 234f–236f, 236t–242t Hypersomnia, 101t
review of systems, 25 lung assessment with, 352–354, 355t–357t Hypertelorism, 214
shape of, 210 maternal health, 199–200, 200t Hypertension, 153, 154b
size of, 210 medical, 23–25 Hypoplasia, 211b
Headaches, hot/cold theory regarding, 65t medication, 25, 237, 265, 283–284, 284t, Hypotelorism, 214
Head circumference, 158, 158f, 170 309, 309t, 331–332, 353, 371, 397, Hypotension, 153
Head circumference-for-age, 184 421, 444, 470
Head-to-toe development, 17, 18f menstrual, 422, 422b
Health beliefs, cultural, 64–65, 65t I
mental disorders assessment with, 514,
biomedical theory, 64 515t–517t, 518b–519b Ignoring, 46
holistic or naturalistic perspective, 64, 65t mouth assessment with, 330–333, 333b, Immigrants, 57t
hot/cold theory, 64, 65t 334t–335t child assessment for, 70–72, 71b, 71t, 72t
magico-religious perspective, 64–65 musculoskeletal assessment with, 442–445, cultural assessment for, 72, 72t
scientific theory, 64 443t, 446t culture shock with, 71–72
yin/yang theory, 64 neck assessment, 262–267, 263t, 264f, history/physical examination for, 70–71
Health practices, 64–70, 67t–70t 265t–267f violence/torture with, 71b
complementary/alternative, 69t–70t neglect assessment with, 499–500 Immigrant status history, 27, 102
acupuncture, 69t neonatal, 24, 201–203, 204t Immunity
aromatherapy, 69t neurologic system assessment with, child anatomy for, 10t
biofeedback, 69t 466–473, 467b, 469t–473t review of systems, 25
dietary supplements, 69t newborn, 199–203, 200t–204t Immunizations
massage, 69t nose assessment with, 330–333, 333b, abdomen assessment with history of, 397
religious, 69t 334t–335t cardiovascular assessment with history
therapeutic touch, 70t nutritional, 398, 445 of, 371
folk, 67t–68t obstetric, 200–201, 201t–203t diphtheria, 95
religious, 70 ocular history, 309 eyes assessment with history of, 308
Hearing past medical, 233–235, 234f–236f, 236t, face assessment with history of, 331
health screening for, 170 262–265, 281–283, 282t, 306–307, health screening for, 172
impairment, language acquisition affected 330, 419, 443, 466 hepatitis B, 95
by, 23b prenatal, birth, and neonatal, 23–24, 91–93, inactivated poliovirus, 95
physical examination of, 31 94t, 105t influenza, 95
Heart rate, cardiovascular assessment with, 217 preparticipation sports examination, lung assessment with history in, 353
Heart sounds, cardiovascular assessment with, 217 173, 173b measles, 95
Heel to ear, 206f, 208 present history, 28 mouth assessment with history of, 331
Height, 157, 157t, 170 present illness, 106–107, 106b, 237–239, mumps, 95
breast- v. formula-fed infants with variations 237t–239t, 267, 285, 286t–289f, 310, neurologic system assessment with history
in, 154 311t–312t, 333, 334t–335t, 354, of, 467
ethnic/racial variations in, 154–155 355t–357t, 372–374, 374t, 398, nose assessment with history of, 331
premature infants with variations in, 154 399t–400t, 422, 423t–424t, 445, 446t, pediatric health history with, 95, 105t
Hematocrit, health screening for, 171 469t–473t, 470, 470b reproductive system assessment with history
Hematologic system OPPQRST mnemonic for, 106b of, 419–420
child anatomy for, 10t primary caregiver, 26 rubella, 95
pediatric health history with, 93t refugee status, 27 tetanus, 95
review of systems, 25 reproductive system assessment with, thorax assessment with history in, 353
Hemoglobin, health screening for, 171 419–422, 420b–422b, 423t–424t varicella, 95
Hemoglobinopathy, health screening for, 170 review of systems, 24–25, 236–237, 262–264, Impetigo, 240t
Hepatic system, child anatomy for, 8t–9t 282–283, 307–308, 330, 352–353, Inactivated poliovirus (IPV), 95
Hepatitis B, 95 370–371, 396–397, 420–421, Infant/child morbidity, 110
Herpes simplex, 241t 443–444, 467 natural/man-made disasters in, 110
Herpes zoster, 241t school progress, 27 psychosocial illness in, 110
Hips, physical examination in assessment of, sexual, 422, 422b statistics for, 110–114
450, 450f sexual abuse assessment with, 506–507 Infant/child mortality, 109
Index • 553
Infants pediatric health history with, 95, 105t skin lesions, primary in, 246t–247t
abdomen of, 7t–8t playground, 113, 113f skin lesions, secondary in, 248t
bow-leggedness of, 12t safety assessment for, 134 skin lesions, vascular in, 249t
breast- v. formula-fed, 154 current injury, 134 Interval pediatric health history, 91, 106
breathing of, 6t previous injury, 134 IOM. See Institute of Medicine
cardiovascular system of, 7t sports-related, 114 IPV. See Inactivated poliovirus
chest circumference of, 4t thorax assessment with history in, 353 Iron, 186
communication with, 52, 53t tricycle, 113
dietary evaluation of, 191t unintentional, 116b
J
dietary intake information for, 194–195 Innocent murmurs, 384–385
Erikson child development theory on, 21t Insect bites, 240t Jaundice, 210
Freud child development theory on, 21t Insomnia, 101t Joints
Gilligan child development theory on, 21t Inspection, 139–141 anatomy/physiology of, 436–437, 438f, 438t
growth/development of, 14 abdomen assessment with, 218, 401–402, 402f pain, hot/cold theory regarding, 65t
head of, 2t anterior to posterior, 141 Jugular veins, physical examination in
immunity of, 10t cardiovascular assessment with, 216 assessment of, 272
integument of, 2t chest assessment with, 215–216
kidneys of, 10t distal to proximal, 141
K
Kohlberg child development theory on, 21t general to specific, 141
mucous membranes of, 5t head to toe, 141 Kidney problems, hot/cold theory regarding, 65t
musculoskeletal system of, 11t–12t integumentary system assessment with, Klumpke’s paralysis, 220
neck of, 3t 244–245, 250–251 Kohlberg child development theory, 21t–22t
nose of, 3t–4t lung assessment with, 215–216 adolescents in, 22t
nutrition history for, 96–97 medial to lateral, 141 infant in, 21t
pediatric health interview with, 90, 90f musculoskeletal assessment with, 220 preschoolers in, 21t
Piaget child development theory on, 21t outside to inside, 141 school-aged children in, 22t
premature, 154 Institute of Medicine (IOM), health care toddlers in, 21t
preterm, 225–228, 227t disparities reported by, 59 Koplik’s spots, C3
safety assessment for, 124–127, 124f, Institutionalization history, 28 Korean, child-rearing differences with, 63t
125t–126t, 127f Integument
sequence of physical examination, 147t ash leaf spots in, 30
L
sleep patterns for, 100t café-au-lait spots in, 30, 211b, 234f, C1
social history assessments for, 102–103, 104t child anatomy for, 2t Laboratory/diagnostic examination,
spleen of, 10t equipment for assessment of, 140b preparticipation sports examination,
teeth of, 3t freckling in, 30 176–177
temperature measurement for, 150t palmar crease in, 30, 30f Lactose intolerance
thermoregulation of, 13t pediatric health history with, 92t African/African American related to, 58t
wellness history assessment for, 164t physical examination of, 30, 30f Asian/Asian American related to, 58t
Infection, hot/cold theory regarding, 65t port wine stains in, 30, 211b, 235f, C2 Hispanic/Latino related to, 58t
Influenza, 95 shagreen patches in, 30 Landau reflex, 224t
Ingestions, pediatric health history with, 95, 105t Integumentary system, 230–256 Language/communication skills
Initial pediatric health history, 90–106 anatomy/physiology of, 230–232 child development of, 14, 20, 23, 23b
functional assessment in, 96–99, 98f, 99f, dermis, 231, 231f developmental milestones for, 32t–35t
99t–101t epidermis, 230–231, 231f factors affecting acquisition of, 23b
elimination, 97–98, 98f, 105t hair, 232 Lanugo, 210
nutrition, 96–97, 105t nails, 232, 232f physical maturity assessment with, 206f, 208
physical activity, 97, 105t skin, 230–231, 231f Laotian, child-rearing differences with, 63t
safety, 98, 105t skin appendages, 232, 232f Large intestine, child anatomy for, 8t
sleep, 98–99, 99f, 99t–101t, 105t subcutaneous glands, 232 Larynx, child anatomy for, 5t
past medical history in, 91–95, 105t subcutaneous tissue, 231, 231f Lead
acute and chronic illnesses in, 93, 105t sweat glands, 232 health screening for, 171, 171b
allergies in, 93, 105t cultural/ethnic considerations in assessment levels of, 40t
childhood infectious diseases in, 93, 105t of, 252–255, 253f, 255t Learned culture, 56
family history in, 95, 105t cutaneous reaction patterns with, Length, 156–157, 157f, 170
growth and development in, 103, 105t 252–253, 255t Lesbian parent families, 79
hospitalizations in, 93–94, 105t dark skin children in, 252–253, 255t Lichenification, C2
immunizations in, 95, 105t hair in, 253 Lipid levels, 186–187, 187t
ingestions in, 95, 105t impact from practices of, 253 Lips, nutrition problems related to, 188t
injuries in, 95, 105t dermatologic arrangement patterns in, 243t Listening, 46–47
medications in, 93, 105t developmental considerations for, 232–233 active, 46
pain assessment in, 96, 96f, 105t hair, 233 ignoring, 46
prenatal, birth, and neonatal history in, nails, 233 pretend, 46
91–93, 94t, 105t skin, 232–233 selective, 46
review of systems for, 92t–93t, 95, 105t skin appendages, 233 Liver, 386
screening procedures in, 95, 105t subcutaneous glands, 233 child anatomy for, 8t–9t
social history in, 99, 102–103, 104t, 105t sweat glands, 233 Locomotion, development of, 17, 19f
spiritual history in, 103, 105t diagnostic studies of, 255–256, 255b Lower extremities, physical examination in
surgeries in, 94–95, 105t focused visit write-up for, 256 assessment of, 450–452, 450f–452f
Injuries edema in, 249–250, 250f, 250t Lung, 348–365, 386
abdomen assessment with history of, 397 history in assessment of, 233–239, anatomy/physiology of, 4t–6t, 349, 350f
