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2015v1.0
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eb eb eb
oo oo oo
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fre fre Clinical f re
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Paediatric
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Examination
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To our children: Kieron, Daniel, Aisling, Meagan, Michael,

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Slaney, Eoin, Cliona, Helene and Aisling and to our respective
wives, Margaret and Helene
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For Elsevier:
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Content Strategist: Pauline Graham


Content Development Specialist: Humayra Rahman Khan
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Project Manager: Andrew Riley


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Designer: Margaret Reid


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Marketing Manager: Deborah Watkins


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Paediatric
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Clinical

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Examination

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Made Easy
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Denis Gill MB BSc DCH FRCPI FRCPCH
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Professor of Paediatrics, Royal College of Surgeons in
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Ireland and The Children’s University Hospital, Dublin,


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Ireland
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Niall O’Brien MB DCH FRCPI


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Consultant Paediatrician, National Maternity Hospital and
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The Children’s University Hospital, Dublin, Ireland

Illustrated by Des Hickey


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SIXTH EDITION
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Search full text online at StudentConsult.Com


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EDINBURGH LONDON NEW YORK PHILADELPHIA ST LOUIS


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SYDNEY TORONTO 2018


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© Longman Group UK Limited 1993
© f
Pearson Professional Limited 1996
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© Harcourt Health Sciences Limited 1998

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© Elsevier Science Limited 2002
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© 2007 Elsevier Limited. All rights reserved

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© 2018 Elsevier Limited. All rights reserved
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The right of Denis Gill and Niall O’Brien to be identified as authors of this work has been

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asserted by them in accordance with the Copyright, Designs and Patents Act 1988.
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No part of this publication may be reproduced, stored in a retrieval system, or transmitted
in any form or by any means, electronic, mechanical, photocopying, recording or
otherwise, without the prior permission of the Publishers. Permissions may be sought
directly from Elsevier’s Health Sciences Rights Department, 1600 John F. Kennedy
Boulevard, Suite 1800, Philadelphia, PA 19103-2899, USA: phone: (+1) 215 239 3804; fax:
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(+1) 215 239 3805; or, e-mail: healthpermissions@elsevier.com. You may also complete
your request on-line via the Elsevier homepage (http://www.elsevier.com), by selecting
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‘Support and contact’ and then ‘Copyright and Permission’.
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First edition 1993

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Second edition 1996


Third edition 1998
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Fourth edition 2002


Fifth edition 2007
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Sixth edition 2018
ISBN: 978-0-7020-7288-8
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International Edition ISBN: 978-0-7020-7289-5


Note
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Neither the Publisher nor the Authors assume any responsibility for any loss or injury

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and/or damage to persons or property arising out of or related to any use of the material
contained in this book. It is the responsibility of the treating practitioner, relying on
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independent expertise and knowledge of the patient, to determine the best treatment and
method of application for the patient.
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The
publisher’s
Working together to grow policy is to use
libraries in developing countries
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paper manufactured
www.elsevier.com | www.bookaid.org | www.sabre.org from sustainable forests
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Printed in China
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Preface to Sixth Edition
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One of the pleasures of writing the preface for a book on
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clinical examination is that the fundamentals don’t change.

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A thorough history, a complete physical examination and a
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logical deduction and conclusion from the findings remain
the basis of clinical interaction. In this edition, we have
responded to critiques by adding extra diagrams, making
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alterations here and there, and improving the layout.
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The good doctor is the good listener, good examiner, good
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interpreter and good problem-solver. We hope that clinical

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ex­amination will not be supplanted by CTs, MRIs, PETs,


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and increasingly sophisticated scanning techniques. Scan-
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ning techniques have improved dramatically in the past 20
years for those based in secondary and tertiary care hospi-
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tals. This has been especially true of ultrasonic examinations


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of the acute abdomen in infants and children, in cardiac

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echographs, and in MRI examination of the newborn and
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infant brain, to cite but a few examples. The primary care
paediatrician working in remote or isolated practice will still
need to rely on his/her diagnostic wit and clinical skills. We
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trust that clinical findings will continue to direct appropri-


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ate investigations. Listening and laying on of hands remain


the cornerstones of clinical contact and contract. Good chil-
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dren’s clinicians do more talking and thinking, and hope-


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fully less blood testing. Children will like them for that.
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Denis Gill
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Niall O’Brien
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Acknowledgements
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We could not have delivered the text without the tireless
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typing of Norma McEneaney, the photographic shots of

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Thomas Nolan, and the lively illustrations of Des Hickey;
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to all of them we are extremely grateful. We thank Profes-
sor Alan Browne for his view of the Hippocratic tradition.
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D.G.G.
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N.O’B
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Internet sites
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There is virtually limitless information available on the
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internet. Students will learn of and access their favourite

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sites. The list below is limited and selective, but hopefully
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contains appropriate starting points.
•   http://journals.bmj.com   BMJ (British Medical Journal)
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•   www.medicalstudent.com
•   www.aap.org   American Academy of Pediatrics
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•   www.omim.org Online Mendelian Inheritance in Man

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•   http://www.medic8.com/MedicalDictionary.htm
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•   www.rarediseases.org
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•   http://www.ncbi.nim.nih.gov/pubmed   PubMed
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•   www.rcpch.ac.uk   Royal College of Paediatrics and
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Child Health
•   www.cdc.gov   Centers for Disease Control and Preven-
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tion (CDC)

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•   http://www.who.int/en/   World Health Organiza-
tion (WHO)
•   http://adc.bmj.com/   Archives of Disease in Childhood
•   http://student.bmj.com/student/student-bmj.html  
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Student BMJ
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Contents
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Preface  v 3. Approaching
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children  33

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The approach code  33
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Acknowledgements  vi
Things not to do  39
Internet sites  vii Point to the part which
hurts  41
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1.  Introduction  1 Putting it together  44
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Children and doctors  3 I don’t know  47
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‘Veterinary’ paediatrics  5 Diagnostic logic  47
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Aims and objectives in Syndrome recognition  48


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The seven ages of 4. Examination at different
children  7 ages  51
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Children in hospital  8 Newborn  51


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Three pillars of Six-week examination  74

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diagnosis  10 The acutely ill infant  79
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The terrified toddler  83
2.  History taking  13
Listening to mothers  13 5. Systems
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Cue words  18 examination  87


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A sample history  19 The chest  87


Let the children speak  25 The cardiovascular
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Talking to parents  27 system  104


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Breaking bad news The abdomen  116


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to parents  30 Examining the glands  131


Clinical evaluation of
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the immune
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system  133
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Ear, nose, mouth and


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throat  133
Skin, hair and nails  141
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CONTENTS

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Neurological 10.  Using your senses  235

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examination  150 A cacophony of cries  235
Musculo-skeletal
f A sense of diagnosis  238
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system  170 The diagnostic touch  239

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The eyes  187 The last word  239

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Surgery  196
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11.  Paediatric tips and

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6. A measure of topics  241
progress  199 Normal findings  242
Tools of the trade  242
7. Hydration and Tricks of the trade  243
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nutrition  209 Biological warning
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Detecting and determining signs  244
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dehydration  209 Clinical curios  245
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Nutrition  214 Rules of thumb  246


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Maternal myths  247
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8. Developmental Acrimonious acronyms  247
assessment  219 A–Z of eponyms  248
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3 months  220 Alarm signals: ? non-


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4–5 months  221 accidental injuries  252

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6–8 months  221 Memorable mnemonics  253
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9–10 months  223 Genetic graphics  256
12 months  225 ‘Growing out’ of disorders/
18 months  226 illnesses  256
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3 years  228 ‘The child is father of the


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4 years  228 man’  258


Tips for the paediatric
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9.  Examining excreta  229 examination  259


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The stool medical Essential clinical


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inspection  229 skills  261


Cast your eye on the Things to be seen
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urine  231 and understood by


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undergraduate
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students  265
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Cliniquiz  267
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CONTENTS

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Children’s Some Latin translations  274

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‘wisdomisms’  268 A question of fives  274
Paediatric synonyms and
f Multiple choice questions
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slang  269 (MCQs) – best of

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Children are different  270 five  275

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Physiological facts: did you Multiple choice questions
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know that . . .  270 (MCQs) – true/false  280

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At what age can a
child . . .  272 Index  285
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Introduction
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Children and doctors   3 The seven ages of children   7
‘Veterinary’ paediatrics   5 Children in hospital   8
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Aims and objectives in Three pillars of diagnosis   10
paediatrics   6
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The text is aimed at undergraduate medical students taking

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their paediatric course and also at postgraduate doctors
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commencing their first post in paediatrics. Experience
has taught us that paediatric residents frequently need to
refresh and retrain themselves in child health and disease.
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The term ‘student’ refers therefore to both postgraduate and


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undergraduate students of paediatrics. Strange though it


may seem, undergraduate and postgraduate education are
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interrelated. The medical graduate has an inherent obliga-


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tion to remain a student for life. Our aims are to emphasize


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the important art of history taking both from parents and


child, to guide in the elicitation and interpretation of physi-
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cal signs in children of varying ages, and to provide some


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sources of further information.


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Doctors caring for little children need to develop their


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observational and instinctual skills. Occasionally the


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1 INTRODUCTION

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combination of an observational clue plus an instinctual

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cue can result in ‘instant diagnosis’. Throughout we wish
to emphasize the value of attentive observation.
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Our approach is essentially clinical, and will be confined

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largely to symptoms and signs. This does not purport to be

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a textbook of paediatrics and no effort is made to include
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descriptions of syndrome identification, clinical conditions,

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laboratory investigations or treatment protocols. These
can all be found in standard textbooks. Our objective is
to expand the first few chapters of the basic text into a
child-centred clinical approach towards problem solving in
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paediatrics.
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We believe that the simple but subtle skills of physical
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examination and history taking are essential if one is to be
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a dedicated doctor to children. Too many students spend


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inappropriate time in the library at the expense of being
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at the bedside. Our philosophy is that the student cannot
examine too many babies, infants or children. To know the
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abnormal, you must first know the normal.


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We suspect that medical students may be exposed to

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a surfeit of unusual cases and conditions at the expense
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of more common and mundane problems. Remember that
what is common is common, and that one must be versed
in the usual to become good at the unusual.
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We have elected to concentrate mainly on the newborn,


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infant and preschool child, for these are the ages of greatest
change and most difficulty. The schoolchild is rational and
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reasonable, and can usually be examined as a ‘mini-adult’


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in an organized fashion.
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This text is written on the understanding that students


taking paediatrics have had previous exposure to clini-
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cal methods. No effort is made, therefore, to define basic


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clinical terms such as, for example, crepitations, clubbing


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or chorea. Studded through the text are boxes contain-


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ing special paediatric terminology with which the student


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INTRODUCTION 1

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may experience difficulty. Textbooks sometimes display

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disease in its most florid form. Insufficient emphasis may
be placed on nuances of disease and degrees of disorder.
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Implicit in paediatrics is an ability to recognize subtle signs

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of sickness and to be able to say with some certainty that a

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baby is ‘off’ or an infant is ‘ill’. Early recognition of problems
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facilitates early intervention and, hopefully, prevention of

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complications.

CHILDREN AND DOCTORS


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Children are brought to doctors for a multitude of
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reasons: to reassure regarding normality; to receive immu-
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nizations; for developmental checks; for recognition of
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rashes; and so on. Insofar as medical students are con-


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cerned, the following are the most important reasons for
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consultation:
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•   for diagnosis of an acute illness (otitis, respiratory, infection,


convulsions, appendicitis, etc.)
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• for diagnosis and/or investigation of a chronic illness (failure
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to thrive, recurrent wheeze, protracted diarrhoea, for example)
• for delay in reaching developmental milestones
• for advice on immunization, nutrition, growth, normal
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variations
•   for reassurance of normality
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•   for recognition and/or confirmation of a syndrome complex.


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We trust that students will enjoy this primer and point out
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to us its deficits as well as their own problems. Paediatrics


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(doctoring of little people) should, above all, be pleasurable.


Think of your children’s experience as being in a ‘learning
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hospital’ rather than a ‘teaching hospital’.


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Listen to and learn from children. And mimic their main


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attribute, that of a constantly questioning nature. Ask ‘Why?’


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over and over again.


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1 INTRODUCTION

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Fig. 1.1  Children are brought to doctors for a multitude of reasons.
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•   Look and you should see
•   Ask and you should be answered.

The basic requirements needed to acquire the clinical skills


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in paediatrics are the same as those for adult medicine in


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the Hippocratic tradition.


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Clinical skill Requirement


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history taking education


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physical examination skill


diagnosis inductive logic
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prognosis experience
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treatment knowledge
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INTRODUCTION 1

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Sufficient incentive should be provided by the needs

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of children for good doctors, and by your need to pass
your assessment. We do hope to transfer some of the skills
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required to examine children and to provide a flavour of the

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rewards to be obtained by good practice.

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Recall at all times the ancient adage:
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•   I hear and forget
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•   I see and remember
•   I do and understand.
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‘VETERINARY’ PAEDIATRICS
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By using the term ‘veterinary’ we are not attempting to be

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derogatory, but are trying to draw your attention to certain


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analogies between young children and animals. We also
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hope to persuade you to commence all examinations as


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veterinarians do – by listening and looking.
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Some attributes shared by animals and small children


are:
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•   they don’t like being stared at
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•   they lie down when sick
•   repeated food refusal is unusual
•   they have limited ability to express themselves
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Fig. 1.2  ’Veterinary paediatrics’: small children and animals share


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certain characteristics.

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1 INTRODUCTION

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•   they adopt the position of comfort when well

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•   their survival instinct is strong.
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Inspection and intuition are therefore important intro-

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ductions to paediatric examination. Some cynic has coined
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the term ‘paediatric zoology’ to describe the collection

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and study of rare cases and conditions in teaching hos-

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pitals!
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AIMS AND OBJECTIVES IN PAEDIATRICS
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Every department of child health will set its own course
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aims and objectives. In broad terms they will include the
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following main headings:

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1.  To teach the recognition and management of the well and ill
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infant and child. fre


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2.  To emphasize the importance of growth and development of
both the normal and the sick child.
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3.  To provide a sound basic knowledge of child health and


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disease.

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4.  To enable the student to acquire sufficient skill to carry out a
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full physical examination of a newborn infant, toddler, child
and adolescent.
5.  To demonstrate adequate medical, developmental, social and
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behavioural history taking from the parents or guardians of


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the child.
6.  To stress the importance of the child’s family and social
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background in relation to his well-being and illnesses.


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7.  To emphasize the importance of prevention in paediatrics;


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in particular, this applies to immunization, nutrition and


avoidance of accidents.
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8.  To demonstrate the relationship between genetic and


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environmental factors in the causation of malformation and of


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illness.
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INTRODUCTION 1

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9.  To provide an understanding of the handicapping conditions

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of childhood and of the services available for their
amelioration.
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A student should set himself the more straightforward and
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simple targets:

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1.  To be able to elicit and interpret findings from history and

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physical examination.
2.  To be able to construct a reasonable differential diagnosis and
problem list.
3.  To be able to prepare plans for appropriate investigation and
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management.
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4.  To be able to communicate adequately with children and with
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their parents.
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THE SEVEN AGES OF CHILDREN


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Children change, grow, mature and develop. One’s style and
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approach to physical examination will very much depend


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on the child’s age, independence and understanding. The

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seven ages of children are:
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1.  Newborn, neonate = first month of life
2.  Infant = 1 month to 1 year
m

m
3.  Toddler = 1 year to 3 years
4.  Preschool child = 3–5 years
co

co

5.  Schoolchild = 5–18 years


e.

e.

6.  Child = 0–18 years


fre

fre

7.  Adolescent = early: 10–14 years


= late: 15–18 years.
ks

ks

Throughout the text the terms ‘he’, ‘him’, ‘his’, should


oo

oo

be taken to be ‘ambisextrous’ and to refer to ‘him’


eb

eb

and ‘her’. We reject the use of neuter ‘it’ in referring to


e

children.
m

7
m

m
co

co
m

om
1 INTRODUCTION

co

c
e.

e.
Paediatrics is the medical care of children up to the com-

re

fre
pletion of growth and development.
f
ks

s
ok
CHILDREN IN HOSPITAL
oo

o
It has been said that the primary function of paediatricians is
eb

eb
to discharge children from hospital. In developed countries

e
m

m
the average inpatient stay has dropped steadily and now
has a mean of 2–4 days. Indeed many children only stay
1–2 days. Students need to be on their toes if they are to
see and learn. About half of all admissions will be infants
m

m
and toddlers – hence the importance, where possible, of an
o

co
omnipresent parent.
.c

e.
Parallel with reduced inpatient stay has been an
e

increased use of day care, both for medical and surgical


re

fre
purposes. Many of the most interesting and complicated
f
ks

ks
paediatric cases are to be found having various procedures
in the plastic, orthopaedic, urological and neurosurgical
oo

oo

units.
eb

eb

Why are children in hospital?

e
m

m
•   For care of acute and chronic illness
•   For surgery, acute and elective
•   For investigative, therapeutic and diagnostic procedures
m

•   For multidisciplinary assessment, particularly if handicapped


•   For their protection (in cases of serious non-accidental injury)
co

co

•   For observation (in behavioural and other disorders)


e.

e.

•   For social reasons.


fre

fre

In the future much of paediatrics will be practised on an


ks

ks

‘ambulatory’ basis – in the day ward, in the outpatient


department and in the community clinic. During your pae-
oo

oo

diatric course, visits to all these activities will be imperative.


eb

eb

In addition, we recommend visits to child-oriented general


e

practices, institutes for the mentally and physically handi-


m

capped, and vaccination sessions.


8
m

m
co

co
m

om
INTRODUCTION 1

co

c
e.

e.
Inner-city children’s hospitals tend to continue to have

re

fre
busy accident and emergency (‘casualty’) departments. In
reality, a large proportion (as much as 50%) of the work of
f
ks

s
these departments relates to primary care problems: that is,

ok
oo

medical conditions that should be handled in the commu-

o
nity. We urge students to avail themselves of the opportu-
eb

eb
nity to see the common problems in practice – respiratory

e
m

m
infections, infectious illnesses, minor injuries, rashes, vague
symptoms, etc., in the accident and emergency department.
Remember that although leukaemia, nephrotic syndrome
and epiglottitis may be relatively common conditions in
m

m
hospital practice, they are distinctly rare in general practice.
o

co
The general practitioner is more likely to encounter iron
.c

e.
deficiency anaemia, urinary tract infection and viral ‘croup’
e

than any of the above.


re

fre
By their nature, children’s hospitals tend to have a dis-
f
ks

ks
proportionate collection of curiosities and congenital disor-
ders. Remember our rules:
oo

oo

1.  First know the normal


eb

eb

e
2.  Then know variants of normal
m

m
3.  Then know abnormality, noting that: normality and
abnormality are closely allied, and thin partitions do their
bounds divide.
m

Some 5–7% of children are admitted to hospital annually,


co

co

and some 50% of children have been in hospital by the age


of 7 years. Observe the effects of hospitalization on children.
e.

e.

Note the trauma of separation if a parent cannot be present.


fre

fre

Learn of the efforts that are now being made to mitigate the
ks

ks

effects of hospitalization on vulnerable children through


preparation, play, parental accommodation, painting and,
oo

oo

above all, pleasant hospital people, from porters to profes-


eb

eb

sors. Although nurses are nearly always nice and doctors


e

do their best, students should be simple, straight and con-


m

siderate in their approach to children. Remember the words


9
m

m
co

co
m

om
1 INTRODUCTION

co

c
e.

e.
re

fre
f
ks

s
ok
oo

o
eb

eb

e
m

m
m

m
o

co
.c

e.
e

Fig. 1.3  Children on hospital ward.


re

fre
f
ks

ks
of Marcus (aged 6) who wrote, ‘Even nasty people are nice
oo

oo

when you’re ill’.


eb

eb

e
When I was sick and lay a-bed
m

m
I had two pillows at my head.
And all my toys beside me lay
To keep me happy all the day.
m

Robert Louis Stevenson


co

co
e.

e.

THREE PILLARS OF DIAGNOSIS


fre

fre

Medical diagnosis rests on the traditional tripod of history,


ks

ks

physical examination and investigation. Paediatric problem


solving rests heavily on history, partly on examination
oo

oo

(observation) and partly on investigation. A carefully taken


eb

eb

and properly recorded history is the clinical keystone. The


e

history should give prime emphasis to the mother’s worries


m

and reasons for bringing the child to the doctor. Physical


10
m

m
co

co
m

om
INTRODUCTION 1

co

c
e.

e.
re

fre
f
ks

s
ok
oo

o
eb

eb

e
m

m
m

m
o

co
.c

e.
e

Fig. 1.4  The three pillars of diagnosis are history, physical examination
re

and investigation.
fre
f
ks

ks
examination, with its techniques, tricks and tribulations, is
oo

oo

described in detail in other parts of this text. The results of


eb

eb

examination need to be recorded in a standard legible style

e
with due emphasis on relevant negative findings. The brief
m

m
designation O/E NAD (on examination, nothing abnormal
detected) is inadequate for undergraduate purposes.
With experience, a thorough examination of infants and
m

children can be completed in a short time. Parents are very


co

co

reassured by doctors who do a thorough examination, not


merely confining themselves to the presenting part, be
e.

e.

that a sore ear or a limp. There is simply no substitute


fre

fre

for examining lots of normal children. Know the normal,


ks

ks

and deviations can be subsequently recognized. Today’s


parents (of smaller families) want to know that their chil-
oo

oo

dren are normal and, if not, what the matter is. Would you
eb

eb

trust a doctor who failed to examine you, performed only a


e

cursory inspection or examined only the apparent present-


m

ing problem?
11
m

m
co

co
m

om
1 INTRODUCTION

co

c
e.

e.
•   History is the keystone

re

fre
•   Examine the whole child
•   See lots of children.
f
ks

s
ok
We shall not refer to investigation in this book, but rather
oo

refer you to your standard text.

o
eb

eb
I seek a method by which the teachers teach less and learners

e
m

m
learn more.
Comenius (1630)
m

m
Clinical binary principles
o

co
two ears to listen
.c

two eyes to look

e.
e

two hands to examine


re

two hemispheres to deduce


fre
f
ks

ks
oo

oo

The skilful doctor knows what is wrong by observing alone,


the middling doctor by listening, and the inferior doctor by
eb

eb

e
feeling the pulse.
m

m
Chang Chung-Ching (c150)
m

m
co

co
e.

e.
fre

fre
ks

ks
oo

oo
eb

eb

e
m

12
m

m
co

co
m

om
2
co

c
e.

e.
re History taking

fre
f
ks

s
ok
oo

o
eb

eb

e
m

m
m

m
o

co
.c

e.
e
re

fre
Listening to mothers   13 Talking to parents   27
Cue words   18 Breaking bad news to
f
ks

ks
A sample history   19 parents   30
Let the children speak   25
oo

oo
eb

eb

A smart mother makes often a better diagnosis than a poor

e
doctor.
m

m
August Bier (1861–1949)

LISTENING TO MOTHERS
m

m
co

co

The most important attribute of any good doctor is to be a


good listener. Listen carefully to mothers and note what they
e.

e.

say. History is the vital cornerstone of paediatric problem


fre

fre

solving. More important information is often gathered from


ks

ks

a good history than from physical examination and labora-


tory investigation.
oo

oo

The first important ground rule in history taking is:


eb

eb

mother is right until proved otherwise. Mothers are, by and


e

large, excellent observers of their offspring and make good


m

interpreters of their problems when sick. Even the most


13
m

m
co

co
m

om
2 HISTORY TAKING

co

c
e.

e.
ill-educated mother will often surprise you by her intuition.

re

fre
She may not know what’s wrong but she certainly knows
something is wrong. If a mother says, ‘I think my baby can’t
f
ks

s
hear properly’, the onus is on the doctor to corroborate or

ok
oo

negate that statement.

o
In our view no one can replace the mother in providing
eb

eb
an accurate and thorough description of the child and his

e
m

m
complaints. Fathers will vary in their expertise, but often
lack the information, insight and instinct that a good mother
can provide. While the principle that mother is usually right
prevails, the corollary must be that fathers can be off cue and
m

m
off course. However, the modern day domesticated father
o

co
is improving. Other caretakers – guardians, aunts, house-
.c

e.
mothers – will vary widely in their knowledge of the child.
e

We have been impressed by the inhibitory nature of some


re

fre
grandparents’ presence at initial interviews and history
f
ks

ks
taking.
At the outset it is important to try to establish a good
oo

oo

rapport with the mother. Allow her to understand that you


eb

eb

are more concerned with what she has to say than what Dr

e
X has suggested. Make sure you understand her idiom and
m

m
her concerns. A useful opening question is: ‘What do you
yourself think really is the cause of his trouble?’ or ‘Do you
have any views as to what is wrong with him?’
m

These questions may lead you in the right direction.


co

co

Alternatively, they may be important to negate following


examination and investigation. Get into the habit of quoting
e.

e.

verbatim from mother. Mothers frequently make statements


fre

fre

whose importance, if not noted and recorded during history


ks

ks

taking, may be subsequently lost. We both have the experi-


ence of saying to ourselves: ‘If only I had listened to that
oo

oo

mother; she was trying to tell me what was wrong’.


eb

eb

Students can unquestioningly accept a mother’s com-


e

plaints about her child without asking her to define her


m

terms. Terms such as ‘diarrhoea’ or ‘vomiting’ require defi-


14
m

m
co

co
m

om
HISTORY TAKING 2

co

c
e.

e.
nition. Does diarrhoea mean frequent stools, semi-formed

re

fre
stools, offensive stools? Do you (or mother) know the normal
frequency of stool passage? Is it reasonable to expect a teen-
f
ks

s
aged single parent to know children? What does the term

ok
oo

‘hyperactivity’ mean to you – are not all children active to

o
varying degrees?
eb

eb

e
m

m
Listen to mother talking
•   What are her worries?
•   What does she think?
m

m
•   Quote verbatim
o

co
•   Understand her idiom
.c

e.
•   Ask her to define her terms (What do you mean by . . . ?).
e
re

fre
You need to establish that you are both talking about the
f

same thing, be it croup, anorexia or breath-holding. You


ks

ks
oo

oo
eb

eb

e
m

m
m

m
co

co
e.

e.
fre

fre
ks

ks
oo

oo
eb

eb

e
m

Fig. 2.1  Listen attentively to mother.

15
m

m
co

co
m

om
2 HISTORY TAKING

co

c
e.

e.
need also to learn her local idiom or slang (for example the

re

fre
penis may be referred to as the ‘private parts’, ‘willy’ or
‘johnny’). In our hospital the residents have come to learn
f
ks

s
that when mothers say that the baby is ‘lobbing and lying’,

ok
oo

they mean something serious is wrong. Australian mothers

o
may state that the infant is ‘crook’.
eb

eb
One needs to know the questions which produce the

e
m

m
desired answers. A good opening ploy is, ‘Tell me about
your baby’, and then simply let the mother talk. As you gain
experience you will learn the important pointers and know
when to interject succinct questions without interrupting
m

m
her flow.
o

co
The student must of course take thorough notes inter-
.c

e.
spersed with pithy quotations or spicy titbits. In time you’ll
e

learn how to cut corners, how to proceed down diagnos-


re

fre
tic avenues and how to recognize important cues. Learn
f
ks

ks
through history taking (receiving) to be a good listener – to
parents primarily, but also to your better teachers as they
oo

oo

elicit clinical histories.


eb

eb

e
m

m
A poorly taken and recorded history
Cough × 3 days
m

Off feeds × 2 days


Wheeze × 1 day
co

co

Temperature × 1 day
e.

e.

