PEDIATRIC ASSESSMENT

PROFORMA
-Dr. Nikita Sawant
DEMOGRAPHIC DATA:

Name:

Age: Gender:

DOB: DOE:

Address:

Primary caregiver:

Reasons for referral:

HOPI:

She/ He is born out of non-consanguineous/consanguineous marriage, stays in a

nuclear/joint family with parents and [mention family member] where mother is

her/his primary caregiver. He is a first/ second child; born in [hospital name]

almost a month preterm/ post term through normal delivery/elective

LACS/emergency LACS due to [reason]. His/her birth weight was ___kgs and

CIAB/ NCIAB but shifted to NICU [reason]. She / He stayed in NICU for ___days

in [hospital name]. According to history giver by mother, [enlist issues faced by

child alongwith treatment given] Mother gave the H/O [any issues faced by mother

during pregnancy, mention month and treatment]

Mention feeding pattern e.g. Initial few days she/he used to take extracted milk

with wati- spoon as she/he was not able to suck well. He/she started taking

mother’s breastfeed from ___ day of life till __year. How was the medical progress

after discharge from hospital. Any other issue note, whom you have consulted and

which medicines the baby is taking now , mention alongwith dose.

Medical investigations:

Date: name of medical investigation

Findings of investigation[ point wise]

Maternal history:
• Mother’s age at the time of marriage:
• Mother’s age at the time of delivery:
• LMP:
• EDD:
• Medical history:
• Surgical history:
• Addictions:
• H/O abortion or miscarriage:
• Unexpected symptoms during pregnancy:
• Treatment during pregnancy:
• USG investigations:
Paternal history:
• Current age:
• Medical history:
• Addictions:
• Job status:
Daily routine:

[name of child] lives in a nuclear/ joint family in [city name] with [mention family

members], the primary caregiver being the mother/ grand mother. Inter-parental

and parent child relationship is poor/ fair/good.

For example,

His/ her day typically starts at 7:00- 8:00am when she/he wakes up by her/ his own

and happy while waking up. Then sits up and plays with her/ his elder brother. After

playing for some time, mother feeds him chapati- sabji/ sandwich whichever she

prepares for other family members. Then mother continues home therapy for him

while playing. At 11:30pm, mother gives him/her bath. While taking bath, she/ he

cries and doesn’t like hair wash.

After taking bath, she/he takes her/his lunch and takes nap for 11/2 -2 hours. After

waking up from nap, she/ he takes evening snacks which usually contains daal/

oats. In the evening, mother takes her/ him to park where she/he enjoys playing in

all equipments except __. After coming from park, she/ he plays with father and

takes dinner by 10:30pm. In dinner also she/ he eats whatever mother prepares for

other family members. Then she/he sleeps by 11:30pm. He/she has deep sleep

and mother needs to pat her/ him to fall asleep. His /her favourite toys are

_______. She/ He mostly likes audio- visual toys.

Developmental milestones: [From history point of view]

Family expectations:

Therapy history:

Type of therapy Name of centre, city Duration Frequency

Adaptive equipment:
Observations during free play:

His/her play seems to be age appropriate and purposeful. He/she likes to play

with other kids also and easily mixes with them. She/ He likes to play with cars,

rings, cones and shape sorter. Usually while playing she/he adopts ring sitting

position/ sinks into base with sacral sitting/ W sitting. While playing, she/he uses

right hand only/ left hand only/ both hands on command/ spontaneously. Grasping

and release of object is possible/ not possible/ difficult.

Examination:

• System examination

• Sensory examination

• Motor examination
SYSTEM EXAMINATION:

• Arousal

• Attention

• Affect

• Action

• State regulation
Arousal:

• Infants ability to maintain alertness and make transitions between states.

• 6 states:

1) Deep sleep,

2) light sleep,

3) drowsy,

4) Quit alert: full attention with no body movements

5) Active alert: less attentive to external stimuli with no body movements

6) Crying
• Under arousal results in low level of alertness.

• Interactions and responses become delayed.

• High and low states of awareness can produce varied reactions to the same

intensity of information.

• A normal state of arousal is required to develop following abilities:

1. Attention to task

2. Impulse control

3. Frustration tolerance

4. Balance of emotional reactions

Attention:

• It is the ability to selectively attend to one from several messages, interpretations

or actions.

• It is through optimal level of alertness that we develop attention.

• Attention and arousal contribute to the ability of our nervous system to filter

information and select important elements for observation to promote learning.

• Attention to novel stimuli is the only the initiation of processing for higher level of

learning.