bicycle, 113 234f–236f, 236t–242t developmental considerations for,
eyes assessment with history of, 308 family history, 235–236 350–352, 351f
face assessment with history of, 331 medications, 237 cultural/racial variations in, 352
firearm, 111–112 past medical, 233–235, 234f–236f, 236t embryonic development in, 350–351
health assessment for prevention of, present illness history, 237–239, function in, 352
116–135 237t–239t structure in, 351, 351f
history in, 117–124 review of systems, 236–237 diagnostic studies on, 364, 364t
history, 25 social history, 237 documenting finding on, 365
lung assessment with history in, 353 physical examination in assessment of, child with respiratory complaint example
mouth assessment with history of, 331 239–251, 243t–244t, 245f, 246t–250t, of, 365
musculoskeletal assessment with history 248f–251f well child sample of, 365
of, 444 inspection for, 244–245, 250–251 history in assessment of, 352–354, 355t–357t
neurologic system assessment with history palpation for, 245–251 allergies, 353
of, 468 skin color, abnormal in, 244t family, 353–354
nose assessment with history of, 331 skin conditions, common pediatric, hospitalizations, 353
pedestrian, 111 240t–242t immunizations, 353
5 5 4 • I nde x
injuries, 353 disruptive behavioral disorders in, 520, 520b Muscle biopsy, 40t
medications, 353 dysthymic disorder in, 524 Muscles, anatomy/physiology of, 441
present illness, 354, 355t–357t eating disorders in, 520–522, 521b, 522b Musculoskeletal system, 436–456
review of systems, 352–353 major depressive disorder in, 523–524 anatomy/physiology of, 11t–12f, 436–441,
social, 354 mood disorders in, 523–524, 524b 437f–441f, 437t, 438t
surgical, 353 oppositional defiant disorder in, 520 joints, 436–437, 438f, 438t
newborns assessment with, 215–216 pervasive developmental disorders in, 517 muscles, 441
physical examination in assessment of, posttraumatic stress disorder in, 523, 523b skeletal system, 436–441, 437f–441f,
345–364, 358f, 359f, 360t–362t, self-injury in, 525, 525b 437t, 438t
361f–362f separation anxiety disorder in, 522–523, 523b tendons, 441
appearance in, 345, 358, 358f social phobia in, 522, 522b common terms for, 220b
auscultation in, 360–362, 361f, 361t, 362t substance use disorders in, 523, 524b cultural/racial considerations with, 442
chest in, 358–359, 358f, 359f suicide in, 524–525, 525b developmental considerations for,
growth parameters in, 345 wellness care with assessment of, 162, 441–442, 442f
palpation in, 362–364, 362f, 363f 162b, 167b diagnostic studies on, 455, 455t
signs of respiratory disease in, 359–360 Metabolic system documenting finding on, 456
vital signs in, 345 child anatomy for, 13t musculoskeletal complaint sample
respiratory mechanics with, 349–350, 350f screening tests, 226t in, 456
Lyme disease, 242t Metabolic testing, 40t normal musculoskeletal sample in, 456
Lymphatic system, 258–276 Metatarsus adductus, 221 history in assessment of, 442–445,
anatomy/physiology of, 9t–10t, 260–261, 260f Mexican/Mexican American, child-rearing 443t, 446t
developmental considerations for, 262 differences with, 63t developmental, 445
pediatric health history with, 92t Michigan alcohol screening test, 542 family, 444
physical examination in assessment of, Microcephaly, 210 hospitalizations, 444
273–274, 274f, 274t Mid-upper arm circumference, 156 injuries, 444
Miliaria, 211b medications, 444
Minority, 57t nutritional, 445
M
Modesty, cross-cultural differences with, 62, 64 past medical, 443
Macrocephaly, 210 Molluscum contagiosum, 241t present illness, 445, 446t
Magico-religious perspective, 64–65 Mongolian spots, 211b, 212f, 234f, C1 review of systems, 443–444
Major depressive disorder, 523–524 Mood disorders, 523–524, 524b social, 444–445
Malaria, hot/cold theory regarding, 65t Morbidity, infant/child, 110–114 surgical, 444
Mal de ojo (evil eye), 66t Moro reflex, 223t, 224f leg and gluteal folds evaluation for, 221
Male genitalia, 219 Mortality, infant/child, 109–114 maneuvers for, 220–221
anatomy/physiology of, 414–416, 415f, 416f Motor function, newborns assessment with, Barlow, 221, 221f
physical examination of, 429–432, 222, 222f, 223t–224t, 224f Galeazzi, 221
430f–432f Motor skills, 22. See also Fine motor skills; Ortolani, 220, 221f
physical maturity assessment with, 206f, 209 Gross motor skills newborns assessment with, 219–221,
Maple syrup urine disease, 226t child development of, 14 220b, 221f
Massage, 69t Motor vehicle safety, 118b, 119–121, 120f, 121b nutrition problems related to, 189t
Maternal health history, 199–200, 200t car seat for, 120f pediatric health history with, 93t
M-CHAT, 39t morbidity/mortality statistics for child in physical examination in assessment of,
Measles, 95 collisions, 110–111 445–455, 447f–454f, 452t, 453t
Measurements proper restraint for, 121b appearance in, 446–452, 447f–452f, 452t
health screening for, 170 Mottling, 210 developmental approach to, 445–446
physical examination of, 29–30 Mouth, 325–346 gait in, 447, 447f
Meconium-stained skin, 210 anatomy/physiology of, 3t–4t, 326–328, head in, 446–447
Media exposure safety, 118b, 123 327f, 328f hips in, 450, 450f
Medical history, 23–25 cultural/ethnic considerations for, 329–330 lower extremities in, 450–452, 450f–452f
Medication history, 25 developmental considerations for, 329 motor function in, 452–455, 453f,
abdomen assessment with, 397 diagnostic studies on, 345, 346t 453t, 454f
cardiovascular assessment with, 371 documenting finding on, 345–346 neck in, 446–447
ear assessment with, 283–284, 284t child with sore throat example of, ninety-second screening, 452, 452t
eyes assessment with, 309, 309t 345–346 preparation for, 445
face assessment with, 331–332 well child sample of, 345 skin in, 446
head assessment with, 265 history in assessment of, 330–333, 333b, spine in, 448–450, 449f
integumentary system assessment with, 237 334t–335t upper extremities in, 447–448, 448f
lung assessment with, 353 allergies, 332 preparticipation sports examination for, 176t
mouth assessment with, 331–332 dental/oral history, 332–333, 333b review of systems, 25
musculoskeletal assessment with, 444 family, 331
neck assessment with, 265 hospitalizations, 331
N
neurologic system assessment with, 470 immunizations, 331
nose assessment with, 331–332 injuries, 331 Nails, 30
pediatric health history with, 93, 105t medications, 331–332 anatomy/physiology of, 232, 232f
reproductive system assessment with, 421 past medical, 330 developmental considerations for, 233
thorax assessment with, 353 present illness, 333, 334t–335t inspection for assessment of, 251
Menstrual period review of systems, 330 nutrition problems related to, 188t
hot/cold theory regarding, 65t social, 331 palpation for assessment of, 251
reproductive system assessment with history surgical, 331 Nasopharynx, anatomy/physiology of, 325–326
of, 422, 422b newborns assessment with, 215 National Center for Complementary and
Mental health nutrition problems related to, 188t Alternative Medicine (NCCAM), 70
anorexia nervosa in, 520–521, 521b pediatric health history with, 92t Native American/Alaskan
anxiety disorders in, 522–523, 522b, 523b physical examination in assessment of, 336t, child-rearing differences with, 64t
Asperger’s disorder in, 517 340–344, 340f–344f folk healing practices of, 68t
assessment of disorders in, 513–525 Multiculturalism, 57t health conditions related to, 58t
communication for, 513–514 Mumps, 95 unintentional injury risk for, 116b
diagnostic studies on, 514, 519t Murmurs NBAS. See Neonatal Behavioral Assessment Scale
history for, 514, 515t–517t, 518b–519b cardiovascular assessment with, 217 NCCAM. See National Center for
physical examination for, 514 continuous, 384, 384f, 385t Complementary and Alternative
attention-deficit hyperactivity disorder in, diastolic, 383–384, 383f, 384t Medicine
520, 520b innocent, 384–385 Neck, 258–276
autistic disorder in, 517 pathologic, 384, 385t anatomy/physiology of, 2t–3t, 258–259,
bipolar disorder in, 524, 524b pulmonary ejection, 385 259f, 260f
bulimia nervosa in, 521, 521b pulmonary flow, 385 developmental considerations for, 261–262
childhood obesity in, 521–522, 522b Still’s, 385 diagnostic studies on, 274–275, 275t
conduct disorder in, 520, 520b systolic, 380–383, 380f, 381f, 381t–383t documenting finding on, 276
Index • 555
history in assessment of, 262–267, 263t, reflex testing, 483–486, 484f, 485f, 486b, scarf sign in, 206f, 207
264f, 265t–267f 486t, 487f wrist flexion angle in, 207
developmental, 265 Romberg test, 482 new Ballard score in assessment of,
medications, 265 sensory examination, 483 205–206, 206f
past medical, 262–265 newborns assessment with, 222, 222f, physical examination for assessment of,
present illness, 267 223t–224t, 224f 203–205, 206f
review of systems, 262–264 nutrition problems related to, 189t assessment sequence with, 205
social, 265 pediatric health history with, 93t gestational age assessment, 205, 206f
surgical, 265 physical examination in assessment of, immediately after birth, 203–204
pediatric health history with, 92t 473–475, 474t, 475f initial impression in, 204
physical examination in assessment of, equipment for, 140b maintenance of physiologic stability for,
271–272, 446–447 review of systems, 25 204–205
equipment for, 140b Neuromuscular maturity, 206–208, 206f, 207t preparation for, 205
review of systems, 25 arm recoil in, 206f, 207, 207t after stabilization, 204–205
Neglect, 493–494. See also Child abuse/neglect heel to ear in, 206f, 208 physical maturity assessment of, 206f,
assessing, 499–500 popliteal angle in, 206f, 207 208–209
history in, 499–500 posture in, 206–207, 206f breasts in, 206f, 208