Vomit × 2.
fre

fre

Many current charts contain such anecdotal and unexplored


ks

ks

facts. While the basic details are stated, there is inadequate


inquisition and description. The diagnosis may then be
oo

oo

recorded as ‘chest infection’, symptomatic of historical


eb

eb

haziness and clinical laziness.


e

Always ask the parents to relate the sequence of events


m

leading to the present complaints. A suitable start might


16
m

m
co

co
m

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HISTORY TAKING 2

co

c
e.

e.
be ‘When was he last well? Which came first, the cough or

re

fre
the wheeze? In what way has he changed?’ In eliciting the
history of a convulsion, details of the time, place, surround-
f
ks

s
ings, stimuli, etc., are of vital importance.

ok
oo

You will need also to obtain a general knowledge of the

o
child. What sort of fellow is he? Is he active? Has he much
eb

eb
energy? Is he outgoing, sociable? How does he sleep? Is

e
m

m
school progress satisfactory? Is he developing normally?
Whose side of the family does he resemble?
m

m
Let mothers talk
o

co
•   Tell me about your baby
.c

e.
•   What sort of fellow is he?
e
re

fre
•   When was he last well?
•   Tell me what happened.
f
ks

ks
Patients also appreciate a doctor who gives them individ-ual
oo

oo

attention and whose time is devoted to them (even though


he may be in a hurry). Listen and you will hear. Time spent
eb

eb

e
on history taking will be well repaid. Try to ensure that
m

m
your written notes reflect adequately the time taken and
interest shown. Some mothers do ‘beat about the bush’,
dragging in all sorts of irrelevancies. With experience you
m

will learn how to conduct and interrupt such garrulous


gabblers.
co

co

Any of your standard texts and tutors will cite examples


e.

e.

of how to fully explore a symptom, such as cough or pain.


fre

fre

When does it occur?


ks

ks

How long has he had it?


Can you describe it?
oo

oo

What brings it on?


eb

eb

Does anything relieve it?


e

How long does it last?


m

What is its pattern and periodicity?


17
m

m
co

co
m

om
2 HISTORY TAKING

co

c
e.

e.
Are there any associated symptoms?

re

fre
What does he do when he has it?
fWhat have you done about it?
ks

s
ok
This will necessarily be followed by a careful and thorough
oo

exploration of the relevant system, and then by a systems

o
eb

eb
review. With time and experience, systems reviews tend to

e
abbreviate and to become more precise. There is nothing
m

m
special or different in paediatrics about the necessity of
obtaining an adequate past history, family history and
social history. Awareness of the child’s place in the family,
m

m
relationship with parents, siblings and peers, is crucial in
o

co
obtaining a broad view of the child. So many of today’s
.c

illnesses have social and behavioural overtones that the

e.
e

importance of the holistic view cannot be overemphasized.


re

fre
A knowledge of the family’s socioeconomic status,
f

present financial situation, housing and employment is


ks

ks
vital. Are the parents married, separated, cohabiting? Is
oo

oo

the mother single? In some cases of handicap or metabolic


disorder it will be prudent to enquire cautiously about
eb

eb

consanguinity.

e
m

CUE WORDS
m
m

Computers accept key words; students ought to look out


for cue words when taking histories. By cue words we mean
co

co

simple statements, hidden in histories, which may be diag-


e.

e.

nostically alerting. Let us cite a few examples:


fre

fre

1.  Cue: ‘She does not like bread or biscuits.’


ks

ks

Think: Could this be gluten enteropathy?


2.  Cue: ‘He just loves salt; he even licks it from things.’
oo

oo

Question: Has he a salt losing state?


eb

eb

3.  Cue: ‘He’s hungry after he vomits.’


e

Answer: This is suggestive of mechanical vomiting, whether


m

due to pyloric stenosis or gastro-oesophageal reflux.


18
m

m
co

co
m

om
HISTORY TAKING 2

co

c
e.

e.
4.  Cue: ‘He’s always drinking, he’ll drink anything, he’ll even

re

fre
drink from toilet bowls.’
Response: This sounds like true polydipsia.
f
ks

s
5.  Cue: ‘I don’t know where all the food goes.’

ok
oo

Comment: When referred to a relatively inactive infant this

o
statement may suggest a malabsorptive state, for example
eb

eb
cystic fibrosis.

e
m

m
Mothers may, of course, unintentionally deceive. A common
complaint is: ‘I can’t get him to eat anything.’ And there in
front of you sits a solemn, pudgy infant sucking on a bottle
m

m
containing a mélange of milk, rusks, and maybe tea. In a
o

co
similar vein, the seemingly contradictory statements, ‘But
.c

he eats nothing doctor’ followed rapidly by ‘He never stops

e.
e

going’ are frequently encountered. They usually reflect the


re

fre
overactive (and perhaps under-disciplined) toddler who is
f

‘addicted to the bottle’ and is consuming excessive carbo-


ks

ks
hydrate by day and night.
oo

oo
eb

eb

A SAMPLE HISTORY

e
m

m
To obtain the right answers any detective must know how
to ask (and frame) the right questions. This simple maxim
applies to any system; nowhere is it more pertinent than
m

m
in taking a history of a fit or convulsion. In any convulsion
one needs to know as much as possible, about the child, his
co

co

environment and the surrounding circumstances.


e.

e.

However, by way of example of a thorough history we have


fre

fre

chosen the questioning of a mother whose child is wetting


the bed (enuretic). This common complaint, source of much
ks

ks

maternal irksomeness but often a dearth of medical interest,


oo

oo

exemplifies the value of detailed and diligent history taking.


eb

eb

What age is he?


e

Where does he come in the family?


m

When did the bed wetting commence?

19
m

m
co

co
m

om
2 HISTORY TAKING

co

c
e.

e.
How frequently does he wet?

re

fre
Does he wet by day?
fHow long can he retain his urine by day?
ks

s
Does he have a good stream?

ok
oo

Has he had any kidney infections?

o
When was he dry by day?
eb

eb
Was dryness achieved easily or with difficulty?

e
m

m
Has he his own bed?
Does he awake when he wets?
Does he waken more than once per night?
Is he in nappies at night?
m

m
Who changes the sheets?
o

co
Have you inside toilets?
.c

e.
What have you done about wetting?
e

Does he want to be dry?


re

Has he had any dry nights? fre


f
ks

ks
What was his best dry period?
Is he dry when away?
oo

oo

Have you lifted him?


eb

eb

Have you restricted his fluids?

e
Have you reprimanded or punished him?
m

m
How does he get on at home and in school?
Have medication or alarms been tried?
Did any of his siblings wet at night?
m

Were either of you (his parents) wet when children?


co

co

How does the wetting affect him?


How does the wetting bother you?
e.

e.
fre

fre

This may seem like a ream of questions but with experience


ks

ks

they can trip off the tongue promptly and buildup a picture
of the child and his problem. Bed wetting is one of those
oo

oo

complaints for which it can be useful to see the child and


eb

eb

mother both together and separately.


e

Similar interrogation in depth can be constructed for


m

a whole variety of symptoms from fits to fainting to


20
m

m
co

co
m

om
HISTORY TAKING 2

co

c
e.

e.
feeding difficulties. There is simply no substitute for

re

fre
a thorough history, properly phrased and fully recorded,
in diagnosing childhood disorders. Try writing one for
f
ks

s
asthma, abdominal pain or anaemia. Think of a suitable

ok
oo

programme of questions one might feed into a computer

o
and have the parents perform themselves while awaiting
eb

eb
consultation.

e
m

m
Did you know that it has been estimated that about 70%
of paediatric diagnoses are based mainly on history?
m

m
Summary 1
o

co
.c

Eight-year-old boy. Recurrent chest infections particularly in winter.

e.
Nocturnal cough. Persistent runny nose. Past history of eczema. No
e
re

fre
physical findings today.
Impression: Asthma.
f
ks

ks
oo

oo
eb

eb

Summary 2

e
Two-year-old girl. Six-month history of diarrhoea. Stools are messy,
m

m
loose and contain undigested food. Three to five bowel motions per
day. Good energy, appetite. Normal height and weight for age. Well
nourished. No findings.
Impression: Toddler diarrhoea (‘peas and carrots syndrome’).
m

m
co

co
e.

e.

Summary 3
fre

fre

Seven-year-old primary school girl. One-year history of staring, vacant


ks

ks

episodes noted by parents and teacher. Eyes flicker. Child stops


momentarily. Child not bothered by events. Carries on as if nothing has
oo

oo

happened. Episodes occur two to three times per week. Occasionally


two to three times per day. Normal intelligence, no past history, no
eb

eb

physical findings.
e

Impression: Primary generalized epilepsy (absence seizures).


m

21
m

m
co

co
m

om
2 HISTORY TAKING

co

c
e.

e.
The above examples show that a good history with the

re

fre
pertinent points abstracted is the best pointer to diagnosis
in paediatrics.
f
ks

s
ok
oo

Help strategy

o
eb

eb
H = History

e
m

m
E = Examination
L = Logical deduction
P = Plan of management
m

m
o

co
Feeding history
.c

e.
Feeding is such an intrinsic part of infancy, and feeding
e

problems so common, that a good history on feeding pattern


re

fre
and content is crucial. Too many doctors when presented
f
ks

ks
with a feeding problem change the milk. The problem does
not usually lie in the milk but in management of feeding
oo

oo

and in the mother–infant relationship (harmonious or other-


eb

eb

wise?). A detailed feeding history is vital if one is going to be

e
able to discuss diet with today’s allergy-conscious mothers.
m

m
Was the baby bottle or breast fed? If breast fed, what was
the duration of exclusive breast feeding? Was this a satisfy-
ing experience for mother and baby? How often did she
m

feed? Was he content? Were there any problems? How did


co

co

he sleep, feed and gain? Did she feed on demand or to some


sort of schedule? Was she complementing the breast milk
e.

e.

with anything else?


fre

fre

If bottle fed, was he fed on formula or unmodified cow’s


ks

ks

milk? Which formula did he receive? How was it prepared?


What volume did he take each feed and how long did he
oo

oo

take over it? Frequency of feeds? Total daily intake? Any


eb

eb

additives (iron or vitamins) given with milk? Duration of


e

exclusive milk feeding?


m

22
m

m
co

co
m

om
HISTORY TAKING 2

co

c
e.

e.
Weaning

re

fre
At what age were solids first introduced? Which solids?
f
ks

s
How were they administered – by spoon or in bottle?

ok
At what age were gluten-containing foods first given?
oo

Had he any preferences? When could he manage lumpy

o
eb

eb
food?

e
Any known food allergies? Why do you think he is aller-
m

m
gic to that substance? Does he suck well? Does he swallow
well? What stops him feeding? Is it, for example, satiety,
sleepiness or breathlessness? Were there weaning prob-
m

m
lems? How did you two get on? Did the father assist with
o

co
bottle feeding? Do you feed him every time he cries? Do you
.c

give him drinks of water?

e.
e

If all these questions fail to sort out the problem, one


re

fre
may have to resort to the request ‘Show me how you do it
f

please’.
ks

ks
Students can benefit from spending time doing nursing
oo

oo

duties – changing, washing, holding and above all feeding


babies. Learn by doing.
eb

eb

e
In conclusion, good history taking is the hallmark of the
m

m
good student of paediatrics. In all histories it is imperative
to get to the root of the problem. It may be worth repeating,
now that you have established rapport with the parent, the
m

following questions:
co

co

•   Remind me again, why did you bring your child along?
e.

e.

•   Just what are you worried about?


fre

fre

•   What do you think is wrong with him?


ks

ks

A full paediatric history will enquire along the following


general lines:
oo

oo
eb

eb

pregnancy
e

delivery
m

23
m

m
co

co
m

om
2 HISTORY TAKING

co

c
e.

e.
perinatal events

re

fre
feeding practice
fdevelopmental progress
ks

s
immunizations

ok
oo

infectious diseases

o
accidents and injuries
eb

eb
hospital admissions and operations

e
m

m
allergies
minor illnesses
medications
serial heights and weight, if known
m

m
school progress
o

co
travel.
.c

e.
e

During the taking of the history, preferably in relaxed sur-


re

fre
roundings, the opportunity should arise to observe how the
f

child separates from the parent, how creatively and inde-


ks

ks
pendently he plays, and occasionally how expressively he
oo

oo

draws.
eb

eb

e
m

m
The whole history and nothing but the whole history
The full facts
The precise sequence of complaints
Changes noted since onset of illness
m

m
co

co
e.

e.

Insofar as students are concerned, the Ten Commandments


fre

fre

of record keeping are:


ks

ks

Thou shalt write legibly


Thou shalt note the date and the time
oo

oo

Thou shalt record thorough histories and examinations


eb

eb

Thou shalt avoid abbreviations


e

Thou shalt write a succinct summary


m

Thou shalt list the important problems


24
m

m
co

co
m

om
HISTORY TAKING 2

co

c
e.

e.
Thou shalt make a diagnosis or, if not possible,

re

fre
Thou shalt assemble a differential diagnosis
Thou
f shalt sign thy name and status
ks

s
Thou shalt not alter entries.

ok
oo

o
LET THE CHILDREN SPEAK
eb

eb

e
While we repeatedly emphasize the value and importance
m

m
of a mother’s history of her child’s complaints, don’t forget
the child. He may be very anxious to tell you his story and
may have a useful contribution to make. Often, especially if
m

m
he’s verbally precocious and outgoing, or if he has a chronic
o

co
condition and much experience of hospital, he may express
.c

e.
himself remarkably lucidly. Children need to be heard and
e

be seen to be noticed. They have a viewpoint which they are


re

fre
frequently eager to express. Children over 5 years should be
f
ks

ks
asked to give their account of events with parental corrobo-
ration of certain points. One brief example. We recently saw
oo

oo
eb

eb

e
m

m
m

m
co

co
e.

e.
fre

fre
ks

ks
oo

oo
eb

eb

e
m

Fig. 2.2  Let the children speak!

25
m

m
co

co
m

om
2 HISTORY TAKING

co

c
e.

e.
re

fre
f
ks

s
ok
oo

o
eb

eb

e
m

m
m

m
o

co
.c

e.
e
re

fre
f
ks

ks
Fig. 2.3  An anxious mother with ill baby.
oo

oo
eb

eb

e
m

m
a bright 10-year-old boy with a proven duodenal ulcer. He
described his pain as being ‘like a laser beam going through
my stomach’. Brilliant!
m

If he’s reticent, shy or mute don’t push him. He may talk


co

co

later. Allowing him to draw himself, his family, their home


may be revealing to those with psychological insight. Use
e.

e.

of a tape recorder, or even a video (if your Department of


fre

fre

Child Health is well equipped) can be useful, particularly


ks

ks

in exploring behavioural or conduct problems.


Make sure you know the child’s pet name as well as his
oo

oo

given name. Laurence may be called ‘Larry’, Robert ‘Bobby’


eb

eb

and Catherine ‘Katie’. In addition, the child recorded as


e

Patrick Joseph, may in fact be called ‘Junior’.


m

26
m

m
co

co
m

om
HISTORY TAKING 2

co

c
e.

e.
TALKING TO PARENTS

re

fre
Parental anxiety is difficult to assess and can vary in degree
f
ks

s
from mild concern to severe emotional upset, sometimes

ok
oo

culminating in aggressive behaviour. Being comfortable in

o
discussions with parents comes from experience and obser-
eb

eb
vation of the approach used by more senior colleagues.

e
Although there is no single correct approach, one must
m

m
adapt to the great variation in paediatric conditions, from
neonatal anomalies, through children with disabilities, to the
otherwise healthy child with an acute illness. Preferably,
m

m
both parents should be present, with the exclusion of other
o

co
relatives unless parents insist.
.c

e.
In many cases both doctor and parents are strangers
e

to each other. The initial approach will be a mutual assess-


re

fre
ment. A quick appraisal of the age of the parents, their
f
ks

ks
education and social status may be helpful to the physi-
cian. It is important to show respect for the parents and,
oo

oo

where possible, to avoid interruption during the discussion.


eb

eb

Always use the child’s name and be fully briefed in relation

e
to age, previous history and if necessary sibling history.
m

m
If appropriate, the child should be present and language
and communication should reflect respect for the child
concerned.
m

It is important to be as factual as can be whatever the


co

co

circumstances, at the same time explaining the limitations


of professional knowledge. When asked about statistical
e.

e.

or percentage chances of recovery be careful to point


fre

fre

out that each child is an individual. It is also pertinent in


ks

ks

present times to have a witness from either medical or


nursing staff present and to make a detailed note in the
oo

oo

patient’s chart.
eb

eb

Good listening is contributory to learning; good commu-


e

nication is the key to cooperative caring.


m

27
m

m
co

co
m

om
2 HISTORY TAKING

co

c
e.

e.
Parents of ill children broadly seek four degrees of

re

fre
information
f
1.  What is it? What is wrong?
ks

s
2.  What caused it? How did it happen?

ok
3.  What will be the outcome?
oo

o
4.  Will it happen again?
eb

eb

e
m

m
Clearly the answers to the above questions will consid-
erably depend on whether the child’s disorder is an acute
one (e.g. meningitis) or whether it is an inherited abnor-
m

m
mality (e.g. cleft palate). It is evident that one has difficulty
o

co
responding to questions 2, 3 and 4 if one cannot answer
.c

e.
question 1. Students should be reticent about discussing
e

causes and consequences with parents until they possess


re

fre
the appropriate acumen and authority. Finally, don’t forget
f
ks

ks
the unvoiced (fifth) question:
Is it leukaemia, or cancer, or some lethal familial trait?
oo

oo

Could we, at the risk of sounding old fashioned and


eb

eb

conservative, remind students to dress presentably. In your

e
final years you are dealing with people as a trainee doctor
m

m
rather than a science student. Many studies have shown that
m

PHYSICAL EXAMINATION
co

co


e.

e.

normality established abnormality detected


↓ ↓
fre

fre

parents reassured abnormality confirmed


ks

ks


oo

oo

abnormality investigated

eb

eb

proceed as appropriate
e
m

Fig. 2.4  Algorithm for action in consulting.

28
m

m
co

co
m

om
HISTORY TAKING 2

co

c
e.

e.
parents interact reluctantly with shabby, unshaven, scruffy

re

fre
students.
An initial office consultation perhaps should be the easiest
f
ks

s
to deal with. However, interpreting the history given – which

ok
oo

may vary from one parent to another – can take time.

o
At some point you should ask the direct question, ‘Is
eb

eb
there some serious condition that you are worried or have

e
m

m
read about?’ The answer, in many cases, will get to the root
of the problem, from where one can embark on physical
assessment, appropriate investigations and possibly early
management. (It is advisable to avoid meeting with relatives
m

m
other than the parents, as in such circumstances the history
o

co
may become more confusing.) In this day and age one must
.c

e.
be prepared for extensive knowledge of some conditions
e

acquired by parents from the internet, but remember that


re

fre
f
ks

ks
oo

oo
eb

eb

e
m

m
m

m
co

co
e.

e.
fre

fre
ks

ks
oo

oo
eb

eb

Fig. 2.5  In this day and age extensive knowledge can be acquired from
m

the internet.

29
m

m
co

co
m

om
2 HISTORY TAKING

co

c
e.

e.
interpretation of such information is where the problem

re

fre
may lie.
f
ks

s
ok
BREAKING BAD NEWS TO PARENTS
oo

o
As an undergraduate student, don’t. You lack the authority,
eb

eb
experience and acquired empathy. You can, however, learn

e
m

m
the necessary attributes through communication skills exer-
cises (videoed and later discussed), or better by sitting in on
real scenarios in the hospital. Telling the parents that their
newborn baby has Down’s syndrome, or that their toddler
m

m
has serious meningitis, or that the infant they rushed in for
o

co
resuscitation has in fact died is always difficult, draining
.c

e.
and demanding. The impact of bad news can be lessened if
e

done quietly, sensitively and responsively.


re

fre
f

•   Speak slowly and simply


ks

ks
•   Avoid medical terms
oo

oo

•   Be as clear and concise as you can


•   Don’t try to transmit too much information
eb

eb

e
•   Ask for questions
m

m
•   Always have a nurse present
•   Express your sympathy.

Never, never give bad news over the telephone. Give the
m

news in private, appropriate surroundings. Allow parents


co

co

time to express their shock, grief, guilt, anger, or whatever


emotion.
e.

e.
fre

fre
ks

ks
oo

oo
eb

eb

e
m

30
m

m
co

co
m

om
HISTORY TAKING 2

co

c
e.

e.
Key paediatric points

re

fre
Listen to mothers and note their concerns
f
Preverbal children’s ability to communicate is limited. Learn to
ks

s
appreciate ‘body language’ and acquire some skills in observation (see

ok
p. 79)
oo

o
Certain illnesses have predilections for certain ages:
eb

eb
bronchiolitis   <1 year

e
laryngotracheobronchitis   <3 years
m

m
transient synovitis   <5 years
slipped upper femoral epiphysis ~10 years.
As parents prepare to leave a discussion, always conclude by asking
m

m
whether there are any points not clearly understood, or whether there
are any further questions which they may have forgotten to ask.
o

co
.c

e.
e
re

fre
f
ks

ks
oo

oo
eb

eb

e
m

m
m

m
co

co
e.

e.
fre

fre
ks

ks
oo

oo
eb

eb

e
m

31
m

m
co

co
m m m
eb eb eb
oo oo oo
ks ks ks
fre fre f re
e. e .c e.
co co o co
m m m m
m m m
This page intentionally left blank

eb eb eb
oo oo o ok
ks ks s
fre fre fre
e. e. e.
co co co c
m m m om
m m m
e e e
m

om
3
co

c
e.

e.
re Approaching

fre
f
children
ks

s
ok
oo

o
eb

eb

e
m

m
m

m
o

co
.c

e.
e
re

fre
The approach code   33 Putting it together   44
Things not to do   39 I don’t know   47
f
ks

ks
Point to the part which Diagnostic logic   47
hurts   41 Syndrome recognition   48
oo

oo
eb

eb

Good current practice would suggest that all children of any

e
age be examined by medical students only in the presence of
m

m
a parent, guardian, nurse or chaperone. Examining children
in the absence of a parent should only be carried out with
their parent(s) consent and with the child’s cooperation if
m

old enough to give it.


co

co
e.

e.

THE APPROACH CODE


fre

fre

The first rules in approaching any child are very similar


ks

ks

to those for crossing the road – stop, listen, look, then use
your senses. The first approach is a hands-off one – stop.
oo

oo

Allow the child to look at you and, insofar as he can, decide


eb

eb

you are a person to be trusted. Let him look at you as


e

you talk to his mother. Take your time, make no sudden


m

moves (for you may frighten a fretful toddler) and be in no


33
m

m
co

co
m

om
3 APPROACHING CHILDREN

co

c
e.

e.
hurry to examine the child. Even better, let him play in your

re

fre
presence. Approach cautiously, be nice and utter reassuring
sounds.
f
ks

s
Listen to the mother. Children may come to the clinic,

ok
oo

surgery or hospital in the company of a variety of caretakers

o
(mother, father, guardian, foster-parent, nurse, relative). In
eb

eb
our view, there is no substitute for the mother. She knows

e
m

m
her child. The guiding principle in listening is: mother is
usually right until or unless proved otherwise. We have
expanded on this in Chapter 2. At the same time you may
have the opportunity to listen to the child talk, relate to his
m

m
mother, and to note his breathing, cough, stridor (if present)
o

co
and other auditory phenomena such as his cry.
.c

e.
Then look. Look at both mother and child. Is he sick
e

or well? Is he normal or abnormal? Does he resemble his


re

fre
parents? Always look at children without staring or looking
f
ks

ks
too closely at them. Some toddlers share attributes with
certain animals who do not like being stared at. Any instinc-
oo

oo
eb

eb

e
m

m
m

m
co

co
e.

e.
fre

fre
ks

ks
oo

oo
eb

eb

e
m

Fig. 3.1  Stop!

34
m

m
co

co
m

om
APPROACHING CHILDREN 3

co

c
e.

e.
re

fre
f
ks

s
ok
oo

o
eb

eb

e
m

m
m

m
o

co
.c

e.
e

Fig. 3.2  Listen!


re

fre
f
ks

ks
oo

oo
eb

eb

e
m

Fig. 3.3  Look!


m
m

tual clues? One must teach students to observe. Any obser-


co

co

vational cues?
e.

e.

Learn to see things.


fre

fre

Leonardo da Vinci
ks

ks

The approach code


oo

oo

Stop
Listen
eb

eb

Look
e

Use your other senses


m

35
m

m
co

co
m

om
3 APPROACHING CHILDREN

co

c
e.

e.
Children are best approached in their position of com-

re

fre
fort – lying flat in infancy, sitting on their mother’s knee
in toddler-hood, on their own two feet when of school
f
ks

s
age. Leave undressing to later – removal of clothes can

ok
oo

be a threatening manoeuvre. Explain what you are about to

o
do and be reassuring repeatedly. Don’t lie the child down
eb

eb
until you have to – he’s very vulnerable in this position.

e
m

m
Keep his mother close at hand. Always leave unpleasant
procedures – throat examination, rectal examination –
until the very last and don’t do unless you feel they will be
contributory.
m

m
Learn by listening to mothers, examining their children
o

co
and then reading the chart. Too often students first read
.c

e.
the notes and then go in search of what they are supposed
e

to find. Students should at times take the opportunity of


re

fre
divesting their white coats – white coats bring needles and
f
ks

ks
tests.
Never examine the presenting part only. From your earli-
oo

oo

est days train yourself to be thorough, and to be a generalist


eb

eb

as opposed to a systems specialist. Remember one of the

e
basic axioms – the good doctor treats the whole person, not
m

m
just the sore belly or foot.
In summary, the best approach to infants and toddlers
is to begin examination with a strict no touch technique. Be a
m

good looker.
co

co

Look with all your eyes, look!


e.

e.