• Without sustained attention cognitive processing and the ability to focus cannot

develop.
Affect:

• Emotional component of behaviour

• Sensation evokes a emotion- child on swing, terror on noise

• Affect is inherent in social relationship.

• Affects relationships and play behaviour

Action:

• Ability to engage in adaptive goal directed behaviour.

• It involves organizing perception and cognition in order to behave for a purpose.

• Although motor abilities are a foundation for action, the action is more

complicated than the movement alone.

The child must be able to form a goal for the action and sequences the series of

actions which is based in the environment. e.g. playing with small trucks or cars.
SENSORY EXAMINATION:
1. Tactile system
2. Vestibular system
3. Proprioceptive system
4. Olfactory system
5. Gustatory/ Oral system
6. Visual system
7. Auditory system
8. Somatosensory system
TACTILE SYSTEM:

• The first sensory system to operate in the uterus is tactile system.

• After 7.5 weeks of gestation, fetus reacts to touch sensation.

• Sensitivity begins with lips and ending with feet and legs [Top and back of

head remain insensitive till birth.

• A few weeks after conception the human embryo consists of 3 layers of

cell and the outer layer their develops into nervous system [NS] and skin.

• Since both our NS and our skin come from the same origin, tactile

systems have a major role in neural organization.

• This explains why the tactile system is involved in most disorder of the

human brain.

• A child cries when some unknown persons cuddles him but when

mother cuddles them, they are calmer , discrimination of touch begins

here.

• The sensation from a wet diaper make the infant uncomfortable , while

the touch of his mother’s hand is comforting.

GUSTATORY/ ORAL SYSTEM:

• Our oral system allows us to communicate with others, and also allows

us to chew, swallow, and experience different textures and tastes, but

what few of us realize is that our oral system is also closely related

to our proprioceptive system.

• The sensory receptors in our mouths allow us to perceive temperature,

texture (e.g. smooth like yogurt, hard like a potato chip, or a mixture of

textures like cereal with milk), and taste (e.g. sweet, salty, bitter, sour).

• Our brains also receive lots of proprioceptive information from the joint

of the jaw as we bite and chew different foods that provide different

types of resistance (e.g. a crunchy carrot).

Oromotor system:

• The oral-motor aspect of eating involves how the mouth muscles

function: how strong the muscles are, how well they coordinate the

range of motion and how far they can move as they manipulate food in

the mouth.

• The oral-sensory aspect of eating involves how the mouth tissues

perceive sensory information such as the taste, temperature and

texture of food. Children have can problems with either part of the

eating process or both; there is often overlap with feeding disorders.

Orosensory system:
• Oral sensory processing also contributes to the way we move our
mouths, control our saliva, and produce sounds for clear speech. The
way our mouths perceive sensory information helps us eat and drink in
a functional, adaptive way and allows us to enjoy and participate in
mealtimes with family and friends.
• Children with healthy oral sensory systems typically eat a variety of
food with a range of tastes and textures. They are willing to try new
foods (within reason…it is common for young kids to avoid certain
foods like green leafy vegetables and certain kinds of meat).
• Kids with healthy oral sensory systems can tolerate eating foods with
mixed textures like cereal and milk or vegetable soup and are able to
tolerate tooth brushing and visits to the dentist with minimal protest.
PROPRIOCEPTIVE SYSTEM: [Position sense]

They can be divided into 2 subtypes:

1. Static position sense

2. Kinesthesia/ dynamic proprioception

• Knowledge of position, both static and dynamic, depends on knowing

the degrees of angulation of all joints in all planes and their rates of

change.

• Both skin tactile receptors and deep receptors near joints are used.

• Proprioception is derived not just from proprioceptors but also from

internal correlates of motor signals that are sent to the muscles once

an action is planned i.e. corollary discharge. This knowledge of our

body and our movement is important in motor planning.

VESTIBULAR SYSTEM:

• The vestibular system might not be one of the five basic senses we

were taught as children, but it is arguably the most fundamental sense.

• The vestibular system has to do with balance and movement and is

centered in the inner ear. Each of us has vestibular organs located

deep inside our ears. When we move our heads, the fluid in these

organs moves and shifts, constantly providing us with information about

the position of our heads and bodies in space (spatial awareness).

• The vestibular system provides information about movement and

gravity. The sense also tells about the body motion, it’s direction and

speed.

• Vestibular stimulation can have a significant impact on the nervous

system. Vestibular sensations also help the nervous system to stay

organized and balanced. Quick and fast movements tend to be alerting,

and slow movements tend to be calming.