physical examination in, 500 scarf sign in, 206f, 207 ears in, 206f, 208–209
Neonatal Behavioral Assessment Scale wrist flexion angle in, 207 eyes in, 206f, 208–209
(NBAS), 225 Neuromuscular system, physical examination female genitalia in, 206f, 209
Neonatal history, 24, 201–203, 204t of, 31 lanugo in, 206f, 208
Neonates New Ballard score, 205–206, 206f male genitalia in, 206f, 209
abdomen of, 8t Newborns, 199–228. See also Neonates plantar surface in, 206f, 208
alveoli of, 5t abdominal assessment for, 218–219 skin in, 206f, 208
blood-brain barrier of, 12t auscultation, 218 preterm infant after hospital discharge,
brain of, 2t inspection, 218 225–228, 227t
cardiovascular system of, 6t–7t palpation, 218–219 screening for, 40t, 225
eyes of, 3t behavioral assessment for, 222, 225 sequence of physical examination, 147t
growth/development of, 14 cardiovascular assessment for, 216–218 skin assessment for, 210, 211b
hearing documentation for, 297 auscultation, 217 color variants, 210
hematologic system of, 10t blood pressure in, 218 rashes, 210
integument of, 2t heart rate in, 217 skin perfusion, 210
kidneys of, 11t heart sounds in, 217 skin variants, 210
larynx of, 5t inspection, 216 vital sign assessment for, 209
liver of, 9t murmurs in, 217 blood pressure, 209
musculoskeletal system of, 12t palpation, 216 pulse, 209
respiratory mucus of, 5t chest assessment for, 215–216 respiratory rate, 209
thermoregulation of, 13t auscultation, 216 Nightmares, 101t
trachea of, 5t inspection, 215–216 Night terrors, 101t
Neuroimaging, 40t palpation, 216 Night waking, 101t
Neurologic system percussion, 216 Ninety-second screening examination, 452, 452t
anatomy/physiology of, 12f–13t, 458–465, comprehensive history for assessment of, Nipples, 216
459f–461f, 462t, 463f 199–203, 200t–204t Nonverbal communication, 48–50, 61
autonomic nervous system in, birth history in, 201–203, 204t body language in, 49–50
463–464, 464f family history in, 199 cross-cultural, 61
blood-brain barrier in, 461 maternal health history in, 199–200, 200t paralanguage with, 48
brain in, 458–461, 459f–461f, 462t neonatal history in, 201–203, 204t physical appearance in, 49
central nervous system in, 458–463, obstetric history in, 200–201, 201t–203t physical environment in, 48–49
459f–461f, 462t, 463f genitourinary assessment for, 219 spatial distance in, 61
central nervous system pathways in, 463 growth assessment for, 207t, 209 time in, 61
cerebral blood supply in, 461 head assessment for, 210–215, 212f, 213f touch in, 61
peripheral nervous system in, ears, 213–214 Norms, 58t
463–464, 464f eyes, 214 Nose, 325–346
somatic nervous system in, 463 face, 213 anatomy/physiology of, 3t–4t, 325, 326f
spinal cord in, 461–463, 463f hair, 212–213, 213f cultural/ethnic considerations for, 329–330
developmental considerations for, 465–466 mouth, 215 developmental considerations for, 329
autonomic nervous system in, 466 nose, 214–215 diagnostic studies on, 345, 346t
central nervous system in, 465 occipital-frontal circumference, 210 documenting finding on, 345–346
peripheral nervous system in, 466 scalp, 212–213, 213f child with sore throat example of,
history in assessment of, 466–473, 467b, shape and size, 210 345–346
469t–473t skull, 212, 213f well child sample of, 345
allergies, 470 lung assessment for, 215–216 history in assessment of, 330–333, 333b,
developmental, 468–470 auscultation, 216 334t–335t
family, 468 inspection, 215–216 allergies, 332
hospitalizations, 468 palpation, 216 dental/oral history, 332–333, 333b
immunizations, 467 percussion, 216 family, 331
injuries, 468 metabolic screening tests for, 226t hospitalizations, 331
medications, 470 musculoskeletal assessment for, 219–221, immunizations, 331
past medical, 466 220b, 221f injuries, 331
present illness, 469t–473t, 470, 470b common terms for, 220b medications, 331–332
review of systems, 467 inspection for, 220 past medical, 330
social, 468 neck assessment for, 215 present illness, 333, 334t–335t
surgical, 468 neurologic assessment for, 221–222, 222f, review of systems, 330
neurologic examination in assessment of, 223t–224t, 224f social, 331
475–489, 476t, 478t–481t, 482f, 484f, deep tendon reflexes in, 222 surgical, 331
485f, 486b–488b, 486t, 487f–489f motor function in, 222, 222f, newborns assessment with, 214–215
cerebellar function assessment, 477, 223t–224t, 224f pediatric health history with, 92t
482–483, 482f postural tone in, 222 physical examination in assessment of, 336t,
cranial nerve assessment, 477, 478t–481t primitive reflexes, 222, 223t–224t, 224f 337–338
finger-to-nose test, 482, 482f sensory function in, 222 equipment for, 140b
heel-to-shin test, 483 neuromuscular maturity assessment of, Nutrition, 182–197
heel-to-toe walking test, 482, 482f 206–208, 206f, 207t abdomen assessment with history of, 398
hopping in place test, 482 arm recoil in, 206f, 207, 207t anthropometrics in assessment of,
mental status evaluation, 475–477, 476t heel to ear in, 206f, 208 182–183, 183t
neurologic soft signs, 486–489, 487b, popliteal angle in, 206f, 207 body mass index for, 183
488b, 488f, 489f posture in, 206–207, 206f growth chart for, 154, 183, 183t
5 5 6 • I nde x
biochemical markers in assessment of, cardiovascular system examination with, genitourinary system, 92t
185–187, 185t, 187t 376–377, 377f gynecologic system, 93t
cholesterol/triglycerides/lipid levels, chest assessment with, 216 head, 92t
186–187, 187t deep, 142f hematologic system, 93t
disease-specific, 187 integumentary system assessment with, integument, 92t
glucose, 187 245–251 lymphatic system, 92t
iron, 186 light, 141f mouth, 92t
serum proteins, 185–186, 185t lung assessment with, 216 musculoskeletal system, 93t
clinical evaluation of, 187–190, 188t–189t thorax assessment with, 362–364, 362f, 363f neck, 92t
eyes, 188t Paranasal sinuses neurologic system, 93t
gastrointestinal system, 189t anatomy/physiology of, 326, 327f nose, 92t
gums, 188t–189t physical examination in assessment of, psychosocial stages, 93t
hair, 188t 338–340, 339f respiratory system, 92t
lips, 188t Parent Evaluation of Developmental Status throat, 92t
mouth, 188t (PEDS), 37t types of, 90–107
musculoskeletal system, 189t Past medical history emergency, 91, 107
nails, 188t ear assessment with, 281–283, 282t focused, 91, 106–107, 106b, 107b
neurologic system, 189t eyes assessment with, 306–307 follow-up, 91, 107
skin, 188t face assessment with, 330 initial, 90–106
tongue, 188t head assessment with, 262–265 interval, 91, 106
dietary evaluation for, 190–193, 191t–192t integumentary system assessment with, Pediatric Symptom Checklist, 39t
dietary questionnaire in, 190–191, 233–235, 234f–236f, 236t Pediculosis, 242t
191t–192t mouth assessment with, 330 PEDS. See Parent Evaluation of Developmental
food records/diaries in, 192–193 musculoskeletal assessment with, 443 Status
twenty-four-hour recall in, 191–192 neck assessment with, 262–265 Pelvic examination, 425–427
evaluation of dietary intake information for, neurologic system assessment with, 466 Penis, anatomy/physiology of, 414, 415f, 416f
193–197 nose assessment with, 330 Percussion, 142–143, 142f, 142t, 143f
adolescents in, 196 reproductive system assessment with, 419 abdomen assessment with, 403, 403f
children with medical conditions in, Patellar reflex, 222 blunt, 143, 143f
196–197 Pathologic murmurs, 384, 385t chest assessment with, 216
infants in, 194–195 PCS. See Primary Care Screener direct, 142, 142f
school-aged children in, 196 PDDST-II. See Pervasive Developmental indirect, 142–143, 143f
young children in, 195–196 Disorders Screening Test-II lung assessment with, 216
growth chart in assessment of, 183–184 PDMS-2. See Peabody Developmental Motor sounds, 142t
body mass index, 183–184 Scales Peripheral nervous system, anatomy/
head circumference-for-age, 184 Peabody Developmental Motor Scales physiology of, 463–464, 464f
stature-for-age, 184 (PDMS-2), 38t Pervasive developmental disorders, 517
weight-for-age, 184 Pedestrian/traffic safety, 118b, 121, 121f Pervasive Developmental Disorders Screening
weight-for-length, 184 morbidity/mortality statistics for child, 111 Test-II (PDDST-II), 39t
weight-for-stature, 184 Pediatric health history, 89–107 Petechiae, 211b
musculoskeletal assessment with history communication for, 89–90 Pharynx
of, 445 conducting interview for, 89–90 anatomy/physiology of, 328–329
pediatric health history with, 96–97, 105t adolescents in, 90 physical examination in assessment of, 344,
adolescents in, 97 developmental considerations in, 89–90 344f
infants in, 96–97 infants in, 90, 90f Phenylketonuria, 226t
preschoolers in, 97 physical surrounding with, 90 Physical abuse, 494, 495t, C4
school-aged children in, 97 reliability/accuracy with, 89 assessing, 500–506, 502f–505f
toddlers in, 97 school-aged children in, 90 differential diagnoses in, 505–506, 505f
physical survey of, 144 emergency, 91, 107 physical examination in, 500–505,
screening, 182 focused, 91, 106–107, 106b, 107b 502f–504f
special conditions in assessment of, 184–185 follow-up, 91, 107 Physical activity, pediatric health history with,
initial, 90–106 97, 105t
acute and chronic illnesses in, 93, 105t Physical examination, 28–31, 138–159
O
allergies in, 93, 105t anthropometric measurements in, 153–158
Obstetric history, 200–201, 201t–203t childhood infectious diseases in, 93, 105t arm span, 157–158
prenatal testing in, 202t elimination in, 97–98, 98f, 105t body mass index, 156, 156t, 170
Obstructive sleep apnea, 101t family history in, 95, 105t breast- v. formula-fed infants with, 154
Occipital-frontal circumference, newborns functional assessment in, 96–99, 98f, 99f, chest circumference, 158