Jules Verne
fre

fre

In small infants inspection (of colour, breathing, activity, etc.)


ks

ks

can be the key to diagnosis. Physical signs are frequently


less florid in sick infants than they are in sick adults; stu-
oo

oo

dents tend to be well trained in the arts of palpation and


eb

eb

percussion, at the expense of inspection. We would agree


e

with the words of Sir Dominic Corrigan (1853): ‘The trouble


m

with many doctors is not that they do not know enough but
36
m

m
co

co
m

om
APPROACHING CHILDREN 3

co

c
e.

e.
that they do not see enough.’ Remember the importance

re

fre
of non-verbal communication. When you have looked,
describe what you see. It is strange how difficult it can be
f
ks

s
to translate the observations into words. To say for example

ok
oo

‘funny looking kid’ (a pejorative term, objectionable to some)

o
without being able to describe what is ‘funny’ is ludicrous.
eb

eb
The road to diagnosis in many dermatological problems is

e
m

m
to set down in words (of English or literate Latin) what one
sees. All too often the descriptive terms elude the student
and he jumps at diagnoses like a salmon at flies.
Syndrome spotting is in the eye and mental computer
m

m
of the beholder. Students need not be syndrome spot-
o

co
ters. However, they should be able to recognize Down’s
.c

e.
syndrome, obvious congenital abnormalities, or significant
e

dysmorphism.
re

fre
First know the normal. Then the abnormal or different
f
ks

ks
may become apparent. Ask yourself, ‘What’s odd about this
face?’ Then describe in simple terms those relevant features
oo

oo

– wide eyes, low-set ears, upturned nose, arched palate –


eb

eb

which contribute to your suspicions.

e
You should try to examine as much with your eyes as
m

m
with your hands. You should also try to listen to the child
‘speaking with his body’ – noting that many childhood
physical complaints have a background behavioural basis.
m

Use your other senses – touch, smell, taste (occasionally) –


co

co

to aid in diagnosis. These we will expand upon later. The


child’s doctor needs to be gentle of touch (cold hands-warm
e.

e.

heart theorizing just will not do), to be able to extemporize


fre

fre

(in other words to do what you can when you can and not
ks

ks

to adhere to a rigid, regimented approach to examination),


but to be thoroughly sensitive and sensible.
oo

oo

It will be frequently necessary to humour the baby or to


eb

eb

distract an infant’s attention when attempting examination.


e

The distraction tricks (common sense really!) described


m

below may help:


37
m

m
co

co
m

om
3 APPROACHING CHILDREN

co

c
e.

e.
•   play with babies, infants and children

re

fre
•   tickle babies (tickles appear at 3 months)
•   play ‘peek-a-boo’
f
ks

s
•   blow ‘raspberries’ at babies

ok
oo

•   blow on their faces (they quite like this)

o
•   allow toddlers to play with the examining instruments
eb

eb
•   give infants something to hold

e
m

m
•   get mother to dangle an attractive toy or bright light
•   talk nonsense/rubbish to young children – they’ve quite a
good sense of humour and may think you’re a likeable idiot.
m

m
You can do anything with children if you only play with
o

co
them.
.c

Otto von Bismarck (19th century)

e.
e

Shake hands with children: curiously, even toddlers may


re

fre
appreciate this formality. Hopefully you have allowed him
f
ks

ks
oo

oo
eb

eb

e
m

m
m

m
co

co
e.

e.
fre

fre
ks

ks
oo

oo
eb

eb

e
m

Fig. 3.4  Establish good eye contact and rapport with the child.

38
m

m
co

co
m

om
APPROACHING CHILDREN 3

co

c
e.

e.
to establish eye contact with you; social sensory contact may

re

fre
facilitate you in applying your examining hands. In other
words, before you start, try to strike a rapport.
f
ks

s
Before proceeding to discuss detailed physical exami-

ok
oo

nation of different ages and various parts of children, we

o
would remind you of the four Cs of clinical examination
eb

eb
which you should aim to achieve:

e
m

m
•   confidence – of child in you (and you in yourself)
•   competence – in handling children
•   completeness – of examination
m

m
•   collation – can you sum up and draw conclusions from
o

co
what you’ve found?
.c

e.
e
re

THINGS NOT TO DO
fre
f
ks

ks
Do not get the gender of the child wrong. This is understand-
ably upsetting to parents. They begin to wonder if it is their
oo

oo

child you are talking about. Never refer to a child as ‘it’. This
eb

eb

is a frequent failing, sure to raise the ire of certain colleagues

e
and examiners.
m

m
Never handle a child roughly. Gentleness must be the
hallmark of a good child’s doctor. Apley used to preach: ‘It’s
my fault if the child cries.’ One need not go as far as this,
m

but must attempt not to cause distress during physical


co

co

examination.
Do not speak derogatively in front of children. Even
e.

e.

little ears are more attuned to doctors’ talk than you


fre

fre

may think. Never refer to a child as an ‘FLK’ (funny


ks

ks

looking kid) in front of the parents or without first


seeing the parents. The term ‘dysmorphic’ might be more
oo

oo

appropriate.
eb

eb

Do not drop the baby; they can be slippery, wriggly


e

creatures especially if covered in vernix caseosa. Our expe-


m

rience of a student dropping a baby (fortunately without


39
m

m
co

co
m

om
3 APPROACHING CHILDREN

co

c
e.

e.
re

fre
f
ks

s
ok
oo

o
eb

eb

e
m

m
m

m
o

co
.c

e.
e
re

fre
f
ks

ks
Fig. 3.5  Don’t handle children roughly.
oo

oo
eb

eb

e
harm) when demonstrating the Moro reflex to examiners
m

m
was salutary.
Do not use potentially worrying terms in front of parents
without explaining them. The term ‘pyloric tumour’ may
m

seem innocuous to you. However, to the layman, tumour


co

co

implies cancer. Similarly, we have given the diagnosis


‘benign recurrent haematuria’ to parents with explanation
e.

e.

and reassurance, without realizing that some of them had


fre

fre

interpreted the word ‘benign’ to imply that the urinary


ks

ks

blood was coming from a benign cancer of the kidney. It is


often prudent to tell parents of children who are anaemic,
oo

oo

‘Of course, it’s not leukaemia’. Fear of cancer lurks in many


eb

eb

a parental mind, at times and on occasions when it never


e

occurs to their attending doctors.


m

40
m

m
co

co
m

om
APPROACHING CHILDREN 3

co

c
e.

e.
Do not misjudge the child’s age – children are remark-

re

fre
ably sensitive on this score. Better to overestimate than to
underestimate age.
f
ks

s
Do not disrespect the child’s intrinsic modesty – which

ok
oo

will vary between and within societies. Some children will

o
not mind being fully undressed; others may need explana-
eb

eb
tion or a compromise.

e
m

m
POINT TO THE PART WHICH HURTS
Pain is a common reason for paediatric consultation. Clearly
m

m
the bulk of the history concerning pain will be sought from
o

co
the parents. However, you must always ask the child to try
.c

e.
to describe his pain.
e

The preschool child will certainly lack the vocabulary and


re

fre
communication skills to describe his pains, but can surely
f
ks

ks
point them out. So ask him to show you the spot which
hurts. He can often pinpoint the appropriate place.
oo

oo

The older child should be asked to describe his pain,


eb

eb

always checking with the parent his accuracy and veracity.

e
A good mother will frequently coax the child without being
m

m
asked: ‘It’s your pain, try to tell the doctor about it’.
Where is the pain?
m

Show me where it is?


What is it like?
co

co

What do you do when you get it?


e.

e.

Does it make you cry?


fre

fre

If the child can point to the spot, this should be reflected


ks

ks

in your notes – ‘left temporal headache’ rather than just


‘headache’, or ‘pain both upper thighs at night’ rather than
oo

oo

merely ‘limb pains’.


eb

eb

A toddler or preschool child may resist abdominal


e

examination. In the first instance distraction techniques


m

41
m

m
co

co
m

om
3 APPROACHING CHILDREN

co

c
e.

e.
re

fre
f
ks

s
ok
oo

o
eb

eb

e
m

m
m

m
o

co
.c

e.
e
re

fre
f
ks

ks
oo

oo
eb

eb

e
Fig. 3.6  Ask the child to point to the part which hurts.
m

may be tried. If these fail, use the child’s hand to guide m


m

yours around the abdomen. A fretful child may allow you


co

co

to assess abdominal pain or tenderness in this fashion.


One not infrequently meets the child with recurrent
e.

e.

abdominal pain who is ‘jumpy’ and who seems to demon-


fre

fre

strate tenderness on palpation, especially in the right iliac


ks

ks

fossa. If in doubt as to the significance of this ‘tenderness’


a useful ploy is to say, ‘I’m just going to listen with my
oo

oo

stethoscope’. Lay it gently on the abdomen and do indeed


eb

eb

listen but gradually increase the pressure. Often, quite


e

firm pressure can be tolerated where previously there was


m

‘tenderness’.
42
m

m
co

co
m

om
APPROACHING CHILDREN 3

co

c
e.

e.
re

fre
f
ks

s
ok
oo

o
eb

eb

e
m

m
m

m
o

co
.c

e.
e
re

fre
f
ks

ks
Fig. 3.7  Small children may allow you to palpate the abdomen over
oo

oo

their own hand.


eb

eb

e
m

m
The child whose pain moves about in erratic fashion, cross-
ing anatomical boundaries and disobeying dermatomes,
needs to be taken with a grain of salt. Conversely, the child
m

whose pain wakes him from his sleep, disturbs pleasurable


activities or causes him to cry needs to be heeded.
co

co

Unwillingness to move or use a limb may suggest pain


e.

e.

therein. Dislike of being handled is typical of meningism.


fre

fre

Pleuritic pain may be evident by splinting of only one side


of the chest – which is an infrequent, subtle sign missed even
ks

ks

by experienced paediatricians. Small children have similari-


oo

oo

ties with pets – when sick or sore they lie down without
having to be told to do so.
eb

eb

The only time children tell the truth is when they are in pain.
m

Bill Cosby
43
m

m
co

co
m

om
3 APPROACHING CHILDREN

co

c
e.

e.
re

fre
f
ks

s
ok
oo

o
eb

eb

e
m

m
m

m
o

co
.c

e.
e
re

fre
f
ks

ks
oo

oo

Fig. 3.8  Using the stethoscope to assess abdominal tenderness.


eb

eb

e
m

m
We don’t agree entirely with the above statement, but do
accept the sentiment that childhood pain is not figmentary.
m

PUTTING IT TOGETHER
co

co

Insofar as undergraduate students are concerned, diagnosis


e.

e.

per se is not important. What is important is the ability to


fre

fre

take a thorough history, elicit the relevant physical signs


ks

ks

following examination, and attempt to interpret them. On


the basis of the history and physical findings, the student
oo

oo

may be able to construct a diagnosis, or a series of possible


eb

eb

diagnoses.
e

Students must be prepared to write down their findings


m

for public scrutiny. One can afford to be wrong as a student


44
m

m
co

co
m

om
APPROACHING CHILDREN 3

co

c
e.

e.
and learn from these mistakes. Being wrong may be a dent

re

fre
to one’s doctoring dignity once qualified – in our opinion
we should be more often prepared to say, ‘I don’t know,
f
ks

s
but I’ll look it up’. Students could usefully cultivate the

ok
oo

practice of writing down things they don’t understand, or

o
findings whose explanation is unclear (for example: What
eb

eb
is the physiology of yawning?), and of seeking the answers.

e
m

m
One should attempt to come to conclusions on the com-
pletion of history and physical examination. For example:
m

m
Problems
o

co
1.  Febrile convulsion
.c

e.
2.  Follicular tonsillitis
e

3.  Innocent murmur.


re

fre
f

It may be useful to add a postscript:


ks

ks
oo

oo

Mother’s worries
eb

eb

1.  Brain damage

e
m

m
2.  Nephew died of meningitis

and to deal with these prior to discharge.


If less sure of one’s conclusions the ‘bottom line’ may
m

read:
co

co

Impression
e.

e.
fre

fre

1.  Failure to thrive


2.  Possible anaemia
ks

ks

3.  Consider malabsorption.


oo

oo

Note: Small, poor parents, no previous measurements.


eb

eb

It should be stated that differential diagnosis tends to


e

play a less important part in paediatrics than in adult medi-


m

cine, in that many childhood illnesses are straightforward


45
m

m
co

co
m

om
3 APPROACHING CHILDREN

co

c
e.

e.
uncomplicated entities compared with the complicated,

re

fre
cumulative, degenerative conditions of adulthood. None­
theless one may have to consider and construct a differential
f
ks

s
diagnosis for diffuse lymphadenopathy, polyarthritis, acute

ok
oo

encephalopathy, ataxia, haematuria, and many other clinical

o
conditions.
eb

eb
Today’s computer-literate students may like the key word

e
m

m
approach: writing down the important positive findings
plus relevant negative findings and attempting to compute
an answer:
m

m
erythematous rash
o

co
Raynaud’s phenomenon
.c

pauciarticular arthritis

e.
e

alopecia
re

weight loss
fre
f

swollen parotid gland.


ks

ks
The above example suggests a connective tissue disorder.
oo

oo

In recording the physical findings of children with mul-


eb

eb

tiple or chronic disorders, the problem-based approach has

e
much to recommend it. Table 3.1 shows an example from
m

m
the notes of a child with spina bifida.
The list could be extended further, but we hope you
have got the message. Detection and diagnosis of problems
m

m
co

co

Table 3.1  Example of a problem-based approach


e.

e.

Problem Plan
fre

fre

Myelomeningocele Repaired after birth


Hydrocephalus, Check function
ks

ks

   ventriculoperitoneal shunt
Moderate scoliosis Physiotherapy, posture
oo

oo

Constipation Discuss diet, nursing


Urinary incontinence Self-catheterization?
eb

eb

Short stature No action


e

Lower limb paralysis Physiotherapy, walking devices


m

46
m

m
co

co
m

om
APPROACHING CHILDREN 3

co

c
e.

e.
is only useful if it can lead to a plan of action for their

re

fre
improvement.
f
ks

s
ok
I DON’T KNOW
oo

o
Teach thy tongue to say:
eb

eb

e
I do not know.
m

m
Maimonides (1135–1204)

Doctors like to surround themselves with an aura of omnis-


cience (how many doctors will consult a text in front of
m

m
patients?). Students are not expected to know everything. If
o

co
asked a question of which you don’t know the answer, be pre-
.c

e.
pared to say so rather than hazarding guesses. But you must
e

later be prepared to look for the answer, solution or informa-


re

fre
tion or to ask the appropriate people to help you in finding out.
f
ks

ks
A constantly questioning mind will serve you well during
your career. The back pages of this text could well be filled
oo

oo

with questions seeking answers. Above all don’t be shy in


eb

eb

asking. Simple questions often provide fascinating answers.

e
m

m
DIAGNOSTIC LOGIC
The purpose of consultation between doctors and parents
m

of sick children is to establish the cause of their concerns,


co

co

to reach, if possible, a diagnosis and to formulate a plan


of appropriate investigation and management. Diagnosis is
e.

e.

essentially a process of deductive logic.


fre

fre

The history, properly taken, establishes facts. Productive


ks

ks

histories will depend on attentive listening and knowing


when and where to ask the salient questions.
oo

oo

The physical examination, properly conducted, should


eb

eb

produce the findings. The facts and findings are collated and
e

hopefully clinical reasoning will suggest a diagnosis or a dif-


m

ferential diagnosis. This entails considering and weighing the


47
m

m
co

co
m

om
3 APPROACHING CHILDREN

co

c
e.

e.
relevant facts and findings, or producing a problem list. The

re

fre
good student excels by the ability to summarize and synthe-
size the critical information gleaned from clinical consultation.
f
ks

s
We often, in our clinics, ask students:

ok
oo

•   Have you formed an impression of the problem(s) presented?

o
eb

eb
•   Can you summarize the key problem?

e
•   Are you approaching a definite diagnosis?
m

m
•   Can you hypothesize a differential diagnosis and weigh the
evidence?

Think of the critical information you would need to collect


m

m
to answer the following clinical scenarios:
o

co
.c

•   7-year-old child still bed-wetting

e.
e

•   8-year-old girl with early breast development


re

•   toddler with multiple forehead bruises


fre
f

•   2-year-old child with only monosyllables.


ks

ks
The good diagnostician picks up the alerting cues and clues,
oo

oo

asks probing questions, and thinks logically: an amalgam of


eb

eb

common sense, instinct, experience and observation.

e
m

m
Observe, record, tabulate, communicate, use your five senses.
William Osler

The well child is lively, a good colour, interactive, usually


m

obliging and able to perform all of your clinical requests


co

co

promptly and reliably. Well children will be seen for exami-


nation in general practitioner clinics, at child welfare clinics,
e.

e.

and at school medicals. Do please practise examination of


fre

fre

well children when permitted!


ks

ks
oo

oo

SYNDROME RECOGNITION
eb

eb

Undergraduate medical students do not need to be experts


e

on recognizing syndromes and major congenital malforma-


m

tions, but they ought to initiate the fundamentals in rec-


48
m

m
co

co
m

om
APPROACHING CHILDREN 3

co

c
e.

e.
re

fre
f
ks

s
ok
oo

o
eb

eb

e
m

m
m

m
o

co
.c

e.
e
re

fre
f
ks

ks
oo

oo
eb

eb

e
m

m
Fig. 3.9  An obviously well child.
m

ognizing and describing dysmorphic infants and children.


Let’s start with Down’s syndrome, the most frequent chro-
co

co

mosomal abnormality seen in paediatric practice. The secret


e.

e.

is to describe what you see, pick up the cues, and assemble


fre

fre

the key words:


ks

ks

•   small head


•   round face
oo

oo

•   epicanthic folds


eb

eb

•   protruding tongue


e

•   short stature


m

•   anteverted nose


49
m

m
co

co
m

om
3 APPROACHING CHILDREN

co

c
e.

e.
•   transverse palmar creases

re

fre
•   stubby fingers
•   short fifth finger
f
ks

s
•   hypotonia

ok
oo

•   delayed motor and cognitive development

o
•   many associated medical problems.
eb

eb

e
The other trisomies, Edwards and Patau’s syndromes, are
m

m
rarely seen in children’s wards since early demise is the norm.
Turner’s syndrome, by contrast, is much more subtle. The
classic textbook example of XO syndrome (neck webbing,
m

m
wide nipples, lymphoedema of hands and feet, short stature)
o

co
is not that commonly seen and many examples of Turner’s
.c

e.
syndrome may be XX/XO mosaics or other chromosomal
e

variations.
re

fre
Students spending some of their paediatric rotation in a
f
ks

ks
tertiary centre may see children with mucopolysaccharidoses
(Hurler’s + variants), chromosome 22 deletion syndrome
oo

oo

(cardiofacial syndrome), fetal alcohol syndrome and exam-


eb

eb

ples of achondroplasia. All that is expected of undergradu-

e
ate students is an attempt to describe the dysmorphisms,
m

m
an initial ability to assemble key words, and a basic idea of
where next to consult. Computer-literate students may know
of OMIM (Online Mendelian Inheritance in Man) or their
m

library may possess the London Dysmorphology Database


co

co

or Australian POSSUM programme. The best reference text is


Smith’s Recognizable Patterns of Human Malformation.
e.

e.

A deceased dysmorphology colleague used to ask stu-


fre

fre

dents: ‘How do you recognize your Aunt Molly?’ Answer:


ks

ks

‘Because you’ve seen her before’! A good look, a little knowl-


edge and a programmed computer is all that undergradu-
oo

oo

ate students require. Postgraduate students and paediatric


eb

eb

trainees will be expected to develop their clinical skills,


e

prime their senses, and progressively recognize paediatric


m

syndromes with experience and maturation.


50
m

m
co

co
m

om
4
co

c
e.

e.
Examination at
re

fre
f
different ages
ks

s
ok
oo

o
eb

eb

e
m

m
m

m
o

co
.c

e.
e
re

fre
Newborn   51 The acutely ill infant   79
Six-week examination   74 The terrified toddler   83
f
ks

ks
oo

oo
eb

eb

e
Paediatrics is a specialty bound by age and not by system.
m

m
Apley

NEWBORN
m

m
co

co

The great majority of newborn infants have had a normal


intrauterine existence, a normal delivery, are in good condi-
e.

e.

tion at birth and are physically normal. However, there is


fre

fre

a considerable variation in size and shape and appearance


ks

ks

within the normal, which depends on parental, familial,


genetic and ethnic factors. The foundation stone of paedi-
oo

oo

atric medicine is only laid when the student has personally


eb

eb

examined a large number of normal neonates, infants, tod-


e

dlers, preschool and older children. The message, therefore,


m

is: know the normal spectrum.


51
m

m
co

co
m

om
4 EXAMINATION AT DIFFERENT AGES

co

c
e.

e.
Delivery room

re

fre
All newborns should be examined at birth to observe
f
ks

s
the general condition and to rule out major anomalies.

ok
The Apgar score (Table 4.1) is valuable because it determines
oo

whether resuscitation is necessary or not, and it is interna-

o
eb

eb
tionally accepted. A poor score (<5) at 5 minutes appears

e
to relate to long-term development. Examination of the
m

m
cord for a single artery may be of some value as to the
possibility of as yet hidden abnormalities. Having
established that the baby does not require special or inten-
m

m
sive care, and is overtly normal, the parents are accordingly
o

co
informed.
.c

e.
e

Postnatal ward
re

fre
f

A further examination is usually carried out on the third


ks

ks
day, at which time the baby is almost unrecognizable from
oo

oo

the one examined at delivery – skin nice and pink, head


assuming normal shape, hair combed and feeding well. The
eb

eb

e
examination at this stage is much more detailed. The mother,
m

m
m

m
Table 4.1  Apgar score
Sign Score
co

co

0 1 2
e.

e.

Colour Blue, pale Pink trunk Pink all over


fre

fre

Blue extremities
Heart rate Absent <100 > 100
ks

ks

Reflex None Grimace Cry


   irritability
oo

oo

Tone, activity Limp Some limb Active movement


   flexion
eb

eb

Respiratory Absent Slow, irregular Good strong cry


e

   effort
m

52
m

m
co

co
m

om
EXAMINATION AT DIFFERENT AGES 4

co

c
e.

e.
and, if possible, the father should be present. Explanation

re

fre
should be offered as the examination proceeds and each
test described as it is being performed. The mother is par-
f
ks

s
ticularly influenced by the appearance of her baby: include

ok
oo

size (is he in normal centiles?), facial appearance, colour and

o
texture of skin, bruising, abrasions, scratch marks, rashes
eb

eb
and subconjunctival haemorrhage. The latter condition is

e
m

m
easily understood if the mother has suffered the same as a
result of labour.
Blotchy erythematous rash is common; this is almost cer-
tainly erythema toxicum. Peeling of the skin that has been
m

m
exposed to meconium is normal. This can be confirmed by
o

co
discolouration of the cord stump and the presence of stained
.c

e.
fingernails. Fingernails are often long and although soft can
e

cause scratch marks. The toenails often appear to be ingrow-


re

ing and this is of no consequence. fre


f
ks

ks
Jaundice is best observed in the sclera, skin and mucous
membranes, preferably in good daylight. Always switch
oo

oo

off phototherapy unit lights when attempting to determine


eb

eb

jaundice. We believe that it remains good practice (although

e
fallible) to attempt to determine the degree of jaundice
m

m
clinically but always measure serum bilirubin of jaun-
diced babies. Phototherapy can induce the ‘bronzed baby’
syndrome.
m

m
co

co

Head and face


e.

e.

As the appearance of the baby is of concern to the mother,


fre

fre

inspection and examination of the head and face should


ks

ks

be carried out first. Local trauma is common and includes


caput succedaneum and moulding, minor abrasions of
oo

oo

the scalp, forceps marks, non-specific facial bruises, sub-


eb

eb

conjunctival haemorrhage and occasionally cephalhae-


e

matoma. In general, these conditions resolve spontaneously


m

within the first week with the notable exception of


53
m

m
co

co
m

om
4 EXAMINATION AT DIFFERENT AGES

co

c
e.

e.
cephalhaematoma, which will calcify and resolve within

re

fre
2–3 months. Cephalhaematoma is most commonly found
over the parietal bone and confined to the edges. Occasion-
f
ks

s
ally both parietal bones are involved. Rarely the condition

ok
oo

can involve the occipital bone when the possibility of an

o
encephalocele should be considered.
eb

eb
Asymmetry of the face may occasionally be due to a tran-

e
m

m
sient 7th cranial nerve paresis, which nearly always results
from a forceps delivery. Head shape varies considerably
during the first week. Marked moulding with caput occurs
in some. Intrauterine pressure (when the fetus is in breech
m

m
position) may produce an elongated head with protuber-
o

co
ance of the occiput. Deflection, giving rise to face presenta-
.c

e.
tion, may be associated with severe bruising and oedema
e

of the face, eyelids and lips. Chvostek’s sign (tapping the


re

fre
facial nerve → twitching of the perioral muscles) is a normal
f
ks

ks
finding in the newborn.
Plagiocephaly is not an uncommon finding related to
oo

oo

intrauterine position. The head is skewed slightly or notice-


eb

eb

ably. The simple trick of placing one finger in each ear of

e
the forward-looking head will demonstrate plagiocephaly
m

m
readily.
The anterior fontanelle is normally open and can
vary from 1 cm to 4 or 5 cm in diameter. Cranial sutures are
m

usually mobile and the posterior fontanelle may accept a


co

co

fingertip.
e.

e.
fre

fre

Ears
ks

ks

Ears can be of different shape and size and the amount of


cartilage can vary. A low-set ear where the top of the pinna
oo

oo

is below a horizontal line from the outer canthus does not


eb

eb

make a syndrome. Nor does the presence of preauricular


e

ear tags.
m

54
m

m
co

co
m

om
EXAMINATION AT DIFFERENT AGES 4

co

c
e.

e.
re

fre
f
ks

s
ok
oo

o
eb

eb

e
m

m
m

m
o

co
.c

e.
e
re

fre
Fig. 4.1  Demonstrating plagiocephaly in the older infant.
f
ks

ks
oo

oo
eb

eb

e
m

m
m

m
co

co
e.

e.
fre

fre
ks

ks
oo

oo

Fig. 4.2  Plagiocephaly.


eb

eb

e
m

55
m

m
co

co
m

om
4 EXAMINATION AT DIFFERENT AGES

co

c
e.

e.
Mouth

re

fre
The shape of the mouth varies and a slanting lower jaw only
f
ks

s
reflects intrauterine head posture. Look for presence of a

ok
tooth, examine gums anteriorly and posteriorly to exclude
oo

ranula or cyst, check the size and shape of tongue.

o
eb

eb
The lingual frenum extends from the undersurface of

e
the tongue to the floor of the mouth and is present in all
m

m
children. Surgery on the frenum may rarely be required if
there is interference with tongue protrusion or with growth
of tongue tip. The soft palate and uvula should be observed.
m

m
o

co
.c

Come to terms: head

e.
e

frontal bossing = prominence of forehead, i.e. part of frontal bone


re

craniotabes = soft compressible skull bones


fre
f
ks

ks
oo

oo

Come to terms: skull shapes


eb

eb

scaphocephaly = boat-shaped head (long, narrow)

e
macrocephaly = large head (synonym = megalencephaly)
m

m
microcephaly = very small head
plagiocephaly = parallelogram (skew) head
turricephaly = tall head (synonym = acrocephaly)
brachycephaly = flat head (short head)
m

synostosis = premature fusion of adjacent bones


co

co

trigonocephaly = triangular-shaped head


e.

e.
fre

fre

Eyes
ks

ks

Oedema of the eyelids is common, more particularly in the


oo

oo

preterm baby. Bruising may also be present. Because of the


eb

eb

oedema, opening the eyes may be difficult; if the examiner


e

holds the baby in the upright or prone position, in most


m

cases the eyes open. Look for conjunctival haemorrhage,


56
m

m
co

co
m

om
EXAMINATION AT DIFFERENT AGES 4

co

c
e.

e.
clear cornea, evidence of cataract. Compare eye size and if

re

fre
in doubt palpate the eyes for size and eyeball pressure.
Squint is common, although rarely paralytic, in which
f
ks

s
case the 6th cranial nerve is usually involved. Accumula-

ok
oo

tion of lacrimal fluid with secondary infection is extremely

o
common and results usually from incomplete drainage of
eb

eb
the nasolacrimal duct. If there is a lot of pus present, a

e
m

m
specific infection such as gonococcal ophthalmia should be
considered.
m

m
Respiratory system
o

co
The respiratory system is best examined by observation.
.c

e.
Observation of the colour of the baby’s lips, mucosa and
e

skin, and observation of respiratory rate and effort is infi-


re

fre
nitely more important than percussion or auscultation.
f
ks

ks
Observation should include the rate of respiration (normally
30–50 per minute at rest), the rhythm of respiration and the
oo

oo

work of respiration. Normal newborn respiration is quiet,


eb

eb

effortless and predominantly diaphragmatic. There is more

e
abdominal than chest movement.
m

m
Respiratory problems are common in the newborn and
will be manifest by tachypnoea, increased respiratory effort
and cyanosis. The baby may develop retraction, reces-
m

sion and variable respiratory rhythm. The student should


co

co

comment on chest shape and outline and use of accessory


muscles of respiration.
e.

e.
fre

fre

Come to terms: respiration


ks

ks

tachypnoea = respiratory rate > 60 per minute


sternal retraction = insuction of sternum in inspiration
oo

oo

intercostal recession = excessive indrawing of intercostal muscles


during respiration
eb

eb

periodic breathing = alternating rhythm of respiration with periods of


e

apnoea (common in preterms)


m

57
m

m
co

co
m

om
4 EXAMINATION AT DIFFERENT AGES

co

c
e.

e.
Cardiovascular system

re

fre
At the outset observe colour, respiratory effort, shape of
f
ks

s
chest, precordial bulge and/or heave. Localization of the

ok
trachea and the apex beat is important. The position of the
oo

apex beat may be difficult to localize but usually is between

o
eb

eb
the 4th and 5th space in the midclavicular line. Precor-

e
dial thrills are not uncommon in the newborn and should
m

m
always be sought. Palpation of the brachial and femoral
pulse may require total concentration, bearing in mind
that too much pressure may obliterate it. The best advice is
m

m
repeti­tive practice.
o

co
The heart sounds should be listened to at both the apex
.c

and base, commenting on the first sound at the apex and the

e.
e

second sound at the base. Not uncommonly a physiologi-


re

fre
cal third heart sound may be heard. The heart rate varies
f

from 100 to 140 per minute. Occasionally extrasystoles may


ks

ks
be noted and usually are of no significance. Heart block
oo

oo

without a structural anomaly of the heart is extremely rare


and can be diagnosed antenatally.
eb

eb

e
Systolic murmurs are common and usually best heard
m

m
along the left sternal border. A short high-pitched localized
murmur which is not transmitted is generally benign and
in the absence of any other positive finding a diagnosis of
m

innocent murmur is made. As a precaution this should be


rechecked before discharge and again at 3 and 6 weeks. The
co

co

student should only be concerned with systolic murmurs


e.

e.

in this age group. Listen to as many as possible – examine,


fre

fre

examine, examine! With practice and in older babies you


may pick up diastolic murmurs as the heart rate is slower.
ks

ks
oo

oo

Abdomen
eb

eb

Again, first observe. The abdomen is often generally


m

somewhat distended – more so after a feed (so enquire!).