• This sense allows us to maintain our balance and to experience

gravitational security: confidence that we can maintain a position

without falling. The vestibular system allows us to move smoothly and

efficiently. It also works right alongside all of our other sensory

systems, helping us use our eyes effectively and process sounds in

our environment. Overall, vestibular processing helps us feel

confident moving and interacting with our surroundings.

OLFACTORY SYSTEM:

• The sensory receptors in the nose pick up information about the odors

around us and pass that information along a channel of nerves where it

eventually reaches the brain. In humans, the olfactory system can

discriminate between thousands of different odors and helps us

recognize whether smells are dangerous, strong, faint, pleasurable, or

foul.

• The olfactory system is also associated with the sense of taste, helping

to create the flavors that we taste in food. This is why nothing seems to

taste quite right when you have a bad cold.

• The olfactory system includes chemical receptors with direct

neuronal connections to the limbic system (responsible for emotional

memory).

• A child with a healthy olfactory system is able to tolerate smelling

foods and other odors in his environment. He can even tolerate

unpleasant odors (within reason) without extreme reactions. A

functioning olfactory system helps a child know the difference

between “good” smells – those that are safe, pleasant, or associated

with positive emotions – and “bad” smells – those that are

dangerous, displeasing, or reminders of negative experiences.

VISUAL SYSTEM:

• The sensory organ of the visual system is the eye. The eye and the

brain communicate and work together to help us interpret our physical

surroundings using sight, or, what we see. This happens through

interpretation of light.

• The visual pathway is the neural pathway that visual input travels to

the brain.

• This pathway consists of the eye, the optic nerve, optic chiasm, optic

tract, lateral geniculate nucleus (LGN), optic radiation, and visual cortex.
• In visual cortex, the object is identified and given meaning. This includes

details regarding color, three dimensional depth perception, where the

object is in space, memory of the image, and gives the image context in

the environment. Vision is closely integrated with all of our other senses.

E.g. If we see freshly baked cookies, we become hungry as our sense of

smell and our taste buds kick in! If we see a large spider, our tactile

system goes to work – we get goose bumps and may feel a sense of

fear. Vision helps us process, understand, and take action in our

environments.

• The visual system can also play a role in execution of gross motor skills.
AUDITORY SYSTEM

• When we hear a sound, it travels to our brains to be analyzed in order

for us to generate a response. What should we do next? What is going

on around us? Is the sound alerting us to something dangerous or

important, like a fire alarm or a honking car horn? Is the sound quiet

and calming, like classical music

• The inner ear has two important organs that, as partners, have big jobs.

In general, the cochlea translates and interprets every sound we hear

(what is it?) and the vestibule helps move the sound along to the brain

to integrate the sensations we receive and help process motor

responses to the sound (what should I do next?).

• The inner ear and the sense of hearing also contributes to our

vestibular system, helping us with movement and balance.

• Children with healthy auditory systems are able to respond to sounds

naturally, looking when their names are called or turning their heads

toward a sound. They are able to follow verbal directions from their

teacher or parent. A child with a functioning auditory system is able to

filter out sounds that are not important, such as a friend tapping his

pencil on the neighboring desk, while tuning into sounds

that are important, such as the teacher’s direction to start working on

an assignment.
SOMATOSENSORY SYSTEM:

• Somato sensation refers to the sensations arising from the skin. These

sensations include the ability to feel light touch, localize a touch,

discriminate temperature, identify an object through the sense of touch

(somato sensation), discriminate the sharpness of an object, and the

ability to feel pain. Somatosensory impairment refers to any type of

impairment that affects one’s ability to effectively and accurately process

input received from sensory receptors in the skin. Somatosensory

impairments can occur in any part or area of the body.

• Somatosensory system is a combination of tactile and proprioceptive

system.
SENSORY PROCESSING DISORDER:

• Sensory processing disorder, or SPD, is a neurophysiological condition

in which the brain struggles to appropriately interpret and process

information that comes from the body’s senses. It can cause some

people to be over-sensitive [hypersensitive] to stimuli, and in others, it

can make them under-sensitive [Hyposensitive]

• Children with hypersensitivity to sensory input may exhibit extreme or

fearful responses to touch, textures, noise, crowds, lights, and smells,

even when these inputs seem begin to others.

• Children with hyposensitivity to sensory input may exhibit an under

reaction or high tolerance to pain, may constantly and inappropriately

touch or bump into people and objects.