assessment with, 210 99t–101t children with chronic conditions
Ocular fundus, C3 growth and development in, 103, 105t with, 155
Ocular history, eyes assessment with, 309 hospitalizations in, 93–94, 105t ethnic/racial variations with, 154–155
Older first-time parent families, 80 immunizations in, 95, 105t growth charts for, 154, 183, 183t
Omphalocele, 218 ingestions in, 95, 105t head circumference, 158, 158f, 170
Oppositional defiant disorder, 520 injuries in, 95, 105t height, 157, 157t, 170
OPPQRST mnemonic, 106b medications in, 93, 105t length, 156–157, 157f, 170
Oral health, wellness care with assessment of, nutrition in, 96–97, 105t mid-upper arm circumference, 156
162, 162b pain assessment in, 96, 96f, 105t premature infants with, 154
Ortolani maneuver, 220, 221f past medical history in, 91–95, 105t skinfold thickness, 156
Osteogenesis imperfecta, 214 physical activity in, 97, 105t weight, 155–156, 155f, 170
Otalgia, 286t prenatal, birth, and neonatal history in, weight-for-length, 157, 170
Otitis media 91–93, 94t, 105t weight-for-stature, 157
hot/cold theory regarding, 65t review of systems for, 92t–93t, 95, 105t blood pressure in, 152–153, 154b, 170
Native American/Alaskan related to, 58t safety in, 98, 105t hypertension, 153, 154b
Otorrhea, 287t screening procedures in, 95, 105t hypotension, 153
sleep in, 98–99, 99f, 99t–101t, 105t carotid arteries, 272
social history in, 99, 102–103, 104t, 105t developmental approach to, 145–146, 145f
P
spiritual history in, 103, 105t ear assessment with, 30–31, 285–293, 289f,
Pain assessment surgeries in, 94–95, 105t 291f, 292f, 292t
pediatric health history with, 96, 96f, 105t interval, 91, 106 equipment for, 140b
Wong-Baker FACES pain rating scale for, 96f review of systems for, 91, 92t–93t, 95 external auditory canal, 290–293,
Palmar crease, 30, 30f cardiovascular system, 92t 291f, 292f
Palmar grasp, 17, 20f, 223t, 224f chest, 92t external ear, 289–290, 289f
Palpation, 141–142, 141f, 142f ears, 92t general appearance, 289
abdomen assessment with, 218–219, endocrine system, 93t hearing acuity, 294–296, 295t
404–405, 404f, 405f eyes, 92t tympanic membrane, 291–292, 292t
cardiovascular assessment with, 216 gastrointestinal system, 92t equipment for, 139, 140b
Index • 557
eyes in, 30–31, 310–322, 313f–322f, 321b, 322t breasts, 432–434, 433f physical examination for, 173b, 174f–177f,
color vision in, 314 female genitalia, 422–429, 424f, 425t, 176, 178t, 179t
equipment for, 140b 427f–429f Ohio High School Athletic Association
extraocular eye structure in, 316–319, male genitalia, 429–432, 430f–432f form, 174f–177f
318f, 319f pelvic examination, 425–427 physical examination forms for, 174f–177f
extraocular muscle function in, 314f–317f, speculum examination, 427–428, Preschoolers
315–316 427f, 428f communication with, 52–53, 53t
internal eye structure in, 319–320, 320f respirations in, 151–152, 153t Erikson child development theory on, 21t
ophthalmoscopic examination in, sequencing of, 146, 147t–148t Freud child development theory on, 21t
320–322, 321b, 321f, 322f sexual abuse assessment with, 507–508 Gilligan child development theory on, 21t
palpation in, 320 sinuses, 338–340, 339f growth/development of, 14
peripheral visual fields in, 314–316, techniques for, 139–143 integument of, 2t
314f–317f auscultation, 143 Kohlberg child development theory on, 21t
visual acuity in, 310–313, 313f, 314f inspection, 139–141 nutrition history for, 97
face in, 30–31, 31f, 333–337, 335f, 336t palpation, 141–142, 141f, 142f Piaget child development theory on, 21t
general approach to, 28, 145–146, 145f, percussion, 142–143, 142f, 142t, 143f safety assessment for, 127–130, 128t–129t
147t–148t teeth, 342–343, 342f sequence of physical examination, 148t
general survey for, 143–145 temperature in, 148–151, 149t, 150t sleep patterns for, 100t
appearance in, 144 thorax assessment with, 345–364, 358f, social history assessments for, 102–103, 104t
behavior, 144–145 359f, 360t–362t, 361f–362f wellness history assessment for, 165t
development, 145 appearance in, 345, 358, 358f Present history, 28
gait in, 144 auscultation in, 360–362, 361f, Present illness history
hygiene in, 144 361t, 362t abdomen assessment with, 398, 399t–400t
level of consciousness in, 144 chest in, 358–359, 358f, 359f cardiovascular assessment with, 372–374, 374t
mobility in, 144 growth parameters in, 345 ear assessment with, 285, 286t–289f
nutritional status, 144 palpation in, 362–364, 362f, 363f eyes assessment with, 310, 311t–312t
position in, 144 signs of respiratory disease in, 359–360 face assessment with, 333, 334t–335t
posture in, 144 vital signs in, 345 head assessment with, 267
head in, 30–31, 31f, 267–271, 268f, 269f, 269t thyroid gland, 272–273, 273f integumentary system assessment with,
hearing in, 31 tongue, 343–344, 343f 237–239, 237t–239t
immigrant/refugee children assessment, tonsils, 344–345, 344f, 344t, 345f lung assessment with, 354, 355t–357t
70–71 vision in, 31, 310–313, 313f, 314f mouth assessment with, 333, 334t–335t
integument in, 30, 30f wellness care with, 167, 168t–169t musculoskeletal assessment with, 445, 446t
jugular veins, 272 Physical maturity assessment, 206f, 208–209 neck assessment with, 267
lung assessment with, 345–364, 358f, 359f, breasts in, 206f, 208 neurologic system assessment with,
360t–362t, 361f–362f ears in, 206f, 208–209 469t–473t, 470, 470b
appearance in, 345, 358, 358f eyes in, 206f, 208–209 nose assessment with, 333, 334t–335t
auscultation in, 360–362, 361f, 361t, 362t female genitalia in, 206f, 209 reproductive system assessment with, 422,
chest in, 358–359, 358f, 359f lanugo in, 206f, 208 423t–424t
growth parameters in, 345 male genitalia in, 206f, 209 thorax assessment with, 354, 355t–357t
palpation in, 362–364, 362f, 363f plantar surface in, 206f, 208 Pretend listening, 46
signs of respiratory disease in, 359–360 skin in, 206f, 208 Preterm infant, assessment of, 225–228, 227t
vital signs in, 345 Piaget child development theory, 21t–22t Primary caregiver history, 26
lymphatic system, 273–274, 274f, 274t adolescents in, 22t Primary Care Screener (PCS), 39t
measurements in, 29–30 infant in, 21t Primitive reflexes, 222, 223t–224t, 224f
mental disorders assessment with, 514 preschoolers in, 21t asymmetric tonic neck reflex, 223t, 224f
mouth, 336t, 340–344, 340f–344f school-aged children in, 22t Babinski reflex, 224t
musculoskeletal system assessment with, toddlers in, 21t Corneal reflex, 224t
445–455, 447f–454f, 452t, 453t Pincer grasp, 17, 20f Extrusion reflex, 224t
appearance in, 446–452, 447f–452f, 452t Pinna abnormalities, 31 Landau reflex, 224t
developmental approach to, 445–446 Placing reflex, 223t Moro reflex, 223t, 224f
gait in, 447, 447f Plantar grasp, 223t, 224f palmar grasp, 223t, 224f
head in, 446–447 Plantar surface, physical maturity assessment placing reflex, 223t
hips in, 450, 450f with, 206f, 208 plantar grasp, 223t, 224f
lower extremities in, 450–452, 450f–452f Playground injuries, morbidity/mortality rooting, 223t
motor function in, 452–455, 453f, statistics for, 113, 113f stepping reflex, 223t, 224f
453t, 454f Plethora, 210 sucking, 223t, 224f
neck in, 446–447 Pneumonia, hot/cold theory regarding, 65t truncal incurvation reflex, 223t
ninety-second screening, 452, 452t Poisonings, morbidity/mortality statistics for Privacy, family/children communication with,
preparation for, 445 child, 112 44–45
skin in, 446 Polydactyl, 221 Psoriasis, 242t
spine in, 448–450, 449f Popliteal angle, 206f, 207 Psychosocial stages
upper extremities in, 447–448, 448f Port wine stains, 30, 211b, 235f, C2 child development with, 14
neck, 271–272 Posttraumatic stress disorder, 523, 523b pediatric health history with, 93t
neglect assessment with, 500 Posture, 206–207, 206f review of systems, 25
neurologic assessment with, 473–475, physical survey of, 144 Puerto Rican, child-rearing differences with, 64t
474t, 475f Poverty, culture of, 59 Pulmonary ejection murmur, 385
neuromuscular system in, 31 PPE. See Preparticipation sports examination Pulmonary flow murmur, 385
newborns assessment with, 203–205, 206f Prealbumin, 185t Pulse
gestational age assessment, 205, 206f Prejudice, 58t factors affecting rates of, 151t
immediately after birth, 203–204 Premature infants, 154 grading of, 152t
after stabilization, 204–205 Prenatal, birth, and neonatal history, 91–93, newborns assessment with, 209
nose, 336t, 337–338 94t, 105t physical examination with, 151, 151t
paranasal sinuses, 338–340, 339f Prenatal history, 23–24
pharynx, 344, 344f Prenatal testing, 202t
R
physical abuse assessment, 500–505, 502f–504f Preparticipation sports examination (PPE),
preparation of child for, 139 173–179, 173b, 174f–177f, 178t, 179t Race, 58
preparation of environment for, 138 cardiovascular screening for, 173b abdomen, variations with, 396
preparticipation sports examination for, high-risk behaviors to assess with, 173b anthropometric measurement variations
173b, 174f–177f, 176, 178t, 179t history for, 173, 173b with, 154–155
provider preparation for, 139 family, 173b child-rearing differences between, 62, 63t–64t
pulse in, 151, 151t personal, 173b culture/ethnicity as different from, 56
reproductive system assessment with, laboratory/diagnostic examination for, defined, 58t
422–434, 424f, 425t, 427f–433f 176–177 health conditions related to, 58t
anus, 432 musculoskeletal screening examination musculoskeletal system with, 442
bimanual examination, 428–429, 429f for, 176t reproductive system with, 418–419
5 5 8 • I nde x
Racism, 58t reproductive system assessment with, Native American/Alaskan, 116b