58
m

m
co

co
m

om
EXAMINATION AT DIFFERENT AGES 4

co

c
e.

e.
Respiration is reflected in abdominal movement via the

re

fre
diaphragm and this is normal. If in doubt about distension
measure at a marked point above or below the umbilicus.
f
ks

s
Observe the umbilicus. Is it ageing normally – any blood or

ok
oo

discharges? Is there a smell? Is there periumbilical inflam-

o
mation? Is the umbilical vein visible? Is it inflamed? Reas-
eb

eb
sure mother that the cord will part spontaneously around

e
m

m
the fourth or fifth day. Is there any evidence of an early
umbilical hernia? Occasionally palpation of the abdomen
may cause the baby to regurgitate mucus or feed. So be
very careful.
m

m
Palpate the abdomen gently (with the aid of a soother if
o

co
necessary). Use your right hand to examine for the spleen,
.c

e.
whose tip is often readily palpable. It does not matter from
e

which side you approach the examination of a newborn


re

fre
abdomen – just be comfortable. Check the liver edge by
f
ks

ks
placing your palm between the umbilicus and right iliac
crest. Get the feel of the abdomen and then slowly proceed
oo

oo

towards the rib cage. Remember that the right lobe of the
eb

eb

liver is what you are going to meet first. The liver edge is

e
usually soft and easily missed. It is nearly always palpable
m

m
up to 2–3 cm below the costal margin. There is little doubt
that the kidneys in the average newborn can be palpated,
particularly the lower poles. However, this is not easy and
m

requires considerable practice. The most suitable method is


co

co

to place one hand under the upper lumbar region, exerting


gentle pressure upwards while doing the actual palpation
e.

e.

with the other hand. The examiner is trying to establish


fre

fre

the presence of both kidneys and whether or not they are


ks

ks

enlarged.
The bladder (when full) is an abdominal organ in the
oo

oo

newborn and is best felt approximately 15 minutes after a


eb

eb

feed. Starting just below the umbilicus using the index and
e

second finger and thumb, gently feel for the bladder, gradu-
m

ally moving pincer grasp downwards until felt. When a


59
m

m
co

co
m

om
4 EXAMINATION AT DIFFERENT AGES

co

c
e.

e.
bladder is palpable, gentle massage will produce a contrac-

re

fre
tion, following which a midstream specimen can be obtained
without contamination. A large bladder is frequently noted
f
ks

s
where the infant has asphyxial encephalopathy or a severe

ok
oo

neural tube defect.

o
Note that inguinal lymph nodes are often palpable in the
eb

eb
newborn and are a normal finding.

e
m

m
Genitalia
Female. Labia may be quite red and minora not covered, par-
m

m
ticularly in the preterm. Labial fusion is sometimes present
o

co
and is easily dealt with if required. Vaginal tags are common
.c

e.
and should be ignored. They will resolve spontaneously
e

during the first week. Vaginal haemorrhage (‘newborn


re

fre
period’) occasionally occurs. Bruising may be present, par-
f
ks

ks
ticularly if the baby had a breech delivery. Increased pig-
mentation and enlargement of the clitoris should be noted.
oo

oo

Male. Is the penis of normal size and shape? Is there any


eb

eb

evidence of hypospadias? (Epispadias is exceedingly rare.)

e
Hypospadias is commonly glandular (or coronal), infre-
m

m
quently in the shaft (penile), and rarely at the base (peri­
neal). Are the testes palpable and of normal size? If testes
are not in the scrotum, commence in the inguinal area and
m

palpate downwards. If a testis appears bigger than average,


co

co

consider hydrocele (common) and confirm by transillumi-


nation. There may be an associated inguinal hernia, which
e.

e.

is more common in males, particularly in the preterm. Very


fre

fre

rarely an enlarged testis may be due to torsion; the testis


ks

ks

then feels hard and is discoloured.


oo

oo

Musculo-skeletal system
eb

eb

The examination of bones, joints, ligaments and the attached


m

muscles is of fundamental importance in the newborn.


60
m

m
co

co
m

om
EXAMINATION AT DIFFERENT AGES 4

co

c
e.

e.
Dislocatable (loose) hips

re

fre
The term developmental dysplasia of the hips (DDH) has
f
ks

s
replaced the term congenital dislocation of the hips. Clini-

ok
cal examination for dislocated or dislocatable hips is not
oo

entirely reliable. Ultrasonic screening is used to augment

o
eb

eb
clinical examination.

e
True dislocation is rare at birth, with the notable
m

m
exception of the baby with severe neural tube defect (menin-
gomyelocele). Unstable hip, however, is common and occurs
in approximately 15–20 per 1000 live births. This condition
m

m
is extremely uncommon in the preterm. Overall, unstable
o

co
hip is more common in the female except following breech
.c

presentation where the risk is equal in both sexes. Talipes

e.
e

calcaneo valgus may also be associated with it. The left hip
re

fre
is twice as likely to be involved as the right hip.
f

The earlier the hip examination is carried out the better.


ks

ks
Day 1 is now the day of choice with the best chance of posi­
oo

oo

tive diagnosis. In general, Barlow’s method of examination


eb

eb

e
m

m
m

m
co

co
e.

e.
fre

fre
ks

ks
oo

oo
eb

eb

e
m

Fig. 4.3  Examining hips in the newborn baby.

61
m

m
co

co
m

om
4 EXAMINATION AT DIFFERENT AGES

co

c
e.

e.
is preferred. It is important that the baby is placed on a flat

re

fre
table (approximately waist high from the examiner), in the
supine position and if possible relaxed. Position the hips
f
ks

s
and knees at 90° and grasp both knees between thumb and

ok
oo

index and second fingers, the tips of which are over the

o
outer trochanter of each femur. Press the hips gently back-
eb

eb
wards and then abduct and lift with the outside fingers – if

e
m

m
the hip is loose a clunking feeling is noted when lifting the
head of the femur back into the socket. The gentler this test
is performed the better the response. It is important to be
gentle when carrying out this test and it certainly should not
m

m
be done repetitively. It is very easy to damage the hip joint.
o

co
Total abduction of the hip joint should never be carried out
.c

e.
during physical examination.
e

Ortolani’s (relocation) test. Ortolani’s test relocates a


re

fre
dislocated hip into the joint. The click/clunk is caused
f
ks

ks
by the head crossing the acetabulum. One way to remember
it is:
oo

oo

ORTOLANI = O, I (out → in)


eb

eb

e
Please remember that Barlow’s and Ortolani’s tests can
m

m
only be performed in the neonatal period. By age 6 weeks
these manoeuvres are unproductive because of increased
muscle tone. After 6 weeks the only reliable clinical test for
m

dislocation is limited hip abduction.


co

co
e.

e.

Feet
fre

fre

Mobility of the foot joints is the major factor determining


ks

ks

the need for treatment or non-treatment. Deformities of the


foot are common and vary in type.
oo

oo
eb

eb

Tarsus varus. This is extremely common – a degree occurs in


e

nearly every baby. The foot is turned inwards to a varying


m

degree at the tarsal joints. Spontaneous recovery is the rule,


62
m

m
co

co
m

om
EXAMINATION AT DIFFERENT AGES 4

co

c
e.

e.
although occasionally transient manipulation and massage

re

fre
may be necessary.
f
ks

s
Calcaneo valgus. This condition is also common and appears

ok
to occur more often in the post term and may occasionally
oo

be associated with a loose hip. The dorsum of the foot is in a

o
eb

eb
position close to the shin. As calf muscle tone improves, the

e
foot is pulled into the normal position; this usually occurs
m

m
within 6–8 weeks.
Talipes equino varus (primary club foot). This condition occurs
in 1 per 1000 births and is twice as common in the male
m

m
baby. In 50% of cases it is bilateral. Usually there is a fixed
o

co
structural deformity with involvement of both the fore- and
.c

e.
hindfoot and associated wasting of the calf muscles. Early
e

manipulation and fixation is advisable.


re

fre
Other minor anomalies of the toes occur, including over-
f
ks

ks
riding (usually 3rd or 4th) and overlapping of the 5th toe.
Toenails always appear ingrowing in the newborn – this is
oo

oo

a normal phenomenon. Treatment is usually not required


eb

eb

for any of these conditions.

e
Minor variants not minor anomalies:
m

m
•   mild to moderate bowing of lower leg
•   mild syndactyly of 2nd and 3rd toes
m

•   shallow sacral dimple


•   hydrocele of testes
co

co

•   single upper palmar crease.


e.

e.
fre

fre

Spine
ks

ks

Examination of the spinal processes should be carried out


with the baby lying in the prone position and palpating each
oo

oo

spinal process. Occasionally a spina bifida occulta or dermal


eb

eb

sinus may be noted. More often a postanal dimple is present;


e

this is of no consequence (Table 4.2), and the parents should


m

be reassured.
63
m

m
co

co
m

om
4 EXAMINATION AT DIFFERENT AGES

co

c
e.

e.
Table 4.2  Types of congenital malformation

re

fre
System Major Minor
f
ks

s
Craniofacial Cleft lip/palate Plagiocephaly

ok
   Sutural synostosis
oo

Abdominal Exomphalos/ Umbilical hernia

o
   Gastroschisis
eb

eb
Spinal Neural tube defect Sacral dimple

e
Foot Talipes equino varus 2–3 toe syndactyly
m

m
m

m
Central nervous system
o

co
Examination of this system in the newborn is entirely dif-
.c

e.
ferent from that of the older child. It is the assessment of
e

posture and tone, movement and primitive reflexes. There-


re

fre
fore, much information may be obtained (once again)
f
ks

ks
by spending a few minutes observing the infant. In
general, the posture is entirely flexor although abnormal
oo

oo

intrauterine posture can distort this: for example, extended


eb

eb

breech or deflexed head. The complete flexor posture is

e
not fully adopted until 37 completed weeks. Observe limb
m

m
movements – are they normal? There is a great variation
ranging from tremulous movements of one or all limbs to
jittery movements, both of which may be normal. Feel the
m

upper and lower limbs, establish flexor recoil and compare.


co

co

If doubt exists then the examination should be repeated


with the head held in the midline. Having the ‘posture-
e.

e.

picture’, proceed to assess tone by doing the neck traction


fre

fre

test. Here hands are firmly grasped and the infant is pulled
ks

ks

to the sitting position. The head should flex and follow the
traction to upright position and hold momentarily. This is
oo

oo

an important test (see Fig. 4.4).


eb

eb

Vertical suspension is assessed by grasping the infant under


e

each axilla. The normal baby supports himself in this posi-


m

tion. The term baby who slips through suggests hypotonia.


64
m

m
co

co
m

om
EXAMINATION AT DIFFERENT AGES 4

co

c
e.

e.
re

fre
f
ks

s
ok
oo

o
eb

eb

e
m

m
m

m
o

co
.c

e.
e

Fig. 4.4  Neck traction.


re

fre
f
ks

ks
oo

oo
eb

eb

e
m

m
m

m
co

co
e.

e.
fre

fre

Fig. 4.5  Ventral suspension.


ks

ks
oo

oo

Ventral suspension is assessed by placing the baby prone


eb

eb

on the palm of the hand. In the normal response the back


e

extends, arms and knees flex, hips extend and head lifts
m

and rotates.
65
m

m
co

co
m

om
4 EXAMINATION AT DIFFERENT AGES

co

c
e.

e.
Lower limb posture in the supine position is usually

re

fre
flexor with the hips slightly abducted. Full abduction of
the hips in a supine term baby indicates hypotonia and is
f
ks

s
abnormal.

ok
oo

It must be stressed that when one or more of these

o
tests suggest hypotonia a repeat examination in 24 hours
eb

eb
may confirm or otherwise the significance of the previ-

e
m

m
ous examination. Remarkable changes in tone and posture
can occur in a matter of hours during the first week
of life.
Deep tendon reflexes can be readily elicited – particularly
m

m
the knee tendon reflex. Flex the particular joint and hold
o

co
the limb with the same hand and tap tendon with fingertip.
.c

e.
Intermittent ankle clonus may also be present in the normal
e

baby and is detected by gentle but sudden dorsiflexion of


re

the foot. fre


f
ks

ks
oo

oo

Pointers to hypotonia
eb

eb

e
•   Head lag
m

m
•   Slips through on upright suspension
•   Like ‘rag doll’ in ventral suspension
•   Total hip abduction.
m

m
co

co

Primitive reflexes
e.

e.

A number of primitive reflexes are present and easily elic-


fre

fre

ited in the normal term baby. These gradually disappear


ks

ks

and are not present at the end of the sixth month with
the notable exception of the blink response, which remains.
oo

oo

Do these tests properly since the best response is usually


eb

eb

obtained on the first test. The response tends to wane on


e

repeated testing.
m

66
m

m
co

co
m

om
EXAMINATION AT DIFFERENT AGES 4

co

c
e.

e.
Blink response.  A gentle tap above the nasal bridge usually

re

fre
evokes the blink response. This test is nearly always normal
except in the very ill baby.
f
ks

s
ok
oo

Cardinal signs.  These collectively refer to sensory stimu-

o
lation of the cheek and skin around the mouth and lips.
eb

eb
Pressing a finger on the cheek near the mouth and moving

e
m

m
it laterally will cause the baby to open his mouth and turn
the head to root for a nipple. When a soother or nipple is
placed in the mouth, the normal baby will suck vigorously
(depending somewhat on the timing of the previous feed)
m

m
and swallow in unison.
o

co
.c

e.
Grasp and traction response.  This has been referred to pre-
e

viously in relation to tone. This test, however, can be


re

fre
f
ks

ks
oo

oo
eb

eb

e
m

m
m

m
co

co
e.

e.
fre

fre
ks

ks
oo

oo
eb

eb

Fig. 4.6  Cardinal points.


m

67
m

m
co

co
m

om
4 EXAMINATION AT DIFFERENT AGES

co

c
e.

e.
provoked unilaterally by placing a finger or pencil in the

re

fre
baby’s palm. This causes grasping and with gentle upward
traction the forearm and shoulder muscles will contract.
f
ks

s
When carried out properly the infant may be lifted 2–3 cm

ok
oo

from the surface of the cot. When the baby is lowered, gentle

o
stroking of the ulnar surface of the palm will disengage the
eb

eb
grasp.

e
m

m
To record an optimal response in the following tests it is
preferable that the baby’s head is in the midline.
Asymmetrical tonic neck reflex.  This test may easily be elicited
m

m
by leaving the infant lying in the supine position and slowly
o

co
turning the head 90° to the right and left. The upper and
.c

lower limbs extend on the facial side and, similarly, there

e.
e

is flexion on the occipital side, producing the classic sword


re

fighting or fencing posture.


fre
f
ks

ks
Moro reflex.  This is the most widely known and frequently
elicited test. The baby is laid supine on the forearm and
oo

oo
eb

eb

e
m

m
m

m
co

co
e.

e.
fre

fre
ks

ks
oo

oo
eb

eb

e
m

Fig. 4.7  Palmar grasp and shoulder traction response.

68
m

m
co

co
m

om
EXAMINATION AT DIFFERENT AGES 4

co

c
e.

e.
re

fre
f
ks

s
ok
oo

o
eb

eb

e
m

m
m

m
o

co
Fig. 4.8  Toe grasp.
.c

e.
e
re

fre
f
ks

ks
hand and the head is held in the other hand. The response
occurs when the head is ‘dropped’ a few centimetres. The
oo

oo

upper limbs abduct, extend and flex in a flowing move-


eb

eb

ment symmetrically; a poor or no response indicates a

e
major problem. However, a unilateral response confirms
m

m
the damage (usually transient) to the fifth and sixth cervical
roots producing the classic Erb’s paresis.
m

Spinal curve or Galant reflex.  Hold the baby on one hand


co

co

(similar to ventral suspension test) and stroke the lateral


border of the spinal muscle from the mid-thoracic area
e.

e.

downwards. This will cause the pelvis to curve to the same


fre

fre

side. A similar response should be evoked on the opposite


ks

ks

side.
oo

oo

Crossed extension reflex.  While keeping the baby in the supine


eb

eb

position, extend one knee and stroke the foot on the same
e

side; this will cause the opposite leg to flex, abduct and
m

extend ‘to push away’ the provoking hand.


69
m

m
co

co
m

om
4 EXAMINATION AT DIFFERENT AGES

co

c
e.

e.
re

fre
f
ks

s
ok
oo

o
eb

eb

e
m

m
m

m
o

co
.c

e.
e
re

fre
f
ks

ks
oo

oo

Fig. 4.9  Moro response.


eb

eb

e
m

m
Extensor thrust, placing and walking reflex.  These movements
relate and provide evidence of lower limb function. With
the baby held between both hands, the legs lowered to the
m

surface, pressure on the soles of the feet may cause the lower
co

co

limbs to suddenly extend, producing an extensor thrust. If


the lower limbs, with the baby still held in the same position,
e.

e.

are pressed against the edge of the examining table one foot
fre

fre

will flex to place. By bringing the baby’s limbs further on to


ks

ks

the table leaning forwards at an angle of 10–20° a walking


movement may be produced.
oo

oo
eb

eb

Hearing.  A crude hearing response can certainly be elicited


e

in the newborn. The simplest test is to say ‘aaah’ into the


m

crying baby’s ear from a distance of 3–4 cm. Usually this


70
m

m
co

co
m

om
EXAMINATION AT DIFFERENT AGES 4

co

c
e.

e.
re

fre
f
ks

s
ok
oo

o
eb

eb

e
m

m
m

m
o

co
.c

e.
e
re

fre
f
ks

ks
oo

oo

Fig. 4.10  Placing reflex.


eb

eb

e
m

m
produces a cessation of crying. A startle response to a loud
noise may be a crude indicator of hearing. Specific screening
tests are now available.
m

m
co

co

Vision.  The newborn can see and will readily turn to a light
source. The infant may, for example, turn his head to the
e.

e.

room or cubicle window. Also, when seated comfortably


fre

fre

and with the baby held in the supine facing the examiner
ks

ks

at an angle of about 30°, eye fixation can be established at a


distance of about 20 cm. A red ball of 5–6 cm in diameter can
oo

oo

be brought slowly across the baby’s visual field, at which


eb

eb

time following may occur. These latter tests require time, a


e

cooperative baby and a certain expertise. Positive responses


m

to vision and hearing tests are very reassuring to the mother.


71
m

m
co

co
m

om
4 EXAMINATION AT DIFFERENT AGES

co

c
e.

e.
Conclusion

re

fre
Examination of the central nervous system in the newborn
f
ks

s
requires attention to detail, a deal of patience and a baby in

ok
the right mood. The value of transient alteration of one, two
oo

or even three tests is as yet not precisely clear. However,

o
eb

eb
much research has and is being carried out in this area and

e
there is little doubt that diligent and repetitive examination
m

m
can be both rewarding and educational. The record of such
a detailed examination may be of vital importance to the
developmental paediatrician in later years.
m

m
o

co
.c

Newborn examination: purposes

e.
e

Day 1 1. to assess general condition


re

2. to
fre
establish normality
f

3. to detect major abnormalities


ks

ks
Days 3–5 (discharge) 1. to confirm normality
2. to detect minor abnormalities
oo

oo

3. to assess neurological status


eb

eb

e
m

m
The preterm baby following discharge
As more very low birth weight and immature babies
m

survive, they unfortunately can bring many clinical prob-


co

co

lems through to general paediatric medicine. Therefore,


clinical and developmental assessment should target suspect
e.

e.

areas specific to such children. In assessing development,


fre

fre

allowance should be made for the duration of immaturity


ks

ks

in weeks and also the extent and duration of serious illness


during the postnatal period. As the child reaches 3–4 years
oo

oo

this time factor becomes of little consequence.


eb

eb

In general, most babies of less than 30 weeks’ gesta-


e

tion will have a long narrow-shaped head due to an initial


m

inability to turn the head from side to side. This shape of


72
m

m
co

co
m

om
EXAMINATION AT DIFFERENT AGES 4

co

c
e.

e.
head does not relate to developmental status. Emphasis in

re

fre
examination should be placed on head size (periventricular
haemorrhage is common in infants less than 30 weeks) and
f
ks

s
the presence of a ventriculo-peritoneal shunt. Muscle tone

ok
oo

and gross motor status may be less than optimum – mainly

o
because of perinatal morbidity. Vision and fine movement
eb

eb
and social behavioural assessment can give useful guid-

e
m

m
ance to developmental quotient. Hearing impairment is
not uncommon in the preterm infant. However, early more
precise hearing tests are now available.
Retinopathy of some degree is common in the very
m

m
immature but most infants will have had a thorough eye
o

co
examination and treatment (laser) where required, prior to
.c

e.
discharge. Overall, however, visual problems are common
e

and assessment for strabismus should be detailed.


re

fre
Bronchopulmonary dysplasia (BPD) commonly extends
f
ks

ks
through the first and sometimes second year. Such infants
are more prone to episodes of respiratory infections such as
oo

oo

bronchiolitis. However, there is a gradual return to normal


eb

eb

respiratory function. During clinical examination of such

e
babies, tachypnoea at rest may be noted. Respiratory rate
m

m
may also be influenced by the use of respiratory stimulant
(theophylline) which some receive, particularly during the
first year.
m

Umbilical hernias are commonly found but rarely require


co

co

treatment. Inguinal hernias occur in approximately 25%


of male preterm babies. Recognition of inguinal hernias is
e.

e.

urgent as strangulation and obstruction may occur.


fre

fre

In general, gastrointestinal problems are uncommon.


ks

ks

However, if the baby had necrotizing enterocolitis in


the postnatal period then secondary disaccharide intoler-
oo

oo

ance may result and in some cases strictures may cause


eb

eb

problems.
e

Scarring of skin may be present due to drip sites, chest


m

drains and particularly trauma from heel blood sampling.


73
m

m
co

co
m

om
4 EXAMINATION AT DIFFERENT AGES

co

c
e.

e.
Occasionally with prolonged tracheal intubation there may

re

fre
be alteration in the shape of the soft palate – this is referred
to as a palatal groove. Capillary haemangiomas occur more
f
ks

s
commonly in the preterm baby. After an initial growth

ok
oo

period, spontaneous regression can be expected in the first

o
2–5 years.
eb

eb
Although talipes equino varus (TEV) can occur in the

e
m

m
preterm, developmental dysplasia of the hip is very uncom-
mon. However, if there is a strong positive family history
of hip dysplasia then further evaluation should be carried
out during the first year, possibly including ultrasound
m

m
examination.
o

co
.c

e.
e

SIX-WEEK EXAMINATION
re

fre
The 6-week examination is an important postnatal event
f
ks

ks
and all babies should be seen at this time.
oo

oo

The 6-week examination: purposes


eb

eb

e
1.  to evaluate feeding pattern
m

m
2.  to measure growth and weight gain
3.  to detect abnormalities not noted in neonatal period
4.  to assess early development
5.  to ensure infant–maternal bonding
m

m
co

co

It is important at the 6-week assessment to have all the


e.

e.

relevant perinatal details, including birth weight, head cir-


fre

fre

cumference and crown–heel length.


ks

ks
oo

oo

Measurement (centiles)
eb

eb

•   Head circumference


e

•   Length
m

•   Weight.
74
m

m
co

co
m

om
EXAMINATION AT DIFFERENT AGES 4

co

c
e.

e.
Adverse perinatal history to note

re

fre
•   Asphyxia
f
ks

s
•   Low birth weight

ok
•   Preterm
oo

•   Infection

o
eb

eb
•   Hypoglycaemia

e
•   Trauma.
m

m
The process of examination should be careful and gentle.
Take the fully dressed infant from his mother and lay him
on a covered table. You should not allow the mother or
m

m
nurse or anyone else to undress the infant. Do it yourself as
o

co
the examination proceeds; get the feel of the baby yourself.
.c

e.
Observe, without disturbing if possible. Look at the way the
e

infant is dressed and the general picture of care. Look at the


re

fre
face – good colour, clean, no rash, scalp clear, normal quiet
f
ks

ks
respiration or otherwise, any evidence of snuffles or noisy
breathing? Is there any evidence of anaemia? Are the lips a
oo

oo

good colour? Gently check the conjunctiva.


eb

eb

Feel the head and fontanelle, look for seborrhoea. If the

e
infant is awake, try to get eye fixation from about 20 cm.
m

m
Having achieved eye fixation often the baby will smile in
return. Smiling with meaning is an important milestone. If,
however, the infant is crying, say ‘aaah’ into his ear in low
m

tone and crying may cease. If it does not, hold the infant
co

co

upright and tip him forwards. Crying may cease and the
eyes open. Then start again.
e.

e.