VESTIBULAR DYSFUNCTION

Hypersensitive to movement:

• Prefers sedentary tasks

• Dislikes elevators/ escalators

• Afraid of heights

• Fearful of feet leaving the ground

• As an infant, they never like baby swings

• Fearful of activities which require good balance

• Gravitational insecurity
Vestibular function

Hyposensitive to movement:

• Craves for spinning, , intense movement experiences

• Loves being tossed in air

• Could spin for hours, never appear to be dizzy

• Always jumping on furniture

Proprioceptive system:

Hyposensitive:

• Bites, chews objects e.g. top of pencil or pen

• Hyperextended joints

• Hold objects tightly in hand

• Write too hard on paper

• Prefer run, jump or stamp continuously

• Like to fall on floor intentionally

Proprioceptive system:

Hypersensitive:

• Difficulty in chewing or chews slowly

• Doesn’t like to stretch his body or reach out

• Avoid all possible collision with objects, people.

• Prefers walking slowly on ground.

Olfactory hypersensitivity:

Children with hypersensitivity to smell tend to struggle at mealtimes, both

with smelling the foods on their plates and with tasting the food that’s

presented to them. They don’t experience pleasure with smells that most

of us associate with pleasant memories or good experiences, like smelling

chocolate chip cookies baking in the oven.

Olfactory hyposensitivity:

Other children demonstrate decreased sensitivity to smells

(hyposensitivity). They seem to crave certain smells, frequently holding

non-food items to their noses to smell them (e.g. crayons, toys,

etc.). These children may not have an understanding of “safe” versus

“dangerous” smells, which can lead to safety issues (e.g. being drawn to

strong smells like cleaning chemicals or strong-scented permanent

markers).
Auditory hypersensitivity:

• A child who is hypersensitive to auditory input is overwhelmed and even

frightened by the volume, pitch, and unpredictability of common

environmental sounds. This child may attempt to avoid and withdraw

from noisy, crowded environments. He may startle easily or appear

very distracted, focusing on every noise around him. This child may

appear agitated and always ready to flee. A child that is hypersensitive

to sound may show physical signs of avoidance such as covering his

ears or ducking his head.

• Fear of sounds from hair or hand dryers, vacuums, flushing toilets, etc
• Overreaction to loud or unexpected sounds (covering ears, crying,

running away, aggression)

• Annoyed or distracted by sounds most of us either don’t notice or

become used to such as fans, clocks, refrigerators, outside traffic, etc

• Becomes upset with others for being too loud

Auditory hyposensitivity:
• This child does not register important auditory cues in his environment.
He may appear as though he does not hear the sounds around him and
may not generate appropriate motor responses to auditory input (e.g.
following directions, turning to look when his name is called, looking in
the direction of a loud noise). He may be a noisy child, always talking,
singing, humming, and making sounds to generate additional auditory
input for himself. He may talk out loud while performing a task,
prompting himself as he completes each step. He may not respond to
you when you are speaking to him because he simply did not know you
were talking to him. This child may also have difficulty remembering
what you have told him.
• Enjoys making noise just to make noise

• Doesn’t respond promptly to name being called

• Needs you to repeat yourself often or doesn’t seem to understand what

you said

• Unable to recognize where sound is coming from

• Prefers to keep television, radio, or music very loud

Visual hypersensitivity:

• A child may be highly distracted by the visual stimuli around him. He

may be overwhelmed by the many colors in the room, the posters or art

on the walls, and the movement of others around him. The movement

of the picture on the television catches his attention. He may see activity

outside the window or want to count the tiles on the floor that are

different colors and textures.

• Because of all of these visual distractions, it may be impossible for him

to focus on a task like coloring a picture. This child needs an

environment that is visually simplified. He would benefit from a neat,

clear area to work and a classroom without so many visual distractions.

This may mean fewer posters on the wall, more uniform color in the

room, low lighting, and important information presented in a bold color.

He may need a privacy divider to do his best work in a busy

room. When receiving directions, he may benefit from the adult

establishing eye contact with him first, ensuring that he is listening and

attending.
Visual hyposensitivity:

He barely notices his surroundings unless details and objects are pointed

out to him. He may stare at the same point for extended periods of time. He

gets lost in a visual activity quickly and loses interest. This child needs a

visual boost! He needs more visual stimulation in order to function. He

may benefit from a bright piece of paper under his work to help him

with paying attention and learning materials that are written in bright, large,

or bold font. This child typically does well with online learning and

applications that use movement and color. Visual sticker charts keep this

child motivated. He needs to see more to stay alert.