Railroad track ears, 31 420–421 nonmodifiable, 116
Rashes, hot/cold theory regarding, 65t respiratory system in, 92t parenting related, 115
Refugee, 58t thorax assessment with, 352–353 unintentional injury, 116b
child assessment for, 70–72, 71b, 71t, 72t throat in, 92t sport/recreation, 118b, 122
cultural assessment for, 72, 72t Rhonchi, 216 stranger, 118b, 122–123
culture shock with, 71–72 Rinne test, 296–297, 297f sun, 118b, 122
history/physical examination for, 70–71 Risk factors, 114–116 water, 118b, 122
violence/torture with, 71b delays in child development, 28b Salmon patches, 235f, C2
Refugee status history, 27 developmental, 115 Scabies, 242t
Religious therapies, 69t environmental, 115–116 Scalp
Reproductive system, 413–435 Haddon’s matrix for assessment of, 114t caput succedaneum of, 212, 213f
anatomy/physiology of, 413–417, 414f–417f hearing acuity, 293b, 294b cephalhematoma of, 212, 213f
breast, 416, 416f, 417f Native American/Alaskan, 116b newborns assessment with, 212–213, 213f
female genitalia, 413–414, 414f, 415f nonmodifiable, 116 Scarf sign, 206f, 207
male genitalia, 414–416, 415f, 416f parenting related, 115 Scarlet fever, 241t
penis, 414, 415f, 416f unintentional injury, 116b School-aged children
scrotum, 414–416, 415f, 416f Rooting, 223t brain of, 3t
testicles, 414–416, 415f, 416f Roseola, 241t communication with, 53–54, 53t
cultural/racial considerations with, 418–419 Rubella, 95, 241t dietary evaluation of, 192t
developmental considerations for, 417 Rubeola, 241t dietary intake information for, 196
diagnostic studies on, 434, 434b Rubs, 216 endocrine system of, 14t
documenting finding on, 434–435 Erikson child development theory on, 22t
symptomatic child sample, 434–435 Freud child development theory on, 22t
S
history in assessment of, 419–422, Gilligan child development theory on, 22t
420b–422b, 423t–424t SAD PERSONS scale, 545 growth/development of, 14
family, 421, 421b Safety, 109–135 Kohlberg child development theory on, 22t
immunizations, 419–420 age/developmental stage risk assessment for, nutrition history for, 97
medications, 421 124–134 pediatric health interview with, 90
menstrual, 422, 422b adolescents, 130, 132t–133t, 133–134 Piaget child development theory on, 22t
past medical, 419 infants, 124–127, 124f, 125t–126t, 127f safety assessment for, 130, 130t–131t
present illness, 422, 423t–424t preschoolers, 127–130, 128t–129t sequence of physical examination, 148t
review of systems, 420–421 school-aged children, 130, 130t–131t sinuses of, 4t
sexual, 422, 422b toddlers, 127, 127f, 128t–129t sleep patterns for, 100t
social, 421–422, 421b animal, 118b, 122 social history assessments for, 103, 104t
surgical, 421 bicycle, 118b, 121–122, 121f wellness history assessment for, 165t
physical examination in assessment of, burn prevention, 118b, 122 School progress history, 27
422–434, 424f, 425t, 427f–433f fire, 118b, 122 Scientific theory, 64
anus, 432 firearms, 118b, 123 SCQ. See Social Communication Questionnaire
bimanual examination, 428–429, 429f general health practices, 118b, 123–124 Screening procedures
breasts, 432–434, 433f home environment, 117–119, 118b, 119b alcohol, 542
female genitalia, 422–429, 424f, 425t, rural homes, 119, 120b cardiovascular, 173b
427f–429f urban homes, 117–119, 119b cervical dysplasia, 172
male genitalia, 429–432, 430f–432f hospitalized child assessment for, 134–135 developmental screening in, 31–36
pelvic examination, 425–427 infant/child morbidity with, 110 drug abuse, 543
speculum examination, 427–428, 427f, natural/man-made disasters in, 110 dyslipidemia, 171–172, 172b
428f psychosocial illness in, 110 eye exams, 170–171
physiologic changes at puberty for, 417–418, infant/child mortality with, 109 hearing, 170, 296–297, 296f, 297f
418f–420f injuries assessment for, 134 conduction tests, 296
females, 417–418, 418f, 419f current injury, 134 Rinne test, 296–297, 297f
males, 418, 419f, 420f previous injury, 134 Weber test, 296, 296f
Respirations, 215–216 injury prevention through health whisper test, 296
factors affecting children’s, 153t assessment for, 116–135 hemoglobin, 171
newborns assessment with, 209 history in, 117–124 hemoglobinopathy, 170
physical examination with, 151–152, 153t leading causes of death with child, 110 lead, 171, 171b
Respiratory mechanics, 349–350, 350f media exposure, 118b, 123 metabolic system, 226t
Respiratory system morbidity/mortality statistics and, 110–114 musculoskeletal, 176t
pediatric health history with, 92t all-terrain vehicles, 113 newborns in, 40t
review of systems, 25 bicycle/tricycle injuries, 113 ninety-second screening, 452, 452t
Retinol-binding protein, 185t burns, 111 nutrition, 182
Review of systems, 24–25 choking, 111 pediatric health history with, 95, 105t
abdomen assessment with, 396–397 drowning, 111 sexually transmitted infections, 172
cardiovascular system in, 92t, 370–371 falls, 112–113 tuberculosis, 171, 172b
chest in, 92t firearm injuries, 111–112 wellness care, 170–173, 171b
ears in, 92t, 282–283 fires, 111 Scrotum, anatomy/physiology of, 414–416,
endocrine system in, 93t homicide, 112 415f, 416f
eyes assessment with, 92t, 307–308 motor vehicle collisions, 110–111 Sebaceous fat necrosis, 211b
face assessment with, 330 pedestrian injuries/deaths, 111 Sebaceous gland hyperplasia, 211b
gastrointestinal system in, 92t playground injuries, 113, 113f Sebaceous glands, child anatomy for, 2t
genitourinary system in, 92t poisonings, 112 Seborrhea, 242t
gynecologic system in, 93t sports-related injuries, 114 Selective listening, 46
head in, 92t, 262–264 strangulation, 111 Self-injury, 525, 525b
hematologic system in, 93t suffocation, 111 Sensory function, newborns assessment with, 222
integumentary system assessment with, suicide, 112 Separation anxiety disorder, 522–523, 523b
236–237 toy safety, 112 Serum proteins, 185–186, 185t
integument in, 92t motor vehicle, 118b, 119–121, 120f, 121b albumin, 185t
lung assessment with, 352–353 car seat for, 120f prealbumin, 185t
lymphatic system in, 92t morbidity/mortality statistics for child retinol-binding protein, 185t
mouth in, 92t, 330 in, 110–111 transferrin, 185t
musculoskeletal system in, 93t, 443–444 proper restraint for, 121b Sexual abuse, 495
neck in, 92t, 262–264 pedestrian/traffic, 118b, 121, 121f assessing, 506–509
neurologic system in, 93t, 467 pediatric health history with, 98, 105t differential diagnoses in, 508
nose in, 92t, 330 risk factors for, 114–116 history in, 506–507
pediatric health history with, 91, 92t–93t, developmental, 115 physical examination in, 507–508
95, 105t environmental, 115–116 Sexual history, reproductive system assessment
psychosocial stages in, 93t Haddon’s matrix for assessment of, 114t with, 422, 422b
Index • 559
Sexually transmitted infections, health universal assessments of, 102 T