Now check head growth, feel the anterior fontanelle and


fre

fre

sutures. Look for early head control. When holding the


ks

ks

infant in the sitting position the head may fall forward but
there should be reasonable, if wobbly, head control. Look
oo

oo

at limb movements and check limb tone. Observe the hands


eb

eb

– look for thumb abduction and finger flexion. If fisting is


e

present, open the palm and observe for accumulation of


m

dirt in the palmar creases. The skin of the palm may be


75
m

m
co

co
m

om
4 EXAMINATION AT DIFFERENT AGES

co

c
e.

e.
moist and pale. This suggests the hands have been tightly

re

fre
clenched since birth. Look for persistent ankle clonus.
Check primitive reflexes, looking for accentuation of par-
f
ks

s
ticularly the Moro, asymmetrical tonic neck and walking

ok
oo

reflexes. Look at the state of nutrition, respiratory rate and

o
general well-being. Is there any evidence of dehydration,
eb

eb
loss of subcutaneous fat or wasting? Gently examine the

e
m

m
mouth, particularly observing for evidence of monilial infec-
tion. Look for evidence of conjunctival infection. Roll tip of
finger over inner canthus to clear lacrimal duct.
Transient blockage of nasolacrimal duct is very common.
m

m
Check nose for snuffles – again an extremely common
o

co
finding and usually of no serious consequence. Swelling of
.c

e.
the infant’s breasts may be present, and occasionally there
e

is evidence of inflammation and abscess formation. Inflam-


re

fre
mation and infection of the corners of the fingernails and
f
ks

ks
toenails (paronychia) are fairly common.
oo

oo
eb

eb

Developmental indicators

e
frowning 3–6 weeks
m

m
smiling with meaning 5–8 weeks
early head control (5–10 s) 5–8 weeks
eye fixation on examination of face 6 weeks (20–30 cm)
vocalization (coo) may be present 6-week-old
m

   (usually in a infant with siblings)


co

co
e.

e.
fre

fre

Skin
ks

ks

Look for evidence of seborrhoea in the scalp and/or napkin


dermatitis. Usually facial ‘stork bite marks’ are fading.
oo

oo

Conversely, strawberry naevi become more defined and


eb

eb

are growing. Port wine stain unfortunately becomes more


e

defined as the skin becomes paler. Occasionally physiological


m

jaundice may have persisted, particularly in association with


76
m

m
co

co
m

om
EXAMINATION AT DIFFERENT AGES 4

co

c
e.

e.
breast feeding. However, the re-emergence of jaundice at 6

re

fre
weeks is a sinister sign and must be thoroughly investigated.
f
ks

s
ok
Respiratory
oo

o
Observe the infant’s rate and type of breathing. Is it noisy?
eb

eb
If so, what kind of noise – upper, lower, inspiratory or

e
m

m
expiratory? Laryngomalacia is a common cause of inspira-
tory stridor in this age group. Coughing implies a lower
respiratory infection – though specific abnormal sounds are
rarely localized on auscultation.
m

m
o

co
.c

Cardiovascular

e.
e

Heart rate and pulses should be checked. The pulse will


re

fre
alter significantly if crying. Check the precordium and apex
f
ks

ks
beat. Remember, a thrill is more easily felt in this age group.
Listen to the heart sounds at the apex and also at the base,
oo

oo

commenting on the first sound in the former and the second


eb

eb

sound at the latter. Is there a murmur (which, with few

e
notable exceptions, is nearly always systolic in nature)?
m

m
Where is it best localized? Does it radiate? Is it loud? Is there
a thrill? Most important of all, what is the duration and is it
pansystolic? Try to decide if the murmur is significant or not.
m

Remember – a benign systolic murmur is short, high


co

co

pitched, soft, not transmitted and there is no thrill. A venous


hum (more common in toddlers) may be heard at the base.
e.

e.

Pressure on the jugular vein should reduce this sound


fre

fre

considerably.
ks

ks
oo

oo

Abdomen
eb

eb

Look at the shape. Is there any distension? Has the umbili-


e

cus healed completely? Is there any residual granulation


m

tissue or is there any herniation? Palpate for the spleen, the


77
m

m
co

co
m

om
4 EXAMINATION AT DIFFERENT AGES

co

c
e.

e.
tip of which may well be palpable. Feel the liver edge (2–

re

fre
3 cm) and percuss if necessary. Check for palpable bladder
and perhaps lower poles of kidney. This latter examination
f
ks

s
becomes more difficult as the infants get older. Look at the

ok
oo

genitalia. Are both testes palpable? Is there any evidence of

o
hydrocele or inguinal hernia? Is there a reasonable preputial
eb

eb
opening? In the female, check for labial fusion. Look at the

e
m

m
anus, observe for blood staining and/or early fissure – a not
uncommon problem.
m

m
Musculo-skeletal
o

co
In the majority the feet are normal, tarsus varus and calca-
.c

e.
neo valgus having resolved spontaneously in the previous
e

4 weeks.
re

fre
Examination of the hips is again important although much
f
ks

ks
less rewarding than during the first week. Again use Barlow’s
test. One may find benign adductor spasm in some infants.
oo

oo

Do not force the hips into full abduction as this manoeuvre


eb

eb

can damage the hip joint. Subluxation at 6 weeks is rare.

e
m

The 6-week examination: 3 Hs and warning signals


3 Hs to highlight at 6 weeks m
m

1.  head: too big = ? hydrocephalus; too small = ? microcephaly


co

co

2.  heart: murmurs may become apparent!


3.  hips: test abduction
e.

e.

A thorough examination is from head to toe and is easy to do. Six-


fre

fre

week-old babies and their mothers usually enjoy this examination.


Warning signals: 6 weeks
ks

ks

major maternal anxiety


oo

oo

unusually small or large head


hypotonia = poor ventral suspension, poor neck traction
eb

eb

persistent irritability
e

persistent thumb adduction


m

78
m

m
co

co
m

om
EXAMINATION AT DIFFERENT AGES 4

co

c
e.

e.
THE ACUTELY ILL INFANT

re

fre
It is clear that further reductions in infant mortality will
f
ks

s
require doctors to sharpen their diagnostic wits and instincts.

ok
Infants have a very limited clinical vocabulary with which
oo

to express themselves and the identical symptoms (food

o
eb

eb
refusal, vomiting, fever, lethargy) may reflect meningitis,

e
pneumonia, or urinary tract infection.
m

m
Infants can become ill very rapidly – happily for the
practising doctor they also recover promptly if appropri-
ately treated. In infancy one must always heed the mother’s
m

m
judgement and opinion. We will now repeat the importance
o

co
in approaching ill infants of:
.c

e.
•   careful observation
e
re

fre
•   thorough examination
•   instinctual suspicion.
f
ks

ks
Certain symptoms in infancy demand our immediate atten-
oo

oo

tion. Some of them are listed in the following box. Mothers


will vary in their rapidity of response but most will rec-
eb

eb

e
ognize the seriousness of these complaints and seek help.
m

m
Mothers in our country use the idiomatic expression ‘he’s
not himself’ to imply a significant change in their infant’s
well-being.
m

m
co

co
e.

e.

Always serious symptoms in infancy


fre

fre

High-pitched screaming or crying


Alternating drowsiness and irritability
ks

ks

Convulsion
Refusal to feed (two or more consecutive feeds)
oo

oo

Repeated vomiting
Rapid, laboured breathing, with or without grunting
eb

eb

Episodes of unusual blueness or paleness


e

Spreading purpuric spots >2 mm in diameter


m

79
m

m
co

co
m

om
4 EXAMINATION AT DIFFERENT AGES

co

c
e.

e.
Less serious symptoms, but ones not to be ignored, are

re

fre
detailed in the following box. Infants with these complaints
will need to be kept under close observation. Croup is a
f
ks

s
source of great parental anxiety even though their infant

ok
oo

may be apparently coping.

o
eb

eb

e
m

m
Usually serious symptoms in infancy
repeated diarrhoea
prolonged crying
croup (stridor, hoarseness, barking cough)
m

m
high fever (40°C/104°F)
o

co
persistent crankiness
.c

e.
e
re

fre
f

One’s first approach to the acutely and seriously ill infant


ks

ks
is to observe the infant in his position of comfort. Note the
oo

oo

heart rate, respiratory rate and effort, presence or absence of


a rash, colour and temperature. Ill infants frequently have
eb

eb

e
a mottled (or marbled) appearance to their skin. They lie
m

m
still. Breathing is often rapid and grunting. The eyes have
a glazed or distant look. They may be centrally warm and
peripherally cold. They convulse easily with fever.
m

Note movement (or lack of it). Refusal to use a limb


may suggest infection therein: for example, osteomyelitis.
co

co

Splinting of the chest is occasionally seen in pneumonia.


e.

e.

Arching of the neck occurs with meningitis. An immobile


fre

fre

abdomen is very significant, appendicitis and peritonitis


being notoriously difficult to detect in infancy.
ks

ks

One needs to make a statement about:


oo

oo

•   degree of sickness


eb

eb

•   hydration
e

•   nutrition
m

•   circulation.
80
m

m
co

co
m

om
EXAMINATION AT DIFFERENT AGES 4

co

c
e.

e.
Before proceeding to detailed examination, weight, tem-

re

fre
perature, pulse rate and respiratory rate will of course be
recorded. Ill infants are usually fairly passive and can be
f
ks

s
examined in an organized fashion.

ok
oo

o
Degree of sickness
eb

eb

e
This can only be learned by experience and observation
m

m
and not taught in texts or tutorials. So do spend time in
the emergency room and admitting office. See and assess,
regard and remember. Is he seriously ill? Is he moderately
m

m
ill? Is he mildly ill?
o

co
.c

Hydration

e.
e

This can easily and rapidly be assessed (see p. 210). One


re

fre
wishes to determine if the infant is normally hydrated,
f
ks

ks
dehydrated, or less commonly, overhydrated.
oo

oo

Nutrition
eb

eb

e
Nutrition can be quickly assessed by looking at and feeling
m

m
subcutaneous fat, inspecting buttocks and muscle bulk,
looking for lax skinfolds in the axilla and groin, and of
course weighing the infant. Skinfold thickness and mid-arm
m

circumference can be determined later if necessary. Is he


plump, ‘normal’ or poorly nourished?
co

co
e.

e.

Circulation
fre

fre

What is his circulation like? Is the colour of tongue, lips,


ks

ks

mucous membranes and nail beds normal? Is he mottled or


cyanosed? Are the peripheries warm? Is capillary refill in
oo

oo

the feet reasonably rapid? Warm toes (especially with palpa-


eb

eb

ble dorsalis pedis or posterior tibial pulse) are a reasonably


e

good indicator of satisfactory circulatory state. One must


m

not omit to measure blood pressure in acutely ill infants.


81
m

m
co

co
m

om
4 EXAMINATION AT DIFFERENT AGES

co

c
e.

e.
re

fre
f
ks

s
ok
oo

o
eb

eb

e
m

m
m

m
o

co
.c

e.
e
re

fre
f
ks

ks
oo

oo
eb

eb

e
Fig. 4.11  The acutely ill infant.
m

m
m

m
co

co

Acute illness in infancy


Medical sickness Surgical sickness
e.

e.

meningitis intussusception
fre

fre

pneumonia appendicitis/peritonitis
osteomyelitis intestinal obstruction
ks

ks

gastroenteritis incarcerated hernia


septicaemia
oo

oo

urinary tract infection


croup syndromes
eb

eb

e
m

82
m

m
co

co
m

om
EXAMINATION AT DIFFERENT AGES 4

co

c
e.

e.
Simple observations

re

fre
Simply by looking at a baby or infant you can make some useful
f
statements as for example:
ks

s
ok
normal infant
oo

moderately ill

o
normally hydrated
eb

eb
well nourished

e
possibly anaemic
m

m
query respiratory tract infection.
Food refusal is a serious symptom in infancy. By contrast, the infant
who feeds well may be ill, but not seriously so. We reassure mothers
m

m
that their infants are reasonably well if they fulfil the 3 Fs:
o

co
good form
.c

good feeding

e.
e

no fever.
re

fre
f
ks

ks
oo

oo

Think intussusception!
infant 6–12 months
eb

eb

acute episodes of pain with crying, drawing up of legs

e
extreme pallor
m

m
palpable abdominal mass
unexplained shock
m

m
co

co

THE TERRIFIED TODDLER


e.

e.

That enfant terrible of paediatrics, the toddler (1–3 years),


fre

fre

warrants special mention. He can be clinging, resistive,


ks

ks

screaming or downright impossible to examine. Approach


him as you would any creature who feels he is cornered
oo

oo

– slowly, carefully and with calculated caution. With


eb

eb

experience and expertise you may be able to examine him


e

surreptitiously and superficially. Do not remove him from


m

his place of safety, his mother’s knee, or embrace.


83
m

m
co

co
m

om
4 EXAMINATION AT DIFFERENT AGES

co

c
e.

e.
re

fre
f
ks

s
ok
oo

o
eb

eb

e
m

m
m

m
o

co
.c

e.
e
re

fre
f

Fig. 4.12  Toddler in mother’s arms – a safe examination position.


ks

ks
oo

oo
eb

eb

He does not like having his head circumference meas-

e
ured, his ear drums examined or his throat inspected; leave
m

m
these until last. Give him toys (or even spatulae) to occupy
both hands. Above all learn to be expedient and speedy in
your examination. But don’t rush him. The simple ploy of
m

first placing your stethoscope on his knee may enable him


co

co

to allow you to auscultate his heart.


One will always have to use one’s wits and instincts
e.

e.

in approaching the toddler. A lot can be achieved by


fre

fre

examining him when asleep – you can observe colour,


ks

ks

note rate and depth of respiration, palpate the pulse


(e.g. preauricular), feel his skin temperature, see if he’s
oo

oo

coping and comfortable, determine hydration and nutrition


eb

eb

and assess circulation (by feeling toe temperature). Diag-


e

nose by eye and by instinct. The experienced observer can


m

84
m

m
co

co
m

om
EXAMINATION AT DIFFERENT AGES 4

co

c
e.

e.
re

fre
f
ks

s
ok
oo

o
eb

eb

e
m

m
m

m
o

co
.c

e.
e
re

fre
f
ks

ks
oo

oo
eb

eb

e
m

m
Fig. 4.13  The terrified toddler.
m

m
co

co

quickly decide whether the sleeping toddler is seriously ill


e.

e.

or not.
fre

fre

Some toddlers defy proper examination despite stealth


ks

ks

and patience. Try again when he may be in more benign


humour. John Apley (a famous paediatrician) has said, ‘It’s
oo

oo

my fault if a child cries’. We would not entirely agree. Tod-


eb

eb

dlers have a very low threshold and tolerance for strange


e

faces and stethoscopes. Occasionally you will meet the truly


m

85
m

m
co

co
m

om
4 EXAMINATION AT DIFFERENT AGES

co

c
e.

e.
terrified toddler (a ‘screamer’) on whom examination is well

re

fre
nigh impossible. One may have to record failure:
f
ks

s
Funduscopy – impossible

ok
Blood pressure not recorded (crying)
oo

o
and be prepared to try again later. Some ‘tricks of the trade’
eb

eb
are mentioned on pages 243–244.

e
m

m
Clinical conundrum : early sepsis
Sepsis needs to be considered in infants and young children with
m

m
symptoms of fever, irritability, anorexia and lethargy. Such children
o

co
may look pale and unwell, but localizing physical findings may be
.c

minimal or absent on examination. One needs to consider:

e.
e

•  bacteraemia/early septicaemia
re

•  pyelonephritis (urinary tract infection)


fre
f

•  meningitis
ks

ks
•  osteomyelitis.
oo

oo

By contrast, pneumonia is nearly always accompanied by physical


signs – tachypnoea, grunting, flaring of alae nasi, and increased
eb

eb

work of breathing.

e
m

m
Numbers to be recorded (‘vital signs’)
height
weight
m

head circumference
co

co

pulse (heart rate)


respiratory rate
e.

e.

blood pressure (where appropriate)


fre

fre

peak expiratory flow rate (where appropriate)


temperature
ks

ks
oo

oo

ILL acronym
Irritable
eb

eb

Lethargic
e

Low capillary refill


m

86
m

m
co

co
m

om
5
co

c
e.

e.
re Systems

fre
f
examination
ks

s
ok
oo

o
eb

eb

e
m

m
m

m
o

co
.c

e.
e
re

fre
The chest   87 Ear, nose, mouth and throat   133
The cardiovascular system   104 Skin, hair and nails   141
f
ks

ks
The abdomen   116 Neurological examination   150
Examining the glands   131 Musculo-skeletal system   170
oo

oo

Clinical evaluation of the The eyes   187


immune system   133 Surgery   196
eb

eb

e
m

THE CHEST m
m

The single most common reason for infants and toddlers to


co

co

present to their family doctor is an acute respiratory tract


infection, usually upper (see Ear, nose, mouth and throat).
e.

e.

However, the good observer can often distinguish between


fre

fre

infections involving the upper and/or lower respiratory


ks

ks

tract (U/LRTI) by looking and listening carefully. All too


often students are keen to get their hands and stethoscopes
oo

oo

into play. Better to stand back and observe.


eb

eb

Observe the pattern of breathing, the work of breathing


e

and the rate of breathing. Listen for an expiratory grunt.


m

Note the type of cough. Does the infant display frothiness


87
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
or flaring of the alae nasi? Does he have a wheeze? Can he

re

fre
cope with a feed? What is his colour like?
f
ks

s
History

ok
oo

The history in respiratory tract infection consists of some

o
eb

eb
combination or permutation of the symptoms of cough,

e
wheeze, stridor, croup, poor feeding and fever. In more
m

m
severe cases there may be rapid respiration, grunting, cya-
nosis, restlessness or even collapse.
It is very difficult to individually distinguish viral from
m

m
bacterial infections. However, we have found ‘Lightwood’s
o

co
law’ to be of some value: this states that bacterial infections
.c

tend to localize – to one ear, to a tonsil, to a lobe of lung –

e.
e

whereas viral infections tend to spread. Measles is a good


re

fre
example of a spreading virus – red eyes, red ears, red throat,
f

red skin and, if you could see it, red trachea. ‘Toxicity’ is
ks

ks
difficult to describe clinically. Children with severe bacte-
oo

oo

rial infections tend to be more ‘toxic’ – more sick, more still,


more mottled.
eb

eb

e
It is also useful to try to distinguish upper from lower
m

m
respiratory infections, remembering that URTI and LRTI
can co-exist. One should attempt to correctly sequence from
the onset of symptoms, as for example:
m

•   cough for 4 days


co

co

•   poor feeding for 2 days


•   fever for 2 days
e.

e.

•   wheeze for 1 day


fre

fre

•   dyspnoea for 1 day.


ks

ks

It may be important to ask:


oo

oo

•   Which came first, the cough or the wheeze?


eb

eb

•   Is he getting progressively worse?


e

•   Has he maintained a good colour?


m

•   Can he manage a bottle or feed?


88
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
The four components of examination of the respiratory

re

fre
system are inspection, palpation, percussion and ausculta-
tion. Of these, inspection is surely the most valuable, espe-
f
ks

s
cially in infants. By inspection we include listening as well

ok
oo

as looking. We find ourselves frequently reminding stu-

o
dents that the experienced paediatric ward sister can make
eb

eb
an accurate stab at diagnosis from the door of the cubicle

e
m

m
nursing an infant with an acute respiratory infection.
Palpation and percussion are not particularly useful
exercises in acute LRTIs in infants and toddlers. The liver
is frequently pushed down by a flattened diaphragm, the
m

m
trachea is rarely displaced and demonstration of hepatic or
o

co
cardiac dullness not particularly helpful. Lobar pneumonias
.c

e.
demonstrable as dullness to percussion are infrequent in
e

infancy. It must be emphasized that the above remarks are


re

fre
applicable only to infants. In childhood the traditional arts
f
ks

ks
of percussion and palpation, as taught in ‘adult’ medicine,
are important.
oo

oo
eb

eb

e
Inspection
m

m
Inspection will include comments on and recording of:
  1.  Colour.
m

  2.  How the child is coping: Is he comfortable? Is he noisy but


co

co

managing? Is he in respiratory distress? Is he unstable, with


very laboured breathing?
e.

e.

  3.  What is his position of comfort?


fre

fre

  4.  Respiratory rate – What is normal for a given age? (see Table
ks

ks

5.1)
  5.  Chest movement. Is it symmetrical? Is there splinting of one
oo

oo

side of the chest?


eb

eb

  6.  Chest shape. Is the chest overblown or barrel shaped? Is


e

there pectus excavatum (hollow chest), pectus carinatum


m

(pigeon chest) or Harrison’s sulcus?


89
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
Table 5.1  Normal respiratory rate (at rest)

re

fre
Age Range of normal Rapid
f
ks

s
(respirations/min)

ok
Newborn 30–50 >60
oo

Infant 20–30 >50

o
Toddler 20–30 >40
eb

eb
Child 15–20 >30

e
m

m
  7.  Pursing of lips in expiration?
m

m
  8.  Presence of frothiness, nasal flaring or grunting?
o

co
  9.  Type of respiratory movement. Normal respiration is a quiet
.c

in-out movement of the chest.

e.
e
re

Come to terms: breathing fre


f
ks

ks
tachypnoea = increased rate of respiration
oo

oo

dyspnoea = laboured or difficult respiration


hyperpnoea (hyperventilation) = increased depth of respiration
eb

eb

orthopnoea = dyspnoea at rest

e
m

Defining tachypnoea (WHO criteria) m


m

in infants <2 months >60 breaths/min


in infants 2–12 months >50 breaths/min
co

co

in children >12 months >40 breaths/min


e.

e.

WHO, World Health Organization.


fre

fre
ks

ks

Come to terms: chest shapes


oo

oo

pectus carinatum = prominent sternum; pigeon chest


pectus excavatum = marked sternal depression
eb

eb

Harrison’s sulcus = indrawing of lower chest with rib flaring


e

(diaphragmatic tug)
m

90
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
10.  Dyspnoea? This will be manifest by increased respiratory

re

fre
effort ‘at rest’. Increased work of respiration is shown by
suprasternal, intercostal and subcostal recession. Unilateral
f
ks

s
recession is sometimes seen in lobar pneumonia or with

ok
oo

inhaled foreign body.

o
eb

eb
Increased rate and work of respiration are the most impor-

e
tant signs of pneumonia in infants.
m

m
11.  Is there finger clubbing? Clubbing of fingers and toes in
children is usually secondary to cyanotic congenital heart
disease or to chronic suppurative lung disease. If unsure
m

m
about finger clubbing, look at the great toe. Clubbing may
o

co
also be familial or associated with chronic diarrhoeal states.
.c

e.
Clubbed fingers have a loss of the angle between skin and
e

nail bed, increased convex curvature in both directions, may


re

fre
be beaked, and demonstrate transverse fluctuation.
f
ks

ks
oo

oo
eb

eb

e
m

m
m

m
co

co
e.

e.
fre

fre
ks

ks
oo

oo
eb

eb

e
m

Fig. 5.1  Finger clubbing.

91
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
12.  Presence of sputum: the expectoration of sputum is a rela-

re

fre
tive rarity in young children, being mainly the province of
fchildren with chronic suppurative lung disease, for example
ks

s
cystic fibrosis. Even though a cough may correctly be called

ok
oo

productive in infancy, sputum is not seen since it is swal-

o
lowed. Evanson & Maunsell (1838) correctly stated: ‘The
eb

eb
young child almost always swallows any matter expecto-

e
m

m
rated, and therefore this can scarcely become an object of
diagnosis.’ The swallowing of sputum is partly responsible
for the vomiting which frequently follows a bout of coughing
in childhood. Post-tussive vomiting is most typically seen in
m

m
pertussis.
o

co
13. Traumatic petechiae may sometimes be seen on the eyelids,
.c

e.
face and around the neck following a severe bout of cough-
e

ing. They may also occur following prolonged crying or


re

fre
enforced restraint as for a lumbar puncture.
f
ks

ks
oo

oo

Palpation
eb

eb

Palpation should include a comment on symmetry and

e
extent of chest expansion. Chest expansion should be about
m

m
3–5 cm in school age children.
The position of the trachea should be determined. Devia-
tion of the trachea is infrequent in infants and toddlers.
m

Vocal fremitus can be assessed by palpation of the infant’s


co

co

chest when crying. Transmitted sounds may be palpated.


e.

e.
fre

fre

Percussion
ks

ks

Percussion should of course be performed gently, compar-


ing sides. The percussion note in infants and toddlers tends
oo

oo

to be more resonant than in adults. Detailed percussion in


eb

eb

infants and toddlers may not be very rewarding. However,


e

in the preschool child and schoolchild percussion should be


m

carried out as in the adult.


92
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
Asthma at first sight?

re

fre
Asthmatic children may have:
f
ks

s
•   jerky respiration (up-down chest movement rather than

ok
oo

in-out movement)

o
•   a tendency to raise their shoulders towards their ears on
eb

eb
deep inspiration

e
m

m
•   an overblown upper chest while the lower chest may have an
early Harrison’s sulcus.

Auscultation
m

m
o

co
The stethoscope
.c

e.
The stethoscope should preferably have a paediatric dia-
e

phragm and bell; one sees many students today using the
re

fre
f
ks

ks
oo

oo
eb

eb

e
m

m
m

m
co

co
e.

e.
fre

fre
ks

ks
oo

oo
eb

eb

e
m

Fig. 5.2  Hyperinflated chest of asthma.

93
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
re

fre
f
ks

s
ok
oo

o
eb

eb

e
m

m
m

m
o

co
.c

e.
e
re

Fig. 5.3  Measuring maximal chest expansion. fre


f
ks

ks
oo

oo

diaphragm for all purposes. The bell is a much more useful


sound-piece for infants, toddlers and children.
eb

eb

e
m

m
The bell is best
•   The bell is smaller – the diaphragm of an adult stethoscope
m

covers a large area of the chest of a neonate or infant.


•   The bell is warmer – diaphragms can be very cold.
co

co

•   The bell applies better to the chest.


e.

e.