Somatosensory system disorder:

• Somatosensory impairment is any form of impairment affecting one’s

capability to efficiently and accurately process sensory information

received by sensory receptors in the skin.

• Somatosensation refers to sensations perceived by the skin.

• Effective somatosensation means being able to distinguish

temperature, feel light touch, feel pain, and being able to determine

the sharpness of an object.

• Somatosensory impairments can occur in any part or area of the body.

Hypersensitivity to somatosensory system:

• Sensitive to texture and fit resulting in avoidance of some types of

clothing (e.g., ties, turtlenecks, pantyhose).

• Dislikes crowds or jostling in public places (e.g., standing in lines or

shopping).

• Becomes irritated with light or unexpected touch. May have difficulty

with intimate touch. Limited engagement in food and meal preparation

and/or variety in diet.

• Dislikes eating with hand, always demand spoon or fork

• Dislikes playing in mud or with clay

Hyposensitivity to somatosensory system:

• May not discriminate when clothes are not properly align.

• May give delayed or no response if tap from behind on their shoulder

• May not discriminate when food is on their face

Oromotor problems:
Symptoms of a motor problem could include:
• Delayed advance of textures because the child can’t physically manage
chewing solid foods
• Slow or inefficient chewing
• Food left in the mouth
• Food falling from the mouth
• Gagging
• Coughing or choking
• Low intake of food (the child may not consume enough calories because
it takes so long to eat)
• Delayed advance of other feeding milestones (such as transitioning to a
regular open cup from a sippy cup)
Orosensory system:

Symptoms of a sensory problem could include:

• Gagging

• Refusal to eat

• Crying during meal times

• Vomiting

• Delayed eating milestones (the child may be able to tolerate liquids and

purees but have trouble with chewable foods, or vice versa)

• Unusual taste preferences

• Food falling from the mouth

MOTOR ASSESSMENT:
• Gross motor development
• Fine motor development
• Neonatal reflexes
GROSS MOTOR DEVELOPMENT:
Supine and prone progression:

Normal attainment age Milestone Remark

3 months Head control
4-5 months Rolling to sides
Prone to supine
6months
Supine to prone
Weight bearing on
6.5 months
one hand in prone
8 months Crawls
9 months Creeps
10 months Bear walk
Sitting progression:

Normal attainment
Milestone Remark
age

5 months Supported sitting

Independent sitting with arm

6- 7 months
supported forward

Independent sitting without

8 months
support

10- 11 months Pivot sitting

15 months Sitting on chair

Standing and walking progression:

Normal attainment
Milestone Remark
age
9 months Pull to stand

12 months Cruising around the furniture

Independent standing

13 months
Walk with broad BOS with one
hand held

15 months Creeps on stairs

Normal attainment
Milestones Remark
age

15 months Climb up the stairs

18 months Walk down the stairs
2 years Run
2.5 years Jump with both feet

Climb upstairs with one

3 years
foot at a time

Goes downstairs one foot

4 years
at a time

Skip on one foot

6 years Skip on feet
Fine motor development:
Hand eye coordination
Hand mouth coordination
Normal attainment
Milestone Remark
age

1 month Hand closed [fist]

Hold toy for a second if place

3 month
in hand

3-4 month Hand regard

Midline play

5 month Voluntary hand grasp

6 month Ulnar grasp

Normal Attainment
Milestone Remark
age

Transfer object from one

7 month
hand to another

8- 9 month Radial grasp

9- 10 month Finger thumb opposition

Development of grasp &

10- 12.5 month
pinches

12 month Mature grasp

Normal attainment
Milestone Remark
age

13 month Build tower of 2 cubes

Hold 2 cubes in one hand

15 months
Scribbles spontaneously

Build a tower of 3 to 4
18 months cubes
Turn pages of book
Build tower with 6 to 7
cubes
2 years
Can put shoes, socks and
pant, turn door knobs
Normal attainment
Milestone Remark
age

Build tower of 8 cubes

2.5 years
Can thread beads

Can dress & undress

3 years [require help for buttons]

Can draw & paint

Buttoning & unbuttoning

4 years
possible

5 years Ties shoelaces

Hand to mouth coordination:

Normal attainment
Milestone Remark
age

6 months Mouthing of all objects

Tries to feed self but spills

1 year
some content

Can feed self from the cup

15 months
without much spilling
Neonatal reflexes
BALANCE:
Sitting balance:
1] Static
2] Dynamic
Standing balance:
1] Static
2] Dynamic
Gait:
• Standing balance
• Balance during walking
• Walking pattern
• Stepping
• Noticeable deformity
• Base of support
THANK YOU