screening for, 172 economic status, 102
Shagreen patches, 30 emergency room use, 102 Taboo, 58t
Shamanic healing practices, 67t family, 102 Talipes calcaneovalgus, 221
Shared culture, 56 home environment, 102 Teen parent families, 79–80
Sickle cell disease, African/African American immigrant status, 102 Teeth, physical examination in assessment of,
related to, 58t Social phobia, 522, 522b 342–343, 342f
Single-parent families, 78 Socioemotional development, 23 Teething, hot/cold theory regarding, 65t
Sinuses. See also Paranasal sinuses developmental milestones for, 32t–35t Telangiectatic nevi, 211b, 212f
child anatomy for, 3t–4t Somatic nervous system, anatomy/physiology Temperament, 20, 23t
physical examination in assessment of, of, 463 Temperature
338–340, 339f Sore throat, hot/cold theory regarding, 65t factors affecting, 149t
Skeletal system, anatomy/physiology of, Soul loss. See Susto measurement for infants/children of, 150t
436–441, 437f–441f, 437t, 438t Speculum examination, 427–428, 427f, 428f physical examination with, 148–151,
Skin Speech, evaluation of, 345 149t, 150t
abnormal color of, 244t Spinal cord, anatomy/physiology of, routes for measurement of, 150t
anatomy/physiology of, 230–231, 231f 461–463, 463f axillary, 150t
assessment for newborns with, 210, 211b Spine oral, 150t
color variants, 210 child anatomy for, 11t rectal, 150t
acrocyanosis, 210 physical examination in assessment of, temporal artery, 150t
harlequin, 210 448–450, 449f tympanic, 150t
jaundice, 210 Spiritual health, wellness care with assessment Tendons, anatomy/physiology of, 441
mottling, 210 of, 162 Tetanus, 95
plethora, 210 Spiritual history, 103, 105t Thalassemia, Caucasian/European ancestry
common pediatric conditions of, 240t–242t Spleen, child anatomy for, 10t related to, 58t
cutaneous reaction patterns with dark, Sport/recreation safety, 118b, 122 Therapeutic touch, 70t
252–253, 255t morbidity/mortality statistics for child, 114 Thermoregulation, child anatomy for, 13t
developmental considerations for, 232–233 Stature-for-age, 184 Thorax, 348–365
inspection for assessment of, 244–245 Stepfamilies, 78 anatomy/physiology of, 4t–6t, 348–349,
lesions, primary of, 246t–247t differences from first-time families 349f, 350t
lesions, secondary of, 248t and, 83b pleural cavity, 349
lesions, vascular of, 249t Stepping reflex, 223t, 224f thoracic cage, 348, 349f, 350t
nutrition problems related to, 188t Stereotype, 58t thoracic cavity, 348
palpation for assessment of, 245–250 Still’s murmur, 385 developmental considerations for,
physical examination in assessment of, 446 Stomach 350–352, 351f
physical maturity assessment with, 206f, child anatomy for, 8t cultural/racial variations in, 352
208 hot/cold theory regarding pain in, 65t embryonic development in, 350–351
review of systems, 25 Stranger safety, 118b, 122–123 function in, 352
skin perfusion, 210 Strangulation, morbidity/mortality statistics for structure in, 351, 351f
skin variants, 210 child, 111 diagnostic studies on, 364, 364t
lanugo, 210 Strawberry marks, 211b, C2 documenting finding on, 365
meconium-stained skin, 210 Strawberry tongue, C3 child with respiratory complaint example
vernix caseosa, 210 Streeter’s dysplasia, 221 of, 365
vascular lesions of, 211b Stridor, 216 well child sample of, 365
Skin appendages Subculture, 58t history in assessment of, 352–354, 355t–357t
anatomy/physiology of, 232, 232f Subcutaneous glands allergies, 353
developmental considerations for, 233 anatomy/physiology of, 232 family, 353–354
Skinfold thickness, 156 developmental considerations for, 233 hospitalizations, 353
Skull, newborns assessment with, 212, 213f Subcutaneous tissue, anatomy/physiology of, immunizations, 353
Sleep 231, 231f injuries, 353
child needs for, 99t Substance use disorders, 523, 524b medications, 353
patterns for, 100t criteria for intoxication with, 544 present illness, 354, 355t–357t
pediatric health history with, 98–99, 99f, Sucking, 223t, 224f review of systems, 352–353
99t–101t, 105t Sucking blisters, 211b social, 354
pediatric problems with, 101t Suffocation, morbidity/mortality statistics for surgical, 353
states, 225 child, 111 physical examination in assessment of,
Sleep refusal, 101t Suicide, 524–525, 525b 345–364, 358f, 359f, 360t–362t,
Sleepwalking, 101t morbidity/mortality statistics for 361f–362f
Small intestine, child anatomy for, 8t child, 112 appearance in, 345, 358, 358f
Social Communication Questionnaire (SCQ), 39t Sunburn, 242t auscultation in, 360–362, 361f, 361t, 362t
Social environment history, 27 Sun safety, 118b, 122 chest in, 358–359, 358f, 359f
Social history, 25–28 Surgeries, pediatric health history with, growth parameters in, 345
abdomen assessment with, 397–398 94–95, 105t palpation in, 362–364, 362f, 363f
age-specific assessments of, 102–103, 104t Surgical history signs of respiratory disease in, 359–360
adolescents, 103, 104t abdomen assessment with, 397 vital signs in, 345
infants, 102–103, 104t cardiovascular assessment with, 371 respiratory mechanics with, 349–350, 350f
preschoolers, 102–103, 104t ear assessment with, 283 Throat
school-aged children, 103, 104t eyes assessment with, 308 child anatomy for, 3t–4t
toddlers, 102–103, 104t face assessment with, 331 pediatric health history with, 92t
cardiovascular assessment with, 372 head assessment with, 265 Thyroglossal duct cysts, 215
ear assessment with, 284, 285t lung assessment with, 353 Thyroid gland, physical examination in
eyes assessment with, 308 mouth assessment with, 331 assessment of, 272–273, 273f
face assessment with, 331 musculoskeletal assessment with, 444 Tibial torsion, 221
head assessment with, 265 neck assessment with, 265 Tinea capitis, C2
integumentary system assessment with, 237 neurologic system assessment with, 468 Tinea corporis, 241t
lung assessment with, 354 nose assessment with, 331 Tinea cruris, 241t
mouth assessment with, 331 reproductive system assessment with, 421 Tinea pedis, 241t
musculoskeletal assessment with, 444–445 thorax assessment with, 353 Tinea versicolor, 241t
neck assessment with, 265 Susto (soul loss), 66t Tinnitus, 288t
neurologic system assessment with, 468 Sweat glands Toddlers
nose assessment with, 331 anatomy/physiology of, 232 abdomen of, 8t
pediatric health history with, 99, 102–103, developmental considerations for, 233 bow-leggedness of, 12t
104t, 105t Syncope, 373–374 chest circumference of, 4t
reproductive system assessment with, Syndactyl, 221, 221f communication with, 52, 53t
421–422, 421b Systolic murmurs, 380–383, 380f, 381f, Erikson child development theory on, 21t
thorax assessment with, 354 381t–383t Freud child development theory on, 21t
5 6 0 • I nde x
Gilligan child development theory on, 21t Vascular skin lesions, 211b, C2 oral health, 162, 162b
growth/development of, 14 Venous hum, 385 parent-child interaction observation, 170
Kohlberg child development theory on, 21t Verbal abuse, 494 physical examination, 167, 168t–169t
mucous membranes of, 5t assessing, 506 spiritual health, 162
nutrition history for, 97 differential diagnoses in, 506 health screening for, 170–173, 171b
Piaget child development theory on, 21t history in, 506 anticipatory guidance, 172–173
safety assessment for, 127, 127f, 128t–129t Vernix caseosa, 210 cervical dysplasia, 172
sequence of physical examination, 147t Vertigo, 288t–289t dyslipidemia, 171–172, 172b
sleep patterns for, 100t Vietnamese eye exams, 170–171
social history assessments for, 102–103, 104t child-rearing differences with, 64t hearing, 170
spleen of, 10t folk healing practices of, 67t hematocrit, 171
teeth of, 3t Vision hemoglobin, 171
wellness history assessment for, 164t anatomy/physiology of, 305, 305f immunization status, 172
Tongue visual fields, 305, 305f lead screening, 171, 171b
geographic, C3 visual pathways, 305 measurements, 170
nutrition problems related to, 188t visual reflexes, 305 newborn metabolic/hemoglobinopathy
physical examination in assessment of, health screening for, 170–171 screening, 170
343–344, 343f physical examination of, 31 sexually transmitted infections, 172
strawberry, C3 Vital signs tuberculosis screening, 171, 172b
Tonsils, C3 abdomen assessment with, 400, 401b vision, 170–171
physical examination in assessment of, measurement health supervision visit with, 162–173
344–345, 344f, 344t, 345f newborns’ assessment with, 209 timing/frequency of, 162
Toy safety, morbidity/mortality statistics for physical examination equipment for, 140b influences on, 161–162
child, 112 normal child, 527–531 access to care, 161
Trained night feeder, 101t thorax assessment with, 345 culture, 162
Transferrin, 185t Voodoo illness, 66t personal beliefs, 162
Transitional states, 225 provider factors, 161–162
Traumatic brain injury, language acquisition medical home with, 162
W
affected by, 23b preparticipation sports examination for,
Tricycle injuries, morbidity/mortality statistics Walking, development of, 17, 19f 173–179, 173b, 174f–177f, 178t, 179t
for child, 113 Warts, 242t cardiovascular screening for, 173b
Triglycerides, 186–187, 187t Water safety, 118b, 122 high-risk behaviors to assess with, 173b
Truncal incurvation reflex, 223t Weber test, 296, 296f history for, 173, 173b
Tuberculosis Weight, 155–156, 155f, 170 laboratory/diagnostic examination for,
health screening for, 171, 172b breast- v. formula-fed infants with variations 176–177
hot/cold theory regarding, 65t in, 154 musculoskeletal screening examination
Twenty-four-hour recall, 191–192 ethnic/racial variations in, 154–155 for, 176t
Two-parent families, 78 premature infants with variations in, 154 physical examination for, 173b,
Tympanic membrane, 291–292, 292t Weight-for-age, 184 174f–177f, 176, 178t, 179t
Weight-for-length, 157, 170, 184 West Nile virus, 242t
Weight-for-stature, 157, 184 Wheezes, 216
U
Wellness care, 161–179 Whisper test, 296
Upper extremities, physical examination in components in, 162–173, 163b Wong-Baker FACES pain rating scale for, 96f
assessment of, 447–448, 448f behavioral assessment, 167, 170 Wood’s lamp evaluation of skin, 40t
Urticaria, 240t developmental surveillance, 167, 170 Worldview, 58t, 60
discipline practices, 162 Wrist flexion angle, 207
disease prevention, 162
V
health screening, 170–173, 171b
Y
Values, 58t history, 162–167, 164t–166t, 167b
Varicella, 95, 242t mental health, 162, 162b, 167b Yin/yang theory, 64
C1
A B
C D
FIGURE 11-2. Erythema toxicum (A); Milia (B); Mongolian spots (C); and Forceps marks (D).
FIGURE 12-4. Mongolian spot. These congenital blue-gray