•   The bell allows less surface noise and is better attuned to
fre

fre

receive low-pitched chest sounds. Indeed, the latter-day chest


physician had no diaphragm on his stethoscope. Widespread
ks

ks

use of the diaphragm for auscultating chests is undesirable


oo

oo

and deplorable. The diaphragm is primarily designed for


cardiac signs and sounds.
eb

eb

Auscultation implies use of the ear plus the stethoscope.


m

Always listen carefully to the type of cough and attempt


94
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
re

fre
f
ks

s
ok
oo

o
eb

eb

e
m

m
m

m
o

co
.c

e.
e
re

fre
f
ks

ks
Fig. 5.4  Diaphragms can be cold, Doctor.
oo

oo
eb

eb

to describe it carefully. Listen for a grunt. An expiratory

e
grunt is very suggestive of a pneumonic process. An audible
m

m
wheeze, usually expiratory, is heard in a wide variety of
childhood lower respiratory infections, from wheezy bron-
chitis to bronchiolitis to bronchopneumonia. An expiratory
m

wheeze with prolonged expiratory phase is typical of bron-


co

co

chospasm associated with acute asthma.


It is important to remember that the stethoscope can be
e.

e.

an unreliable instrument in the infant. One is occasionally


fre

fre

struck by the finding of pneumonia on chest radiography in


ks

ks

an infant whose chest seemed remarkably clear.


A few words on transmitted sounds. These are often
oo

oo

heard in infants, especially frothy, mucousy infants, and


eb

eb

can cause confusion for students. Transmitted sounds are


e

sounds transmitted from the oropharynx to the chest, and


m

are common in infants and toddlers. These noises arise


95
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
from secretions in the upper respiratory tract, especially

re

fre
the oropharynx. Suction, coughing and physiotherapy may
clear such sounds. They are rough, sometimes leathery
f
ks

s
sounds that are often mistaken by students for a pleural

ok
oo

rub at first hearing.

o
The thin walls of the infant’s chest allows easy
eb

eb
conduction of sound from one side to another and gives

e
m

m
the impression of increased intensity of breath sounds to
the unfamiliar ear. Breath sounds in infancy have a broncho-
vesicular character. In the preschool and schoolchild breath
sounds assume the familiar vesicular quality heard in the
m

m
adult.
o

co
One needs to develop the ability to listen between cries,
.c

e.
to ignore surface movements and transmitted sounds and to
e

compare intensity of breath sounds from side to side.


re

fre
Pleural rub is an infrequent finding in preschool children.
f
ks

ks
Ausculation of childrens’ hearts or lungs through clothing
is utterly unacceptable.
oo

oo
eb

eb

e
Adventitious sounds
m

m
Wheeze = rhonchus = continuous sound = dry sound.
Crackle = crepitation = discontinuous sound = wet sound.
Wheeze in infants is due to air movement through a nar-
m

rowed airway, the narrowing of the tube being caused by:


co

co

•   mucosal oedema


e.

e.

•   excessive mucus


fre

fre

•   bronchospasm.
ks

ks

Of these, bronchospasm is probably the least important.


Several studies have failed to show any appreciable effects
oo

oo

of bronchodilators on wheezy infants under 1 year of age.


eb

eb

We can all see the ‘runny nose’ of rhinitis; consider the


e

‘runny chest’ as analogous. Wheeze can occur in a variety


m

of chest infections, as shown below.


96
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
Wheeze-associated respiratory infections (WARI)

re

fre
acute laryngotracheobronchitis
f
acute bronchitis
ks

s
acute bronchiolitis

ok
acute bronchopneumonia
oo

o
eb

eb

e
m

m
There is lack of uniformity and consistency in the termi-
nology of acute bronchitis. We accept the terms ‘wheezy
bronchitis’ and ‘spasmodic bronchitis’ as synonymous.
‘Winter bronchitis’ is not a helpful term. Most infants who
m

m
wheeze in infancy wheeze infrequently and with infec-
o

co
tion. When wheeze is recurrent the correct term is usually
.c

e.
‘asthma’, or if you wish, ‘asthmatic bronchitis’. There are, of
e

course, other causes of recurrent wheeze including aspira-


re

fre
tion syndromes, foreign body, cystic fibrosis and tracheal
f
ks

ks
compression.
A useful exercise in many systems, including the
oo

oo

respiratory system, is to draw out one’s findings in


eb

eb

diagrammatic form. Some examples are shown in Figures

e
5.5 and 5.6.
m

m
Rhonchi (wheeze, dry sounds) and crepitations (crack-
les, rales, wet sounds) are no different in children than in
adults and we will not describe them. However, it is wise to
m

remember that rhonchi in infants are generated by air flow


co

co

through a tube narrowed by oedema and mucus rather than


being due to bronchospasm per se.
e.

e.

In approaching diagnosis in respiratory infection we find


fre

fre

it useful to divide the respiratory tract into upper, middle


ks

ks

and lower. One too often meets the lazy diagnosis ‘URTI’
or ‘chest infection’ in charts today. This represents clinical
oo

oo

vagueness and uncertainty. One should attempt to be more


eb

eb

specific. There are at least six URTIs and ‘chest infections’.


e

In a similar vein, the modern term ‘pneumonitis’ is equally


m

imprecise.
97
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
re

fre
f
ks

s
ok
oo

o
eb

eb

e
m

m
Fig. 5.5  Left basal crepitations.
m

m
o

co
.c

e.
e
re

fre
f
ks

ks
oo

oo
eb

eb

e
Fig. 5.6  Right middle and lower lobe consolidation.
m

m
m

Upper respiratory tract infection (URTI)


co

co

rhinitis otitis sinusitis


tonsillitis mastoiditis pharyngitis
e.

e.
fre

fre
ks

ks

The term ‘croup’ has come to be a diagnosis. It is not.


The word ‘croup’, from the Scottish word ‘croak’, describes
oo

oo

the harsh, crowing, vibratory inspiratory stridor, usually


eb

eb

accompanied by a barking cough and hoarseness. Croup


e

has many causes, including infection, allergy and foreign


m

body.
98
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
Middle respiratory tract infection (croup)

re

fre
spasmodic laryngitis
f
laryngotracheobronchitis (LTB)
ks

s
epiglottitis (supraglottitis)

ok
oo

o
eb

eb

e
Similarly, the diagnostic designation of ‘chest infection’ is
m

m
not worthy of a medical student or doctor. ‘Chest infection’
is a layman’s term. Again, there are many types of infection
involving the lower respiratory tract.
m

m
o

co
.c

Lower respiratory tract infection (LRTI)

e.
e

tracheitis pneumonia bronchiolitis


re

bronchitis bronchopneumonia
fre empyema
f
ks

ks
oo

oo

Although diagnosis in acute respiratory tract infection


eb

eb

rests on a summation and interpretation of the findings,

e
experience has taught us that certain signs in infancy are
m

m
highly suspicious of certain conditions. Some examples are
listed in Table 5.2.
Somebody has described grunting as a form of
m

‘auto-PEEP’: that is, automatic positive end-expiratory


co

co

pressure.
e.

e.
fre

fre

Table 5.2  Signs highly indicative of underlying condition


ks

ks

Sign Condition
oo

oo

Croup Laryngitis, LTB


Wheeze Wheezy bronchitis (Table 5.3)
eb

eb

Full chest, frothiness Bronchiolitis (Table 5.4)


e

Flaring, grunting Bronchopneumonia (Table 5.5)


m

99
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
Table 5.3  Wheezy bronchitis

re

fre
Symptoms Signs
f
ks

s
Cough Tachypnoea, recession

ok
Wheeze Audible wheeze
oo

Low-grade fever Bilateral rhonchi

o
Variable upset
eb

eb

e
m

m
m

m
o

co
.c

e.
e
re

fre
f
ks

ks
Fig. 5.7  Wheezy bronchitis.
oo

oo

Table 5.4  Bronchiolitis


eb

eb

Symptoms Signs

e
Cough Oral frothiness
m

m
Wheeze Respiratory difficulty
Rapid breathing Over-inflated chest
Poor feeding Diffuse crepitations
m

m
Bilateral rhonchi
co

co
e.

e.
fre

fre
ks

ks
oo

oo
eb

eb

e
m

Fig. 5.8  Bronchiolitis.

100
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
Table 5.5  Bronchopneumonia

re

fre
Symptoms Signs
f
ks

s
Cough Flaring of nasal alae

ok
Wheeze Grunting
oo

Irritability Respiratory difficulty

o
Fever Unilateral or bilateral crepitations
eb

eb
Poor feeding Occasional rhonchi

e
m

m
m

m
o

co
.c

e.
e
re

fre
f
ks

ks
Fig. 5.9  Bronchopneumonia.
oo

oo
eb

eb

e
m

m
Occasional chest findings
1.  Pleuritic pain: children with pneumonia do occasionally complain of
sharp, severe pleuritic pain. Those old enough will point to the area.
Younger children may ‘splint’ the affected side. In our experience a
m

pleural rub is a rare finding in childhood, particularly in preschool


co

co

children.
2.  Pneumothorax: a small pneumothorax or pneumomediastinum may
e.

e.

occasionally complicate acute asthma or a severe coughing spell


fre

fre

in childhood (for example with pertussis). The pneumothorax is not


usually clinically demonstrable; however, auscultation of a loud
ks

ks

crunching noise synchronous with cardiac systole is characteristic.


3.  Subcutaneous emphysema is sometimes seen in acute asthma. The
oo

oo

cardinal clinical sign is a crackling feeling over the upper anterior


chest, over the clavicles or in the neck.
eb

eb

4.  Children with asthma sometimes complain of an itch in their throat.


e

5.  Tracheal pain is a prominent feature of acute bacterial tracheitis.


m

101
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
Textbooks tend to try to classify and may at times over-

re

fre
simplify. Bronchiolitis and bronchopneumonia can in prac-
tice be difficult to distinguish, the balance being tipped one
f
ks

s
way or the other, perhaps, by chest radiograph or peripheral

ok
oo

white cell count.

o
eb

eb
A compendium of coughs

e
m

m
Coughs may be dry or moist (productive). A productive
cough results from an inflammatory or infective exudate on
the bronchial mucosa. An intermittent or persistent dry cough
m

m
may imply irritation of the upper respiratory tract or of the
o

co
bronchial wall by a foreign body or extrinsic mass (glands).
.c

The appearance and amount of sputum should be assessed,

e.
e

remembering that children under 5 years swallow sputum.


re

fre
Clear mucoid sputum or tacky tenacious sputum is often
f

indicative of asthma. Green, yellow, grey (‘dirty’) sputum


ks

ks
usually indicates the presence of infection. Haemoptysis is
oo

oo

now a rare phenomenon in children in developed countries,


other than in children with advanced cystic fibrosis.
eb

eb

e
Listen to coughs and try to describe them. Below are
m

m
listed some of the commoner varieties.
•   Croupy cough: barking associated with stridor and
hoarseness.
m

•   Whooping cough: inspiratory gasp, prolonged distressing


co

co

cough, ending in a whoop, followed by vomiting.


•   ‘Chesty’ cough: moist, fruity, productive cough.
e.

e.
fre

fre

The type and timing of a cough (Table 5.6) can be important


in deciding on the underlying respiratory problem.
ks

ks
oo

oo

Bacterial or viral illness?


eb

eb

Some simple clinical generalizations may assist in sepa-


e

rating viral from bacterial aetiology bearing in mind that


m

exceptions to rules always occur.


102
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
Table 5.6  Type and timing of cough

re

fre
Cough Suggests
f
ks

s
Non-productive nocturnal Postnasal drip, asthma

ok
On exercise Asthma
oo

Paroxysmal Pertussis, foreign body

o
During or after feed Inhalation
eb

eb
Productive in morning Cystic fibrosis, asthma

e
Bovine brassy Tracheitis
m

m
Absent during sleep Psychogenic
m

m
1.  Viruses tend to spread to several sites – throats, ears, skin. A
typical example is the diffuse redness of measles.
o

co
.c

2.  Bacteria tend to localize to one site – lobe of lung, single joint,

e.
e

abscess. However, bacteraemias and septicaemias certainly occur.


re

fre
3.  Bacteria tend to produce pus: for example, follicular tonsillitis.
However, infectious mononucleosis produces a creamy
f
ks

ks
tonsillar exudate.
oo

oo

4.  Children tend to be more toxic with severe bacterial


infections. Delirium, for example, is typically associated with
eb

eb

pneumococcal pneumonia.

e
m

m
Suspect pneumococcal pneumonia
delirium
pleuritic pain
m

rusty sputum
co

co

herpes labialis (cold sore)


e.

e.
fre

fre

The following illnesses can be confidently diagnosed as


almost certainly being viral:
ks

ks

•   rhinitis
oo

oo

•   pharyngitis
eb

eb

•   laryngotracheobronchitis
e

•   bronchiolitis
m

•   wheezy bronchitis.


103
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
The infant/toddler with systemic viraemia looks miserable,

re

fre
has watery, puffy eyes, runny nose, usually a rash and often
a harsh cough.
f
ks

s
ok
oo

o
THE CARDIOVASCULAR SYSTEM
eb

eb

e
Congenital heart disorders (CHD), with an incidence of
m

m
close to 1 per 100 neonates, are the second most common
defects encountered. About half of congenital heart disor-
ders may be detected in the neonatal period; the remain-
m

m
ing will not present until later – hence the importance of
o

co
routine examination at various ages. There are some 40
.c

described varieties of CHD, of which only about 10 are

e.
e

frequent. For convenience we might classify them as


re

follows:
fre
f
ks

ks
Cyanotic CHD: transposition of the great vessels
oo

Fallot’s tetralogy
oo

pulmonary atresia
eb

eb

Potentially cyanotic CHD atrial septal defect

e
   (left-right shunts): ventricular septal defect
m

m
patent ductus arteriosus
Obstructive CHD: coarctation of aorta
pulmonary stenosis
m

aortic stenosis.
co

co

The symptoms and signs suggesting congestive cardiac


e.

e.

failure associated with congenital heart disease in infancy


fre

fre

are:
ks

ks

•   tachypnoea (respiratory rate > 50–60 breaths/min at rest)


•   dyspnoea at rest or following a feed – inability to finish a
oo

oo

feed due to dyspnoea is characteristic


eb

eb

•   sweating – some refer to the circle of sweat on the sheet


e

around the infant’s head as the ‘halo sign’


m

•   unusual weight gain, greater than expected for caloric intake.
104
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
The weight gain signifies fluid retention

re

fre
•   tachycardia (heart rate >140–160 beats/min at rest)
•   hepatomegaly
f
ks

s
•   gallop rhythm

ok
oo

•   cyanosis, especially central – nursing the infant in 100%

o
oxygen may help to distinguish cardiac from respiratory
eb

eb
cyanosis.

e
m

m
Note: Pulmonary crepitations and oedema are relatively late
signs of cardiac failure.
m

m
o

co
.c

Temperature and heart/respiratory rate

e.
e

1°C → increased heart rate: 10 beats/min


re

fre
1°C → increased respiratory rate: 4 breaths/min
f
ks

ks
oo

oo

Approach to cardiovascular examination


eb

eb

Start at the periphery and work towards the heart. Look for

e
cyanosis, clubbing, respiratory difficulty, anaemia or poly-
m

m
cythaemia. Jugular venous pulse and pressure are difficult to
appreciate in infancy due to the relative shortness of the neck.
We would agree with John Apley’s approach to exami-
m

nation of the heart: ‘Use your eyes and hands before your
co

co

ears. Leave the heart to last; and when you come to it leave
auscultation to the last’.
e.

e.
fre

fre

The pulse
ks

ks

Pulses should be felt over the radial, brachial and femoral


oo

oo

arteries. Preferably use finger pulps; if in difficulty use of


eb

eb

thumbs is allowable, if not desirable. Femoral pulses, often


e

difficult to palpate, must always be sought, otherwise coarc-


m

tation of the aorta will be missed. If femoral pulses are


105
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
thought to be diminished, look for evidence of radio-fem-

re

fre
oral delay – this can be hard to detect at rapid heart rates.
Palpation of the dorsalis pedis pulse effectively excludes
f
ks

s
coarctation in infancy. Preauricular pulse is easily felt in

ok
oo

sleeping infants.

o
eb

eb

e
Pulse volume
m

m
Is the pulse of normal, full or small volume? Appreciation of
normal volume, with the finger pulp or tips, implies palpa-
tion of many pulses. Full volume pulses, due to a wide pulse
m

m
pressure, are best appreciated at the radial pulse; easily pal-
o

co
pable foot pulses in neonates and infants may be indicative
.c

e.
of increased pulse pressure.
e

A thready, weak or small volume pulse is indicative of


re

fre
reduced pulse pressure. Most often it is felt in hypoten-
f
ks

ks
sion or impending shock in infants. Pulsus paradoxus is an
appreciable change in pulse volume with respiration.
oo

oo
eb

eb

e
Pulse rate
m

m
Pulse rate is related to age and activity with variations
brought on by distress, fever, excitement and exercise. The
value of simple but careful observation of the pulse can be
m

emphasized by the fact that the earliest signs of rheumatic


co

co

fever are (a) a fixed tachycardia (no variation between sleep


and awake pulse) and (b) loss of sinus arrhythmia.
e.

e.

The pulse rate will rise approximately 10 beats/min for


fre

fre

every 1°C rise in temperature. The normal heart rate at rest


ks

ks

is shown in Table 5.7.


oo

oo

Normal pulse variation


eb

eb

•   Sinus arrhythmia – an increase in pulse rate on inspiration,


m

with slowing on expiration. Very common in children.


106
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
Table 5.7  Normal heart rate at rest

re

fre
Age Average rate Upper limit of normal
f
ks

s
  0–6 months 140 160

ok
  6–12 months 130 150
oo

  1–2 years 110 130

o
  2–6 years 100 120
eb

eb
  6–10 years   95 110

e
10–14 years   85 100
m

m
m

m
•   Occasional ectopics – need be of no concern.
o

co
•   Bradycardia (pulse rate <60 beats/min) in fit children and
.c

e.
adolescents, especially in good swimmers.
e
re

fre
•   Slight tachycardia with excitement due, for example, to clinic
attendance or hospital admission.
f
ks

ks
oo

oo

Blood pressure
eb

eb

This is dealt with below. Postural hypotension is an infre-

e
quent finding in children. Appreciation of postural hypoten-
m

m
sion (a fall of 20 mmHg systolic blood pressure on adopting
the upright posture) is an important sign of hypovolaemia.
Blood pressure should be routinely measured in infants
m

and children with congenital heart disease. Indeed we


co

co

suggest blood pressure measurement on all children admit-


ted to hospital, on most attending outpatient clinics, and in
e.

e.

all sick neonates and infants.


fre

fre
ks

ks

Colour
oo

oo

Central cyanosis is easily detected. Prolonged central


eb

eb

cyanosis may result in plethoric appearance due to poly-


e

cythaemia. Children with severe cyanosis sometimes


m

adopt the squatting position after exercise – this increases


107
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
peripheral resistance, increases pulmonary venous return

re

fre
and increases left-to-right shunting of blood.
Clubbing is dealt with on page 91.
f
ks

s
ok
oo

Blood pressure (Tables 5.8 and 5.9)

o
eb

eb
The most obvious statement about children’s blood pressure

e
m

m
is that it is not taken. Not taken at all, not taken often enough,
or not taken seriously. It is too often held that measurement
of blood pressure in infants and children is difficult and time-
consuming, and results are usually normal. Measurement of
m

m
blood pressure in children merely requires patience, practice
o

co
and a selection of cuffs from 3 cm to 13 cm wide.
.c

e.
e
re

Technique
fre
f
ks

ks
Record blood pressure on right arm.
oo

Child preferably seated or standing.


oo
eb

eb

e
Table 5.8  Normal systolic blood pressure (BP)
m

m
Age Systolic BP Standard Upper limit of normal
(years) (mmHg) deviation (+ 2SD)
1 (neonate)   60–70 10   90
m

1–4 (toddler)   90 10 110


co

co

6 100 10 120
8 105 10 125
e.

e.

10 110 10 130
12 115 10 135
fre

fre

14 120 10 140
ks

ks

Alternatively, systolic BP = 100 mmHg at age 6 years. BP rises by


approximately 2.5 mm/year thereafter. (From Report of Task Force
oo

oo

on blood pressure control in children. Paediatrics 1977; 59: 803.)


Some ‘rounding off’ of standard deviation and other figures has
eb

eb

been done for easier memorability. None of the figures quoted


e

differs significantly from ‘Task Force’ values.


m

108
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
Table 5.9  Normal diastolic blood pressure (BP)

re

fre
Age Diastolic BP Standard Upper limit of normal
f
ks

s
(years) (mmHg) deviation (+ 2SD)

ok
  2 62 8 78
oo

  4 64 8 80

o
  6 66 8 82
eb

eb
  8 70 8 86

e
10 72 8 88
m

m
12 74 8 90
14 76 8 92
Or 60 + age in years = approximately mean diastolic. (From Report
m

m
of Task Force on blood pressure control in children. Paediatrics
o

co
1977; 59: 803.)
.c

Some minor ‘rounding off’ of standard deviation and other figures

e.
has been done for easier memorability.
e

Up to the age of 12 years there are no appreciable differences


re

between boys’ and girls’ BP.


fre
f
ks

ks
oo

oo
eb

eb

e
m

m
m

m
co

co
e.

e.
fre

fre
ks

ks
oo

oo
eb

eb

e
m

Fig. 5.10  Measuring blood pressure in children.

109
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
Child should be relaxed – pressures recorded during crying

re

fre
are unreliable.
fUse the largest cuff width which comfortably fits the upper
ks

s
arm.

ok
oo

Ensure the inner bladder encircles the arm.

o
Doppler ultrasound recording for neonates and infants.
eb

eb
Standard auscultatory sphygmomanometry for older children.

e
m

m
Keep arm–heart–sphygmomanometer on same horizontal
plane.

Diastolic pressure preferably recorded at point of muffling


m

m
(phase 4). There is no clear point of muffling in about 5% of
o

co
children. When this occurs, record phase 5 as the diastolic
.c

pressure.

e.
e

If there is significant difference between phase 4 (muf-


re

fre
fling) and phase 5 (disappearance of sounds), record both
f

points.
ks

ks
Suggested shorthand notation for blood pressure:
oo

oo
°<

Standing
eb

eb

° Sitting

e
m

m
° < Lying

Note the arm used and the cuff size.


Remember that anxiety plus faulty technique are prob-
m

ably the commonest explanations of elevated blood pressure


co

co

in children. Single raised values are of no significance; they


must be repeated several times. Blood pressures recorded
e.

e.

on admission to hospital are notoriously unreliable. The


fre

fre

combination of anxiety plus obesity in the child may also


ks

ks

falsely elevate blood pressure. Getting the child to watch the


mercury rise and fall can be helpfully distracting (Fig. 5.10).
oo

oo

In the newborn, especially if sick, Doppler ultrasonic


eb

eb

methods or oscillometric methods provide the most accu-


e

rate and reproducible measurements of blood pressure. The


m

flush method is an unreliable measure of blood pressure.


110
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
In infancy, the standard auscultatory method can be used

re

fre
with patience and perseverance. By and large, toddlers do
not like having blood pressure recorded, and there is a
f
ks

s
dearth of good data in this age group.

ok
oo

From age 5 years blood pressure is easily recorded in

o
children, and some commentators are now suggesting that it
eb

eb
be recorded annually – not necessarily to detect abnormality

e
m

m
but to establish normality. A range of cuff widths – 7 cm,
9 cm, 11 cm and 13 cm – will be required. We use the simple
rule that the largest cuff which fits comfortably around the
arm should be applied. The child should be the recipient of
m

m
any doubt concerning blood pressure recording.
o

co
.c

e.
e

Frequent errors in blood pressure measurement


re

failure to perform
fre
f

cuffs that are too small


ks

ks
anxious, crying children
oo

oo

oscillations around systolic blood pressure – if you cannot hear phase 1


or phase 5, deflate and start again
eb

eb

over-reliance on automated machines.

e
m

The heart
m
m

Having documented pulse rate, volume, blood pressure,


colour, respiratory rate and effort, one may proceed towards
co

co

the heart. Here the classical skills of inspection, palpation,


e.

e.

percussion and auscultation apply. We shall only refer to


fre

fre

findings applicable to children.


ks

ks

Inspection
oo

oo

Here one is seeking two major things:


eb

eb

•   a precordial bulge


m

•   visible ventricular impulse.


111
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
A precordial bulge will cause the sternum and ribs to

re

fre
bow forwards, giving the chest an overblown appearance.
The right ventricular impulse may be visible under the
f
ks

s
xiphisternum. The left ventricular impulse (or apex beat)

ok
oo

is frequently visible in thin children, in children with hyper-

o
dynamic circulation (due to fever or excitement) and in chil-
eb

eb
dren with true left ventricular enlargement.

e
m

m
Palpation
Palpation implies localization of the apex beat, a search for
m

m
right or left ventricular enlargement, and an appreciation
o

co
of palpable sounds or murmurs. A palpable murmur is
.c

e.
referred to as a thrill.
e

Right ventricular enlargement is best sought with one’s


re

fre
fingertips placed between 2nd–3rd–4th ribs along the left
f
ks

ks
sternal edge. Some people prefer to use the side of their
hand when assessing the right ventricle. The abnormal pal-
oo

oo

pation in right ventricular hypertrophy is called a tap or a


eb

eb

lift. A slight right ventricular tap may be felt through the

e
chest wall of thin children; it is a normal finding. The apex
m

m
beat is found in the 4th intercostal space along the midcla-
vicular (or nipple) line in infants and toddlers. It may be
difficult to localize in plump, healthy infants and toddlers.
m

If you cannot locate the apex beat, think of dextrocardia or


co

co

a pericardial effusion (both rare phenomena).


In schoolchildren the apex beat is in the 4th–5th left
e.

e.

intercostal space in the midclavicular line. Left ventricular


fre

fre

hypertrophy can result in a diffuse, forceful and displaced


ks

ks

apex beat. The feeling is described as a heave.


Palpation of a thrill is always significant. A thrill in the
oo

oo

suprasternal notch may suggest coarctation or aortic steno-


eb

eb

sis. A palpable heart sound usually implies accentuation of


e

that sound (usually pulmonary second sound). Palpation


m

may reveal whether the heart is active or hyperdynamic.


112
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
Percussion

re

fre
We do not find percussion of the heart particularly helpful.
f
ks

s
However, you may be asked to demonstrate cardiac percus-

ok
sion in an examination. The technique is as for an adult.
oo

o
eb

eb
Auscultation

e
m

m
Auscultation, as stated earlier, should always be left to last,
remembering then the old adage – ‘sounds first, murmurs
second’. Insofar as students are concerned the majority of
m

m
murmurs are systolic until proved otherwise. If you can
o

co
appreciate diastolic murmurs at the fast heart rates of
.c

infancy, you are well tuned into auscultation. We do not

e.
e

propose to reiterate the routine of cardiac auscultation,


re

which is the same at all ages.


fre
f

When listening:
ks

ks
•   try to ensure the child is not crying
oo

oo

•   use both diaphragm and bell (preferably paediatric sizes)


eb

eb

•   listen with the child in lying and sitting positions

e
•   note any variation with respiration.
m

m
Sounds first. The first sound is best heard at the apex with
the bell and the second at the base with the diaphragm. In
m

infancy, the first sound may be louder than the second. A


soft first sound is an early sign of carditis. The first sound
co

co

may be normally split.


e.

e.