macular lesions are found primarily in the lumbosacral or glu-
FIGURE 12-3. Café-au-lait spot. Congenital nevus; round to teal area of dark-skinned newborns. These spots usually fade
oval light brown macules, if there are six or more and over by school age and should be differentiated from bruises.
5 mm in diameter, neurofibromatosis may be present.
C2
B D
FIGURE 12-5. Types of vascular skin lesions. A. Port-wine stains are permanent dark red to purple macules;
they do not blanch with pressure or fade with time. They can be associated with congenital syndromes.
B. Salmon patches, also called stork bites, are flat, light pink macules that blanch with pressure and fade
with time. C. A capillary (“strawberry”) hemangioma is a soft, bright red, vascular nodule that appears
soon after birth and involutes spontaneously, usually by the 7 years of age. D. A cavernous hemangioma is
a raised, soft, compressible lesion, light blue in color, that blanches with pressure; it is variable in size.
FIGURE 12-6. Acanthosis nigricans. Linear areas of velvety

thickening and hyperpigmentation of the skin, most often
seen in the skin folds of the neck and axilla; skin tags may also
be seen; most common in African American, Native American,
and Hispanic children; they are related to obesity and may
indicate insulin resistance.
FIGURE 12-8. Lichenification (thickening and roughening of the FIGURE 12-11. Tinea capitis with kerion, a raised, boggy,
skin) is caused by prolonged pressure, rubbing, or scratching. pustular mass that can result in localized scarring.
C3
FIGURE 15-24. Normal ocular fundus. FIGURE 16-16. Strawberry tongue.
FIGURE 16-13. Oral candidiasis. (Source: Langlais, R. P.,

& Miller C. S. (2003). Color atlas of common oral diseases.
Philadelphia: Lippincott Williams & Wilkins.)
FIGURE 16-17. Geographic tongue.
FIGURE 16-14. Koplik’s spots.
FIGURE 16-19. Tonsillar exudate and enlargement, as seen

with streptococcal pharyngitis and infectious mononucleosis.
FIGURE 16-15. Early childhood caries.

C4
FIGURE 23-4. Cigarette burn.

FIGURE 23-2. Bruises in the diaper area and on the lower
back raise a red flag for abuse.
FIGURE 23-6. Bruises caused by the loops made by an

electrical cord.
FIGURE 23-5. Branding injury. This child was held up

against a radiator cover and burned.
FIGURE 23-9. The impetigo lesion on the child’s

nose may be mistaken for a burn.
FIGURE 23-7. Ligature marks from being tied down.

Advanced Pediatric Assessment

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Advanced Pediatric Assessment

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ELLEN M. CHIOCCA, RNC, MSN, CPNP

Copyright © 2011 by Lippincott Williams & Wilkins, a Wolters Kluwer business.

351 West Camden Street 530 Walnut Street

Library of Congress Cataloging-in-Publication Data

Diane B. Boyer, CNM, PhD

Shirley A. Butler, PhD, RN

Pat Hummel, MA, APN, NNP-BC, PNP-BC

Gloria A. Jacobson, PhD, RN

Lisa M. Kohr, RN, MSN, AC-PNP, MPH, CCRN

Joanna M. Kouba, PhD, RN, LDN

Patricia A. Sullivan, BSN, MSN, FNP-BC

Angela Chia-Chen Chen, PhD, RN

Nan M. Gaylord, PhD, RN, CPNP

Anna Marie Hefner, RN, MSN, CPNP

Ann Linguiti Pron, MSN, CRNP

Mary Jo Vollmer-Sandholm, MSN, RN, C-PNP

Section 1: Growth and Development

Section 2: Obtaining the Pediatric Health History

Section 3: Physical Assessment

Section 4: Focused Assessments

Section 5: Assessment of the Whole Child

1 and Illness in Children:

INTRODUCTION ANATOMIC AND PHYSIOLOGIC

Thin layer of subcutaneous fat Newborns Affects temperature control

Sebaceous glands active in Neonates; adolescents Milia develop in neonates; acne

Eccrine glands functional Birth to preschool-age Palmar sweating occurs; helps to

Apocrine glands nonfunctional Adolescents Function of apocrine glands at

Vision undeveloped; by age Neonates to school-age Affects expected findings in and

Obligate nose breathers Birth to 4 to 5 months Nasal passages easily obstructed by

Ability to coordinate Birth until 4 to Increased risk of aspiration and

Chest circumference Infants; toddlers Assists provider in assessing normal

Newborns produce little Neonates Increased susceptibility to respiratory

Larynx is located 2 to 3 cervical Birth until approximately Child vulnerable to aspiration

Breathing becomes thoracic as 8 to 10 years Respiratory rate lowers to near adult

Intercostal, scaleni, Birth until approximately Immature respiratory muscles must

Increased arterial oxygen Neonates Ductus arteriosus closes about 10 to

Vagal parasympathetic tone Neonates; young infants Prone to episodes of bradycardia

Electrocardiogram (EKG) Neonates through EKG changes reflect ongoing

Reduced catecholamine stores; Neonates; infants Poor response to hypotension via

Abdomen cylindrical in shape Infants Peristalsis may be visible and may

Gastric pH is alkalotic at Birth to age 2 years Affects oral medication absorption;

Stomach capacity reaches 1000 Adolescents Correlates with increased appetite

Lower esophageal sphincter Neonates Increases incidence of GER

Prolonged gastric emptying Neonates; infants; Affects absorption of nutrients and

Length of small intestine Infants; toddlers Child loses proportionately more

Large intestine proportionately Infants Less water absorbed, explaining soft

Pancreatic enzyme (e.g., Birth to age 4 to Varied bioavailability of drugs that

Decreased hepatic enzyme Neonates until 3 to Enzyme systems for

Liver conjugation reactions Neonates Jaundice; long drug half-lives

Blood volume is weight- Neonates Overhydration and dehydration

Reticuloendothelial system Birth until Lymphatic tissue, tonsils, and

Renal immaturity in premature Premature neonates Decreased creatinine clearance; poor

Testicles enlarge between 9.5 to School-age to Early puberty if testicles enlarge

Lordosis is a normal variation Infants; toddlers Causes appearance of abdominal

Skeleton grows continuously (at Birth to adolescence Normal growth pattern

Bow-leggedness because of Infants; toddlers Normal growth pattern

Lower muscle mass (Adcock, Neonates Use of intramuscular route for

Blood-brain barrier (BBB) Neonates More permeable BBB allows passage

Thermogenesis by shivering Birth to 6 years Causes need for body heat to

Thelarche normally takes place School-aged children; Affects physical examination;

• Psychosocial and behavioral stages, with which the

The developmental assessment is a significant and Cephalocaudal Development

When evaluating a child’s growth and development, it Proximal to Distal Development