The second sound is usually split in children, this


fre

fre

split being physiological and widening on inspiration.


A third heart sound may be a normal finding in some
ks

ks

children.
oo

oo

Murmurs. Insofar as students are concerned paediatric


murmurs pose two problems:
eb

eb

•   hearing them at all


m

•   distinguishing between a significant and an innocent murmur.


113
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
When listening for murmurs try to wipe out all extraneous

re

fre
noise and listen between the first and second sounds very
carefully, using both diaphragm and bell in all cardiac areas.
f
ks

s
It is usual to grade murmurs 1–6 in an arbitrary fashion for

ok
oo

recording purposes. We propose the simple system given

o
in the box.
eb

eb

e
m

m
Murmur mnemonic
grade 1: barely audible, innocent
grade 2: soft, variable, innocent usually
m

m
grade 3: easy to hear, intermediate, no thrill
o

co
grade 4: loud, audible to anybody, thrill
.c

grade 5: sounds like a train, very significant, thrill

e.
e

grade 6: scarcely requires a stethoscope, thrill


re

fre
f
ks

ks
Murmurs of grades 4–6 are always significant. Grades
oo

oo

1–2 are usually innocent, and grade 3 is intermediate. The


eb

eb

length of the murmur is important, pansystolic implying

e
significance, midsystolic suggesting innocence.
m

m
Innocent murmurs (also known as physiological, ejection,
or flow murmurs) are very common in childhood (being
heard in up to 50% of children). Their distinguishing fea-
m

tures are displayed below.


co

co
e.

e.

Innocent murmurs: usual features


fre

fre

midsystolic
ks

ks

soft in intensity (grades 1–3)


localized
oo

oo

poorly conducted
musical or vibratory in character
eb

eb

variable with position and respiration


e

not associated with other signs of heart disease


m

114
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
Significant murmurs: usual features

re

fre
pansystolic
f
conducted all over precordium
ks

s
soft to loud (grades 4–6) in intensity

ok
associated with a thrill
oo

o
accompanied by other signs, e.g. ventricular enlargement
eb

eb
any diastolic

e
m

m
One innocent murmur which may cause difficulty is the
venous hum. This is a low-pitched, continuous, rumbling
m

m
murmur, best heard under the right clavicle. It is usually
o

co
louder when sitting up, diminishes on lying, and may be
.c

abolished by obliterative pressure over the internal jugular

e.
e

vein.
re

fre
The first hurdle for the student is to distinguish signifi-
f

cant murmurs from innocent murmurs. Clearly all murmurs


ks

ks
must be properly described – systolic, diastolic, loudness,
oo

oo

duration, point of maximal intensity, conduction, etc. Dia-


stolic murmurs are relatively infrequent in children and
eb

eb

e
so require extraordinary auscultatory care if they are to
m

m
be heard. If the student can determine that the murmur
is significant, the next step will be to determine its origin.
This will require consideration of colour, pulses, ventricu-
m

lar impulses, heart sounds and the characteristics of the


murmur. At undergraduate level, examiners are usually
co

co

content with elicitation and elucidation of murmurs. If


e.

e.

pressed towards a diagnosis, the following points may help:


fre

fre

•   cyanosis + murmur usually Fallot’s tetralogy


ks

ks

•   cyanosis + murmur + operation   possibly Fallot’s tetralogy


   or transposition of great
oo

oo

   arteries
eb

eb

•   pink + loud systolic murmur probably ventricular septal


e

   defect (the single


m

   commonest form of CHD)


115
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
re

fre
f
ks

s
ok
oo

o
Fig. 5.11  A cardiac murmur.
eb

eb

e
m

m
•   pink + murmur + impalpable probably coarctation of
   femorals    aorta
•   continuous low-pitched possibly patent ductus
m

m
   murmur    arteriosus
o

co
It is good practice to draw a diagram of the features of a
.c

e.
cardiac murmur (Fig. 5.11).
e
re

fre
f

THE ABDOMEN
ks

ks
In this section we propose to discuss the routine examina-
oo

oo

tion of the abdomen, including the genitalia and rectum.


eb

eb

We will not refer to palpation or auscultation of the ‘acute

e
surgical abdomen’. First a few words on vomiting.
m

Vomiting m
m

Vomiting requires definition and in terms of amount, remem-


co

co

ber that mothers and nurses tend to overestimate volume of


vomitus. What is its frequency and timing? What does it
e.

e.

contain – undigested milk, blood, food, bile? Is it forceful


fre

fre

or effortless? Try to distinguish projectile vomiting from


ks

ks

regurgitant, apparently effortless vomiting. Separate small


‘spits’ from true vomits. All babies vomit occasionally. Is the
oo

oo

vomiting related to feeds? Are feeding volumes appropri-


eb

eb

ate? Is he hungry after he vomits? The statement ‘He’s still


e

hungry despite the vomiting’ is very characteristic of pyloric


m

116
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
stenosis. Does the vomiting bother him? Does the vomiting

re

fre
bother his mother? What has she done about it?
f
ks

s
ok
oo

Inspection

o
eb

eb
The abdomen in toddlers and children is usually protuber-

e
ant in the upright posture. Even experienced physicians
m

m
have difficulty distinguishing a normal ‘pot-belly’ from a
pathological one. Abdominal protrusion is often related to
exaggerated lordosis in the upright position.
m

m
Respiration is normally abdominal in type up to
o

co
schoolgoing age. Small umbilical hernias are a frequent
.c

finding. Slight separation (divarication) of the rectus muscles

e.
e

is normal. Distended veins may be noted. Visible loops of


re

fre
bowel are sometimes noted in malnourished infants.
f

Abdominal fat in growth hormone deficient children


ks

ks
resembles ‘cellulite’ in adults.
oo

oo

Epigastric hernias are infrequent. By contrast inguinal


hernias are common, especially in the male infants. Intra-
eb

eb

e
abdominal masses are occasionally visible. Wilms’ tumours
m

m
can come to medical attention when parents note the swell-
ing on bathing their child. Draw in and label any operative
scars you inspect.
m

Abdominal distension is often gaseous. Simple per-


cussion can help to distinguish between solid, cystic and
co

co

gaseous distension. Abdominal distension could be:


e.

e.

•   fat
fre

fre

•   fluid
ks

ks

•   faeces
•   flatus
oo

oo

•   visceromegaly
eb

eb

•   muscle hypotonia


e

•   exaggerated lordosis.


m

117
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
Palpation

re

fre
It is of prime importance to have the infant and child relaxed
f
ks

s
when trying to palpate the abdomen. This will require

ok
patience, skill and distraction techniques. Hands must be
oo

warm. Try to avoid making the child cry! You may occa-

o
eb

eb
sionally have to palpate the abdomen with the infant crawl-

e
ing. Some toddlers will allow you to palpate their abdomen
m

m
while standing, but object vociferously once you lie them
down.
The purpose of abdominal palpation is to:
m

m
o

co
•   seek the presence of normal abdominal structures.
.c

•   detect enlargement of abdominal organs.

e.
e

•   seek abnormal masses or fluid.


re

fre
f
ks

ks
Feeling the spleen
oo

oo

The spleen is to be found in the left upper abdominal


eb

eb

quadrant and is normally palpable 1–2 cm below the

e
left costal margin in infancy. It is soft and can be tipped on
m

m
inspiration.
The enlarged spleen moves on respiration, is dull to per-
cussion, has a notch and one cannot get above it. Don’t poke
m

for spleens. Lay your right hand gently on the abdomen


co

co

and allow the spleen to come to meet it, with your left
hand below. Splenic size should be recorded in centimetres
e.

e.

below the costal margin. Very large spleens can be missed,


fre

fre

if one fails to begin palpation below the umbilicus and work


ks

ks

slowly upwards. The splenic notch is occasionally visible.


With chronic enlargement the spleen will usually become
oo

oo

firmer. It is rarely tender. The spleen may enlarge medially


eb

eb

towards the umbilicus or downwards toward the left iliac


e

fossa. Splenic enlargement tends to be directly downwards


m

in infancy.
118
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
re

fre
f
ks

s
ok
oo

o
eb

eb

e
m

m
m

m
o

co
.c

e.
e
re

fre
f
ks

ks
oo

oo
eb

eb

e
m

Fig. 5.12  Palpating the abdomen of the toddler standing on a couch.


m
m

m
co

co

Palpating the liver


e.

e.

The liver is a relatively busier and larger organ in infants.


fre

fre

A liver 1–2 cm below the right costal margin is considered


ks

ks

normal up to the age of 2–3 years. The liver when enlarged


is easily palpable in infants and children. Its edge is soft and
oo

oo

it moves down with respiration.


eb

eb

When palpating for the liver don’t poke as this will


e

provoke tightening of the abdominal muscles. Approach


m

from the right iliac fossa (RIF) with the tips of the fingers
119
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
re

fre
f
ks

s
ok
oo

o
eb

eb

e
m

m
m

m
o

co
.c

e.
e

Fig. 5.13  Palpating the spleen.


re

fre
f
ks

ks
oo

oo

or the side of the index finger, lay one’s fingers gently on


eb

eb

the abdomen and allow the child’s respiratory movement to

e
bring the liver to meet your fingers.
m

m
Measure liver breadth in centimetres, not fingers. It can
be useful to percuss out liver dullness and to express total
liver size in centimetres, rather than its level below the costal
m

margin. However, determining the upper border may not


co

co

be easy. Liver span is 6–12 cm in children aged 6–12 years.


A normal-sized liver may be pushed down by a flattened
e.

e.

diaphragm, as in bronchiolitis.
fre

fre

The liver breadth below the costal margin is a very useful


ks

ks

indicator of congestive cardiac failure in infants. Indeed


enlargement of the liver can be the earliest sign of incipient
oo

oo

cardiac failure.
eb

eb

We have not found the scratch test to be particularly


e

helpful in determining liver size. Palpation and percussion


m

should suffice.
120
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
re

fre
f
ks

s
ok
oo

o
eb

eb

e
m

m
m

m
o

co
.c

e.
e
re

Fig. 5.14  Palpating the liver.


fre
f
ks

ks
There are many causes of hepatomegaly in children, from
oo

oo

storage diseases to tumours. Liver tenderness is sometimes


eb

eb

seen in acute hepatitis.

e
In summary, the liver is characterized by the following:
m

m
•   a palpable edge in the right hypochondrium
•   movement with respiration
m

•   dullness to percussion


•   inability to get above the swelling.
co

co

Palpable nodules and audible bruits over the liver are dis-
e.

e.

tinctly unusual in paediatrics. Liver smallness (or atrophy)


fre

fre

is almost impossible to clinically designate in children, since


ks

ks

inability to palpate a liver is not in itself abnormal.


oo

oo

The kidneys
eb

eb

The kidneys are not easily palpable in infants and children,


m

despite the claims by some authors. Indeed we would say to


121
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
the inexperienced student – if you can palpate the kidneys

re

fre
they are probably enlarged.
In the hypotonic newborn the kidneys (especially the
f
ks

s
lower pole) should be palpable and ballotable. Kidneys

ok
oo

move on respiration, have a smooth outline, and one can get

o
above them. Kidneys are best palpated bimanually; we have
eb

eb
not been impressed by the technique of using the thumbs

e
m

m
on anterior approach. The normal fetal lobulation of the
newborn kidney is not clinically appreciable.
Enlargement of the kidney in the newborn may be
bilateral or unilateral. If unilateral, consider congenital
m

m
mesonephroma/nephroblastoma (Wilms’), multicystic dys-
o

co
plasia, hydronephrosis, renal vein thrombosis (where the
.c

e.
kidney is strikingly firm). If bilateral, renal enlargement
e

may indicate polycystic disease, bilateral obstructive uropa-


re

fre
thy (secondary to urethral valves) or congenital nephrotic
f
ks

ks
syndrome.
oo

oo
eb

eb

Bladder

e
m

m
The bladder can be palpated in the neonate and
infant (since it is an abdominal organ) and is easily percussi-
ble when full. A very full bladder may sometimes be visible.
m

m
co

co

Genital examination
e.

e.

Students need to be aware that children are modest, shy


fre

fre

and are taught to be reticent regarding genital inspection


ks

ks

by strangers. It is therefore very important for students to


introduce themselves, explain who they are, what they are
oo

oo

doing and why they are doing it.


eb

eb

Inspection and examination of the genitalia is a routine


e

part of examination of infants, toddlers and schoolchildren.


m

More is learnt by inspection than by palpation.


122
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
Genital examination should always be performed in the

re

fre
presence of the mother or a nurse.
Under no circumstances should unsupervised examina-
f
ks

s
tion of the vagina be performed in young girls. The normal

ok
oo

vaginal appearances can be learned from videos. Inspection

o
of the perineum is part of the examination of girls. It is not,
eb

eb
however, necessary to separate the labia or do any form of

e
m

m
internal examination. If the labia need to be separated, this
is best done by the mother.
In boys, inspection of the penis and testes is part of the
routine examination. In the male one is looking for normal-
m

m
ity (or deviation therefrom) of the penis, scrotum and testes.
o

co
Students need to check that the penis is of normal size,
.c

e.
that the meatus is properly positioned and that the testes
e

are descended. Many ‘undescended testes’ are found on


re

fre
re-examination to represent retractile testes; the over-hasty
f
ks

ks
approach of cold hands has induced a brisk cremasteric
reflex. Indeed any self-respecting testis will ‘run for cover’
oo

oo

if approached threateningly in this fashion. Don’t attack


eb

eb

the testes! Occasionally retraction of the foreskin may be

e
necessary to detect phimosis, etc. The examination of male
m

m
external genitalia can be often satisfactorily performed by
inspection only.
Is the urethral orifice at the normal position on the tips
m

of the glans? If not is there epispadias (dorsal opening)


co

co

or hypospadias (ventral opening)? Hypospadias may be


glandular (common), penile (rare) or perineal (very rare)
e.

e.

(see p. 60).
fre

fre
ks

ks

Male genitalia
oo

oo

Enlargement of the penis occurs in certain endocrine and


eb

eb

neurological conditions. Note that in congenital adrenal


e

hyperplasia the penis is large, but testicular volume is


m

normal. The commonest explanation of a small penis is a


123
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
normal penis buried in fat. True micropenis (where there

re

fre
may be little palpable other than penile skin and urethra) is
rare. Normal penile lengths and circumferences have been
f
ks

s
published.

ok
oo

Inspection of the scrotum should reveal normal rugosity

o
and visible testes. In toddlers and boys, testes are best exam-
eb

eb
ined in the standing position. The next choice is lying flat on

e
m

m
the couch, and the final attempt is made with the child in a
squatting position. The squatting position helps to abolish
the cremasteric reflex and is most valuable in those cases of
retractile testes (Fig. 5.16).
m

m
A small, flat, underdeveloped scrotum may signify true
o

co
maldescent. If uncertain about undescended testes always
.c

e.
repeat the examination. Undescended testes are a common
e

finding in preterm baby boys.


re

fre
Knowledge of normal testicular volume is an attribute
f
ks

ks
not obtained by most practitioners; all that is required is an
oo

oo
eb

eb

e
m

m
m

m
co

co
e.

e.
fre

fre
ks

ks
oo

oo
eb

eb

e
m

Fig. 5.15  Cremasteric reflex.

124
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
re

fre
f
ks

s
ok
oo

o
eb

eb

e
m

m
m

m
o

co
.c

e.
e
re

fre
f
ks

ks
Fig. 5.16  Squatting for examination of testes.
oo

oo
eb

eb

appreciation of approximate normality. Prader (of Zurich)

e
has produced an orchidometer (or ‘testicular rosary’) giving
m

m
a range of testicular volumes. Awareness of testicular
volume may be important, for example, in assessing chil-
dren with leukaemia (the testes may be a site of relapse), or
m

in following a surgically corrected torsion of the testis (is the


co

co

testis growing normally?).


Enlargement of the scrotum may be due to an enlarged
e.

e.

testis, a hydrocele (transilluminable) or an inguinal hernia.


fre

fre

Hydroceles are common in neonates.


ks

ks
oo

oo

Female genitalia
eb

eb

The vulva is usually inspected in girls. Adhesions of the


e

labial mucosa are not infrequent. Vaginal palpation is


m

not usually performed unless there are clear-cut clinical


125
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
indications, such as suspected foreign body, suspected

re

fre
sexual abuse, vaginal discharge.
The clitoris is prominent in preterm baby girls. A bloody
f
ks

s
postnatal vaginal discharge (‘newborn period’) is an occa-

ok
oo

sional normal event. The uterus and ovaries are not nor-

o
mally palpable in infants and children.
eb

eb

e
m

m
Come to terms: abdomen
m

m
atresia = closed lumen
omphalocele (exomphalos) = midline hernia containing abdominal
o

co
.c

contents, sac covers

e.
gastroschisis = paramedian hernia, no sac
e

urachus = embryological connection from bladder to


re

umbilicus
fre
f
ks

ks
oo

oo
eb

eb

e
Examining for ascites
m

m
Ascites in the newborn may be:
•   a transudate, as in hydrops, heart failure
m

•   an exudate, in peritonitis


•   biliary (rupture of common bile duct)
co

co

•   urinary (spontaneous or traumatic rupture of the bladder)


e.

e.

•   chylous (rupture of lymphatic duct).


fre

fre

Of the above, only a transudate is in any way common.


ks

ks

Ascites is also seen in chronic liver disease and is a fairly fre-


quent accompaniment of the nephrotic syndrome in child-
oo

oo

hood.
eb

eb

The ability to demonstrate ascites is frequently sought


e

by examiners, and is therefore an important clinical skill to


m

acquire correctly.
126
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
Gross ascites:

re

fre
•   may be obvious on inspection
f
ks

s
•   the abdomen is distended

ok
•   the umbilicus is everted
oo

•   there are obvious pressure marks on the skin

o
eb

eb
•   the flanks are full

e
•   the skin looks oedematous
m

m
•   the vulva or scrotum are full.

A ‘fluid thrill’ is an unreliable sign, and can easily be elicited


(incorrectly) in very obese children. More reliable by far is
m

m
the sign of ‘shifting dullness’. In looking for dullness one
o

co
should percuss from resonant (above) to dullness (below).
.c

e.
If there is definite dullness in the flank, the child should be
e

rolled onto one side, and a change to resonant percussion


re

fre
note sought – ‘shifting dullness’. One must be careful not
f
ks

ks
to percuss over the iliac crest in determining flank dullness.
The distribution of ascitic dullness is ‘horseshoe shaped’.
oo

oo

The child should be allowed to lie on his side for 30–60


eb

eb

seconds before checking for dullness. The child with ascites

e
m

m
m

m
co

co
e.

e.
fre

fre
ks

ks
oo

oo
eb

eb

e
m

Fig. 5.17  Distribution of ascitic fluid.

127
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
may have a ‘jelly belly’: that is, a feeling of free mobile fluid

re

fre
in the abdomen.
f
ks

s
ok
Putting your finger in the rectum
oo

o
Rectal examination is not routine in children. Always explain
eb

eb
to children before you do it. Tell him you hate doing it, but

e
m

m
have to. Always use lubrication. Relax the child as best
you can. Rectal examination is most often done in acute
abdomens, chronic constipation and rectal bleeding. Use
the little finger for little children (neonates and infants) and
m

m
index finger for older children. Lie the child on his side
o

co
with legs drawn up. Approach the rectum from the infe-
.c

e.
rior, always taking the opportunity to inspect the perianal
e

area prior to inserting one’s finger. One occasionally may


re

fre
see threadworms, skin tags or protruding polyps. Haemor-
f
ks

ks
rhoids are rare in children. On spreading the buttocks apart,
anal fissure may become apparent. Anal fissures (fissure-
oo

oo

in-ano) are most often seen at 6 and 12 o’clock and may be


eb

eb

accompanied by sentinel tags (Fig. 5.19).

e
m

m
m

m
co

co
e.

e.
fre

fre
ks

ks
oo

oo
eb

eb

e
m

Fig. 5.18  Rectal examination.

128
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
re

fre
f
ks

s
ok
oo

o
eb

eb

e
m

m
m

m
o

co
Fig. 5.19  Anal fissures.
.c

e.
e

On insertion of one’s finger anal tone can be easily assessed.


re

fre
A tight anus resisting one’s finger is suggestive of anal ste-
f

nosis. A loose patulous anus usually indicates a lower spinal


ks

ks
lesion such as myelomeningocele or diastematomyelia.
oo

oo

In examining the rectum one is looking primarily for:


eb

eb

•   masses (faeces, polyps, teratomas)

e
•   local abdominal tenderness
m

m
•   blood or other staining on the examining glove.
There are mixed surgical opinions on the value of rectal
examination in the clinical situation of ‘acute abdomen
m

?appendicitis’ in children. We would suggest that it is a


co

co

useful procedure as one may detect tenderness (in a retro-


caecal appendix) and occasionally an appendix mass.
e.

e.

Rectal prolapse and rectal polyps are infrequent findings


fre

fre

in paediatrics. Although children put foreign bodies in all


sorts of orifices, rectal foreign bodies are unusual. Mothers
ks

ks

occasionally bring in roundworms and tapeworms which


oo

oo

have been passed per rectum; these should always be kept


eb

for proper identification.


eb

Inspection of the underwear and perianal region is impor-


m

tant in the child with faecal staining and soiling. Rectal


129
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
examination may be valuable in distinguishing between

re

fre
constipation with overflow incontinence (‘spurious diar-
rhoea’) where the rectum is full of hard faeces, and behav-
f
ks

s
ioural soiling where one finds soft faeces in the rectum.

ok
oo

The anus should always be inspected in the newborn to

o
ensure that it is perforate; imperforate anus is easily missed,
eb

eb
especially in baby girls who may pass meconium through a

e
m

m
vaginal fistula. Hirschsprung’s disease is among the causes
of neonatal intestinal obstruction – the explosive release of
flatus is said to be characteristic.
The ‘anal wink’ or anocutaneous reflex, which is contrac-
m

m
tion of the anus on stroking the perianal region, should be
o

co
sought in infants with spina bifida.
.c

e.
e
re

Child sexual abuse


fre
f
ks

ks
The recognition of the frequency of child sexual abuse has
exposed doctors’ unfamiliarity with normal genital and anal
oo

oo

appearances and variations in children. We believe that it is


eb

eb

beyond the remit of this text to cover child sexual abuse in

e
detail, and would suggest that normal and abnormal find-
m

m
ings will best be learned from slide photographs and videos.
Nonetheless, it is important that students and doctors
appreciate normal introital and hymenal variations in girls.
m

The normal anal appearance is very variable. The effects


co

co

of constipation need to be distinguished from penetrative


sexual abuse. Reflex anal dilatation (widening of anus on
e.

e.

separation of the buttocks) is not necessarily abnormal or


fre

fre

pathological.
ks

ks
oo

oo

Other abdominal findings


eb

eb

1.  Faecal masses can be felt in the central and left lower
e

abdominal quadrants. Sometimes referred to as ‘faecal rocks’


m

130
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
they are mobile, indentable and non-tender. Remember that

re

fre
immobile children, particularly with severe cerebral palsy,
frequently become constipated.
f
ks

s
2.  Trichobezoar (a hair ball) is a rare finding in the stomach of

ok
oo

disturbed children.

o
3.  Tumours: large tumour masses include nephroblastoma,
eb

eb
neuroblastoma, cystic teratoma, hepatoblastoma,

e
m

m
mesenteric cysts. These are most often found in infants and
toddlers.
4.  Ovaries are not usually palpable in girls. Enlarged palpable
ovaries are associated with ovarian cysts, teratomas and
m

m
tumours.
o

co
5.  Adrenal glands are never palpable, even though relatively
.c

e.
large in the newborn. Enlargement of the adrenal is a
e

feature of tumours – usually phaeochromocytoma and


re

neuroblastoma. fre
f
ks

ks
oo

oo

EXAMINING THE GLANDS


eb

eb

Children are frequently brought to doctors because of cer-

e
vical lymph nodes whose apparent persistent enlargement
m

m
can be a source of concern to parents. Neck glands may
be readily visible in thin children. Needless to remark, an
unspoken fear of leukaemia may initiate the consultation.
m

Most often these ‘swollen glands’ are normal, reflect recent


co

co

infections, and need not cause worry. Small, pea-sized, dis-


crete, non-tender, shotty glands are a normal finding in the
e.

e.

cervical and inguinal chains in preschool children. Inguinal


fre

fre

glands are occasionally palpable in newborn infants.


ks

ks

Enlarged unilateral axillary glands are often felt after


neonatal bacille Calmette-Guérin (BCG) vaccination. They
oo

oo

are usually due to local inflammation/infection at the injec-


eb

eb

tion site. Rarely one sees tuberculous axillary lymphadenitis


e

after BCG.
m

131
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
occipital

re

fre

f preauricular postauricular


ks

s
↓ ↓

ok
oo

submental cervical (including tonsillar)

o
↓ ↓
eb

eb

e
submandibular supraclavicular
m

m
↓ ↓
epitrochlear axillary

m

m
inguinal
o

co
Fig. 5.20  Lymph nodes: top-to-toe palpation.
.c

e.
e
re

fre
Examination of the lymphoreticular system is an inte-
f
ks

ks
gral part of the examination of the child. One may either
systematically go over areas where lymph nodes may be
oo

oo

felt, or seek them during examination of individual body


eb

eb

systems. We suggest that lymph nodes are best palpated in

e
a methodical, systematic fashion from ‘top to toe’ – it takes
m

m
but a short time.
Neck glands should be examined from both behind and in
front of the child. Site, size, consistency, tenderness, mobil-
m

ity and attachments of nodes should be carefully recorded.


co

co

The diameter of single enlarged nodes should be noted. If


many lymph glands are enlarged, one must always look for
e.

e.

splenomegaly and hepatomegaly.


fre

fre

Persistent enlargement of cervical lymph nodes usually


ks

ks

reflects acute tonsillitis. Although acute tonsillitis subsides


rapidly, the draining nodes take much longer to do so. Chil-
oo

oo

dren with atopic eczema frequently have enlarged regional


eb

eb

lymph nodes. Generalized lymph node enlargement should


e

initiate a search for acute infection, inflammation or neo-


m

plastic process (see box).


132
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
Lymph node enlargement

re

fre
Cervical lymphadenopathy:
f
tonsillitis, pharyngitis, sinusitis
ks

s
chronic gingivostomatitis

ok
‘glandular fever’ (infectious mononucleosis/cytomegalovirus)
oo

o
tuberculosis (uncommon in developed countries).
eb

eb
Generalized lymphadenopathy:

e
acute exanthemata
m

m
‘glandular fever’
systemic juvenile chronic arthritis (Still’s disease)
acute lymphatic leukaemia
drug reaction
m

m
mucocutaneous lymph node syndrome (Kawasaki’s syndrome).
o

co
.c

e.
e

CLINICAL EVALUATION OF THE IMMUNE SYSTEM


re

fre
f

Nowadays the immune system is usually evaluated


ks

ks
via a series of laboratory parameters, including serum immu-
oo

oo

noglobulins, white cell function and lymphocyte subsets.


Useful clinical examination can, however, be gleaned from
eb

eb

physical examination.

e
m

Clinical evaluation of immune system


Are the tonsils present? m
m

Are the lymph glands palpable?


Has the BCG vaccine taken? (This is a test of lymphocyte
co

co

transformation.)
e.

e.

Any pustular skin infections?


Any allergic rashes?
fre

fre
ks

ks

EAR, NOSE, MOUTH AND THROAT


oo

oo

The ear
eb

eb

The ear is low-set when the helix (top of the pinna) meets
m

the cranium at a level below that of a horizontal plane with


133
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
the corner of palpebral fissure. Pain on pulling the pinna

re

fre
suggests a boil in the external canal. Many mothers suggest
that children with otitis media ‘pull their ears’ or that the
f
ks

s
pinna is red in middle ear infections.

ok
oo

Abnormalities of the pinna are seen in many syndromes,

o
from Treacher Collins to Down’s syndrome. It has been said,
eb

eb
but not substantiated, that abnormalities of the external ear

e
m

m
are associated with kidney abnormalities; the association is
a weak one. Cosmetic abnormalities such as protruding ears
(‘bat ears’) are common. Large ears have been described in
fragile X syndrome.
m

m
o

co
.c

Examining the ear drums

e.
e

It must be said that otoscopy is frequently poorly performed


re

fre
by students – they rush at the child, fail to instruct the
f
ks

ks
mother properly, use too small a speculum and sometimes
hurt the child.
oo

oo

The mother should gently but firmly hold the child


eb

eb

against her chest, one hand over the forehead, the other

e
hand around the chest grasping the child’s hands. The legs
m

m
may be held between the mother’s thighs if necessary.
In the infant the pinna should be pulled downwards since
the canal is directed upwards. In the older child pull the
m

ear up to direct the drum towards the visualizing otoscope.


co

co

Not infrequently wax will obscure one’s view. Should it be


removed? Certainly not by the inexpert student.
e.

e.

Always use the largest speculum you expect to fit. We


fre

fre

prefer the penhold grip as this allows the otoscope to move


ks

ks

readily with any movement of the child. Inspect the canal


on the way in.
oo

oo

If the child is fearful of otoscopy, demonstrate it first on


eb

eb

the mother. Do not push the otoscope in more than 0.5 cm


e

in infants or 1 cm in older children. One may see otitis


m

externa or a furuncle (exquisitely painful) in the canal. One


134
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
re

fre
f
ks

s
ok
oo

o
eb

eb

e
m

m
m

m
o

co
.c

e.
e
re

fre
f
ks

ks
oo

oo
eb

eb

e
m

m
Fig. 5.21  Examining the ear.
m

occasionally comes across an unexpected foreign body, such


co

co

as a bead.
The normal appearance of the drum is greyish-white
e.

e.

and translucent with a clear light reflex. The most common


fre

fre

abnormality to detect is redness, which, if accompanied by


ks

ks

bulging, implies middle ear infection.


Pinkness or redness of the drum is readily determined.
oo

oo

Remember that crying may suffuse the drum and give the
eb

eb

false impression of ‘inflammation’. We have been impressed


e

by the difficulty in locating perforations when pus is exuding


m

from the canal.


135
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
A dull, retracted or full drum with loss of light reflex is

re

fre
indicative of serous otitis media (commonly known as ‘glue
ear’). This condition, which has several causes, is due to
f
ks

s
obstruction of eustachian tube drainage.

ok
oo

Mastoiditis is now a very infrequent condition. Acute

o
mastoiditis can be associated with protrusion of the pinna,
eb

eb
and with redness and swelling over the mastoid. More likely

e
m

m
today a postauricular swelling or tenderness would be
caused by lymph node inflammation. Preauricular sinuses
or pits can be seen in front of the ear; they are congenital
but sometimes may become infected.
m

m
Treat the ear with restraint and respect and it will repay
o

co
you with an appreciation of how redness, retraction and
.c

e.
perforation really appear.
e
re

fre
f

The nose
ks

ks
Respiration in the newborn is usually nasal; nasal obstruc-
oo

oo

tion can result in considerable respiratory difficulty,


eb

eb

even apnoea. Air movement through each nostril can

e
be detected by feeling flow with one’s fingertip, by listen-
m

m
ing with the stethoscope, or by noting condensation on a
mirror held over the anterior nares. If in doubt, in the
newborn, nasal patency can be established by the passage
m

of a catheter. Unilateral or bilateral choanal atresia is a rare


co

co

finding.
A flat nasal bridge is usually normal. However, it is a
e.

e.

notable feature of Down’s syndrome.


fre

fre

The nose is a common receptacle for foreign bodies (beads,


ks

ks

etc.) which may result in unilateral purulent discharge.


The nose may be examined using the auriscope – gently.
oo

oo

A boggy nasal mucosa may suggest allergy. Nasal polyps


eb

eb

suggest asthma or cystic fibrosis. A chronic, mucopurulent


e

nasal discharge through the winter is a frequent finding in


m

cold climates.
136
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
A common complaint concerns the child with persist-

re

fre
ent nasal discharge (‘runny nose’). The discharge may be
clear (as in viral or allergic rhinitis) or purulent (suggesting
f
ks

s
sinusitis or adenoidal obstruction). Bloody nasal discharge

ok
oo

(epistaxis) often results from nose picking. Spontaneous

o
epistaxis usually originates from a minor vascular malfor-
eb

eb
mation of the nasal mucosa (Little’s area). Parents (under-

e
m

m
standably) exaggerate blood loss in epistaxis.

The mouth
m

m
The oral cavity is hostile and often unexplored territory
o

co
to innocent practitioners, paediatric and general alike:
.c

e.
mouths that won’t open, jaws clamped on a prising
e

spatula, teeth ready to snap on probing fingers, a fleet-


re

fre
ing glimpse at tonsils and quivering uvula. Infants and
f
ks

ks
small children do not like to have their mouths and throats
examined. Hence this examination should be left until
oo

oo

just about last. Some will open as wide as a yawning


eb

eb

alligator on the promise that a spatula will not be used.

e
Others have to be coaxed into cooperation. Sometimes
m

m
pressing a finger into each cheek will force open the mouth.
When necessary the child could be appropriately restrained
(Fig. 5.22).
m

m
co

co

The tonsils
e.

e.

Proper inspection of the tonsils requires a good light source,


fre

fre

a well-opened mouth and a speedy observer.


ks

ks

The tonsils can be surprisingly difficult to visualize in


neonates and infants as the tongue seems always to ride
oo

oo

up. It is remarkably and embarrassingly easy to miss a cleft


eb

eb

of the soft palate in the newborn. One occasionally comes


e

across a bifid uvula, which may be associated with a sub-


m

mucous cleft soft palate.


137
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
re

fre
f
ks

s
ok
oo

o
eb

eb

e
m

m
m

m
o

co
.c

e.
e
re

fre
f
ks

ks
oo

oo
eb

eb

e
Fig. 5.22  Examining the mouth and throat.
m

m
m

One has a few fleeting moments to observe redness,


co

co

exudate, or secretions in the oropharynx. The classic


streptococcal tonsillitis produces a unilateral or bilateral
e.

e.

follicular exudate. A creamy, confluent exudate is typical


fre

fre

of infectious mononucleosis; other noteworthy features


ks

ks

of this illness are palatal petechiae and a swollen uvula.


Some texts state that infectious mononucleosis does not
oo

oo

occur in young children; this has not been our experience.


eb

eb

Diphtheria, though now rare, must not be forgotten.


e

It causes a severe lymphadenitis, ‘bull neck’, a greyish


m

membrane and notable toxicity. It needs to be stated that


138
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
gonococcal tonsillitis may have to be considered in atypical

re

fre
or unresponsive infections in adolescents.
While examining the tonsils the student should also look
f
ks

s
at the oropharynx for evidence of pharyngitis, exudate or a

ok
oo

postnasal drip. Postnasal drip may be elicited by asking the

o
child to say ‘aah’ at length.
eb

eb
Tonsillar size is not important unless extreme. By

e
m

m
extremely large tonsils we mean tonsils that meet in the
midline (sometimes referred to as ‘kissing tonsils’). Repeat-
edly infected tonsils may have a pitted appearance.
m

m
o

co
The tongue
.c

e.
A large protruding tongue is a feature of congenital
e

hypothyroidism. Macroglossia may also be caused by a


re

fre
local lymphatic or vascular anomaly. The tongue may
f
ks

ks
appear inappropriately large for a small mouth as in
Down’s syndrome. A geographical tongue is a tongue with
oo

oo

irregular red lines and pale areas. It is of no particular


eb

eb

significance.

e
A white-coated tongue is usually attributable to a recent
m

m
milk feed. Monilial infection (thrush) is manifest by a patchy
white exudate which cannot easily be removed by a spatula.
Herpetic stomatitis affects the tongue, mucosa and buccal
m

border. It is vascular, friable, bleeds to touch, and is associ-


co

co

ated with marked drooling.


e.

e.
fre

fre

Buccal mucosa
ks

ks

Thrush appears as serpiginous white patches on the mucosa.


Koplik’s spots are like a grain of salt with a red rim; they
oo

oo

are found in the buccal gutter during measles prodrome.


eb

eb

Inflammation of the parotid duct usually implies acute viral


e

parotitis (mumps). Recurrent suppurative parotitis (with or


m

without stone) is a rarity in childhood.


139
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
The teeth

re

fre
Dentists have a modicum of medicine. Doctors have a
f
ks

s
minimal knowledge of dentistry, which is virtually absent

ok
from most medical curricula. Particularly in early child-
oo

hood, the doctor has a unique opportunity to practise some

o
eb

eb
preventive dentistry. Even a brief look into the child’s oral

e
cavity and a scan of teeth and gums is a useful exercise.
m

m
Below are some spin-offs of dental examination:
1.  Dental caries is prevalent still, especially in the less well-off
segments of society. Caries of the upper incisors is sometimes
m

m
called ‘nursing bottle caries’.
o

co
2.  Early detection of maleruption, malocclusion and
.c

e.
malalignment.
e
re

fre
3.  Dental staining may be of diagnostic significance. Dental
enamel hypoplasia has been described as a sequela of
f
ks

ks
neonatal hypocalcaemia. Brown or yellow staining (which
oo

oo
eb

eb

e
m

m
m

m
co

co
e.

e.
fre

fre
ks

ks
oo

oo
eb

eb

e
m

Fig. 5.23  Inspecting the teeth.

140
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
fluoresces under Wood’s light) is a side-effect of tetracycline

re

fre
consumption in pregnancy and early childhood. Black
staining of the teeth sometimes follows iron ingestion.
f
ks

s
4.  Flattened teeth are seen in normal and handicapped children

ok
oo

who grind their teeth (bruxism).

o
5.  Absence of teeth is a feature of ectodermal dysplasia.
eb

eb
6.  Gingivitis is frequently associated with caries. Gingival

e
m

m
hypertrophy, with or without gingivitis, occurs in children
consuming phenytoin and ciclosporin long term.
m

m
Come to terms: oral cavity
o

co
.c

ranula = cyst on anterior floor of mouth

e.
quinsy = peritonsillar abscess
e

glossoptosis = backward displacement of tongue


re

micrognathia = small chin


fre
f
ks

ks
oo

oo

SKIN, HAIR AND NAILS


eb

eb

e
In this section we mention some normal skin variations,
m

m
some clinical clues to be found in skin, hair and nails, and
propose that the secret of success in skin conditions lies in
inspection, palpation and description. We shall not refer to
m

acute infectious exanthemata.


co

co
e.

e.

Skin
fre

fre

Skin colour. Discussion of racial variations in skin colours


ks

ks

is beyond our remit. Students will be aware of increasing


cross racial relationships allowing for all sorts of pigmentary
oo

oo

variations.
eb

eb

Mongolian blue spots are black or navy areas over sacrum,


m

buttocks and sometimes shins of infants of Middle Eastern,


141
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
African and Asian parents. Pigmentation of the scrotum

re

fre
may be an associated finding.
f
ks

s
Absence of skin pigmentation occurs in albinism, which is

ok
oo

easily missed at birth as the pink lens may not be noted

o
and skin pigment is light in most infants. Skin pigmentation
eb

eb
increases through infancy.

e
m

m
Freckles (multiple small pigmented spots) are fairly common,
especially in fair-skinned people.
m

m
Café-au-lait spots are pigmented patches more than 1.5 cm
o

co
in diameter. When greater than six in number they may
.c

suggest neurofibromatosis; axillary freckles are characteris-

e.
e

tic of this conditions.


re

fre
f

Small bruises on the forehead are a normal finding in toddlers,


ks

ks
who have recently acquired the skill of walking. Similar small
oo

oo

bruises (as many as 20) are a frequent finding on the knees


and shins of preschool and schoolchildren. The characteristic
eb

eb

sites and appearance of bruises suggestive of non-accidental

e
m

m
injury are described elsewhere (see Chapter 11).

Carotenaemia (yellow discolouration of the skin) has been


described in infants and children consuming excessive
m

amounts of carrots and mandarin oranges.


co

co

Vitiligo is an area of depigmented skin, and may be seen in


e.

e.

tuberous sclerosis and autoimmune conditions.


fre

fre
ks

ks

Come to terms: hair/skin


oo

oo

hirsutism = excessive hairiness; synonym ‘hypertrichosis’


hyperhidrosis = excessive sweatiness
eb

eb

lentigines = brownish pigmented spots on skin


e

vitiligo = depigmented patches


m

142
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
Sclerema is an erythematous thickening and hardening of the

re

fre
skin associated with hypothermia or vascular stasis. Local
sclerema is usually confined to hands and feet. Generalized
f
ks

s
sclerema indicates a serious systemic disorder.

ok
oo

o
Oedema. Generalized oedema of the skin is a normal finding
eb

eb
in preterm infants. Hydropic conditions of the newborn are

e
m

m
accompanied by generalized pitting oedema. Dependent
oedema is unusual in the newborn but may occur in the
propped infant in congestive cardiac failure.
m

m
Lymphoedema (non-pitting) is classically found in the lower
o

co
limbs in Milroy’s syndrome (congenital lymphoedema) and
.c

e.
in the XO neonate (Turner’s syndrome).
e
re

fre
Erythema nodosum is a red, painful raised swelling on the
f
ks

ks
tibial surface (shin). The lesions may vary in size and
number. It is associated with streptococcal infection, drugs,
oo

oo

tuberculosis, inflammatory bowel disease and sarcoidosis.


eb

eb

e
m

m
Hair
Hair colour, thickness and distribution are racial attributes.
Soft downy hair (lanugo) is found in preterm infants.
m

Bushy head hair at birth is a normal variant, but may


co

co

suggest congenital hypothyroidism. Bushy eyebrows are


a feature of mucopolysaccharidoses and of de Lange syn-
e.

e.

drome. Long eyelashes are a normal (sought after) attribute


fre

fre

in girls; they also occur in children with chronic debilitating


ks

ks

disorders.
Prominent dark hair on forearms, nape of neck, and back
oo

oo

is a normal variant. White flecks in the scalp hair are a feature


eb

eb

of Waardenburg’s syndrome. Kinky hair is described in the


e

rare Menkes’ syndrome. Lank ‘lifeless’ hair is sometimes


m

noticed in coeliac disease.


143
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
Absent or short occipital hair may be a feature of infants

re

fre
who are either delayed or deprived; it reflects too much
time spent in the supine position. Children with Down’s
f
ks

s
syndrome typically have straight hair. Total absence of hair

ok
oo

is seen in ectodermal dysplasia (a rare condition), and as a

o
side-effect of cytotoxic drugs.
eb

eb
Local absence of hair in a child may reflect either alopecia

e
m

m
or trichillomania (hair pulling). In alopecia the area may be
totally bald; in trichillomania short hair roots are usually
present.
Nits (pediculosis capitis) are a common finding nowa-
m

m
days. They are adherent to hair shafts, difficult to displace
o

co
and need to be distinguished from dandruff. A paediatric
.c

e.
predecessor of ours used to refer to head lice as ‘mechanized
e

dandruff’.
re

fre
Excessive hair (hypertrichosis, hirsutism) may be a
f
ks

ks
side-effect of several drugs, including phenytoin, diazoxide,
minoxidil, ciclosporin and corticosteroids.
oo

oo
eb

eb

e
Nails
m

m
Nails are often long in the post-term (postmature) neonate.
Absence of nails is a feature of ectodermal dysplasia.
Peripheral cyanosis of nail beds (acrocyanosis) is a normal
m

newborn variant.
co

co

Spoon-shaped nails (koilonychia) are occasionally a


normal variant; they may be associated with anaemia. White
e.

e.

lines across the nails (leuconychia) can be seen with chronic


fre

fre

hypo-albuminaemic states, such as nephrotic syndrome and


ks

ks

liver disorders. Small white spots on the nails do not indi-


cate calcium deficiency.
oo

oo

Pitting of the nails is described in fungal diseases and


eb

eb

in psoriasis. Nail biting is a frequent finding in children,


e

stressed and unstressed.


m

144
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
The secret of success in skins

re

fre
The secret of success in dermatology is to describe what you
f
ks

s
see. Stand back, look carefully at the rash and apply descrip-

ok
tive terms to its colour, appearance, distribution, feel, etc.
oo

Too many students take one look, and jump at a diagnosis

o
eb

eb
like a salmon at flies. It is better by far to use one’s power

e
of description and palpation.
m

m
Today’s students can be inhibited by a lack of even
a smattering of Latin or Greek, which certainly helps
in understanding skins. The student who knows some
m

m
Latin would not call the uniform circular lesions of
o

co
psoriasis ‘erythema multiforme’. Included below is a
.c

glossary of some classic terms in an effort to overcome

e.
e

confusion.
re

fre
We suggest that once you have seen the following rashes
f

you immediately and carefully describe them:


ks

ks
oo

oo

•   psoriasis
•   tinea corporis (ringworm)
eb

eb

e
•   erythema nodosum
m

m
•   anaphylactoid purpura
•   molluscum contagiosum.
m

It is worth assembling a clinical differential of red rashes,


purple (purpuric) rashes, vesicular rashes and bullous
co

co

eruptions.
e.

e.
fre

fre

Examination of skin rashes


ks

ks

inspection
oo

oo

palpation
description
eb

eb

distribution
e
m

145
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
Glossary of dermatological terminology

re

fre
erythema = redness
f
erythema multiforme = redness of many shapes
ks

s
erythema marginatum  = red raised margin

ok
erythema annulare = red, circular
oo

= literally means ‘out of place boiling over’,

o
atopic eczema
eb

eb
‘atopy’ from topos (Greek for place) eczein =

e
to boil over
m

m
centrifugal = fleeing from the centre
centripetal = seeking the centre
morbilliform = measles-like
varicelliform = chickenpox-like
m

m
ichthyosis = dry, scaling skin. From ichthus (Greek for fish)
o

co
.c

e.
Describe a rash as though you were attempting to describe
e
re

fre
it to a blind person – site, size, colour, shape, distribution,
feel. Is it a macule, papule or vesicle? Is it itchy? Is it wet or
f
ks

ks
dry? Is it centrifugal or centripetal? Is it raised or flat? What
oo

oo

does it feel like?


eb

eb

Come to terms: rashes

e
m

m
macule = flat lesion
papule = raised lesion
vesicle = fluid-filled lesion
bulla = large vesicle
m

pustule = vesicle containing pus


co

co
e.

e.

Eczema (atopic dermatitis) is the commonest chronic rash in


fre

fre

childhood. Eczema is a good example of applying descrip-


tion in order to come to a conclusion. The skin in eczema
ks

ks

may be:
oo

oo

•   erythematous (red)


eb

eb

•   dry
e

•   papular (palpably raised)


m

•   scaling (ichthyotic)


146
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
•   excoriated (scratched)

re

fre
•   thickened (lichenified)
•   weeping (? infected).
f
ks

s
ok
Insofar as children are concerned, four irritations of eczema
oo

are:

o
eb

eb
•   itching

e
m

m
•   ichthyosis
•   infection
•   image (of self).
m

m
Palpation of the rash is most important and frequently not
o

co
performed. Few rashes in paediatrics are painful. Measure-
.c

ment of lesions and clinical photography are very useful for

e.
e

recording purposes.
re

fre
Desquamating rashes. Desquamation means shedding
f
ks

ks
or peeling of skin. Desquamation is not common, but can
be diagnostically alerting. Among those children’s rashes
oo

oo

which desquamate are:


eb

eb

•   Kawasaki’s disease: desquamation around nail edges, on

e
m

m
hands and feet and in the nappy area is typical
•   scarlet fever
•   severe measles
m

m
•   staphylococcal scalded skin syndrome.
co

co

Petechiae or purpura? Purpuric rashes are important in


paediatrics. There is some confusion and overlap between
e.

e.

these terms. We have always understood petechiae to be


fre

fre

fine, non-blanching, non-palpable purple spots usually


ks

ks

around 1 mm in diameter. Purpura are also purple, non-


blanching spots of 2 mm or more. Purpura may be palpable.
oo

oo

Purpura has many causes; however, a rapidly spreading


eb

eb

purpuric rash in infancy is suggestive of septicaemia. The


e

rapidity of onset, spread, distribution and association


m

with bruising are relevant clinical factors. The degree of


147
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
sickness (or wellness!) is important. ‘Wet’ purpura (on

re

fre
mucosal surfaces) used to be considered more serious than
‘dry’ purpura (on skin). Common causes of purpura include:
f
ks

s
ok
•   acute meningococcal septicaemia. The appearance of
oo

spreading purple spots in an acutely unwell infant or child.

o
eb

eb
Parents in the UK have been taught on television to do the

e
glass test – the spots fail to blanch when a glass is rolled over
m

m
them.
•   coagulopathy, most commonly idiopathic thrombocytopenic
purpura. The child is usually well and the purpuric spots are
m

m
accompanied by ecchymoses and bruises.
o

co
•   vasculopathy, most commonly Henoch–Schönlein purpura.
.c

The purpuric rash is most prominent on buttocks, backs of

e.
e

legs and arms.


re

fre
There are many causes of purpura, and the clinical
f
ks

ks
discussion is very much related to the child’s age, the
differential being very different in the newborn than in the
oo

oo

adolescent.
eb

eb

It is important to remember that skin, teeth, hair and

e
nails are all ectodermal structures and should be seen as a
m

m
continuum, particularly when dealing with congenital
abnormalities of some part of the system as in ectoder-
mal dysplasia. The state of the hair and skin, in particular,
m

can contribute to a clinical assessment of a child’s state of


co

co

nutrition.
e.

e.
fre

fre
ks

ks

Nappy rashes = ACES


oo

oo

ammonia
Candida
eb

eb

eczema
e

seborrhoea
m

148
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
Napkin area rashes:

re

fre
•   seborrhoeic dermatitis (scalp, neck and axilla also involved)
f
ks

s
•   ammoniacal irritant dermatitis (skinfold flexures usually

ok
spared)
oo

•   Candida (thrush) dermatitis (satellite lesions are characteristic)

o
eb

eb
•   eczema (typical lesions elsewhere)

e
•   acrodermatitis enteropathica (a rare condition associated with
m

m
zinc deficiency)
•   erosive or ulcerated napkin dermatitis is a severe form of
irritant ammoniacal dermatitis.
m

m
Napkin area rashes are very common and need to be seen
o

co
and, if possible, clinically separated as outlined above. The
.c

e.
four major causes are seborrhoea, ammonia, Candida and
e

eczema.
re

fre
f
ks

ks
oo

oo
eb

eb

e
m

m
m

m
co

co
e.

e.

Fig. 5.24  Nappy rash (seborrhoeic dermatitis).


fre

fre
ks

ks

Chilblains (perniosis) are sometimes seen in children living


oo

oo

in cold houses in cold climates. They are noted on the fingers,


eb

eb

toes and occasionally the ears; they are inflammatory blis-


e

ters, which may ulcerate. Keratosis pilaris, or dry bumpy


m

skin on the arms and legs is common and often familial.


149
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
Come to terms: skin infections

re

fre
cellulitis = r edness, heat, swelling due to superficial skin infection in
f various sites
ks

s
impetigo = blistered, crusted, brown skin lesions on face and limbs

ok
scalded skin = erythema, burn-like areas, may be widespread
oo

o
eb

eb

e
Intertrigo may be observed in overweight infants and
m

m
children. This is a wet, red eruption in furrows between
opposed skin surfaces of the groin, axilla and sometimes
neck.
m

m
In summary, examination of any rash must include:
o

co
.c

•   inspection

e.
e

•   palpation
re

•   good description.


fre
f
ks

ks
Come to terms: ‘derm’
oo

oo

dermatoglyphics = s tudy of fingerprint and hand crease


eb

eb

patterns

e
dermatographia = skin writing. white line with red
m

m
margins following scratching of skin
dermoid = teratoma of skin structures
Dermatophagoides pteronyssinus = house dust mite
m

m
co

co

NEUROLOGICAL EXAMINATION
e.

e.

We do not propose to exhaustively deal with the neuro-


fre

fre

logical system, but rather to present some points about the


ks

ks

neurological system and its examination that are different


in infants, toddlers and preschool children. Neurological
oo

oo

examination at these ages cannot always be performed in


eb

eb

an organized fashion.
e

By contrast a ‘classic’ full neurological examination can


m

be carried out on a cooperative schoolchild. Its tricks and


150
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
techniques are fully described in your basic text on clinical

re

fre
methods so we will not elaborate further. The neurological
examination of the neonate is described in Chapter 4. Intrin-
f
ks

s
sic to an understanding of the infant’s neurological system

ok
oo

is that maturation of the central nervous system (CNS) is

o
manifest by a loss of primitive reflexes with a corresponding
eb

eb
gain in positive skills. Developmental examination, includ-

e
m

m
ing speech, hearing, gross and fine movement, is presented
in Chapter 8.
The neurological approach combines:
m

m
1.  Careful history of birth, perinatal events, developmental
o

co
sequence, maternal worries, etc.
.c

2.  Observation of the infant’s activity, symmetry and of the

e.
e

toddler’s movement, play and socialization.


re

fre
3.  Expedient examination of tone, power, coordination, reflexes
f

and sensation. Sensation can be especially difficult to ascertain


ks

ks
in infancy.
oo

oo
eb

eb

e
History
m

m
One will need to enquire about movement in utero. Although
maternal instincts about normal intrauterine movement
may be fallible, in retrospect they may be alerting. Reduced
m

fetal movement may be significant.


co

co

Perinatal events are important. Low Apgar scores (<5) at


1 and 5 minutes, though not in themselves prognostically
e.

e.

valuable, may contribute to concern.


fre

fre

How did the baby suck? And move? Did he pass his
ks

ks

neonatal neurological examination?


Tell me about his development. Was a normal pattern
oo

oo

followed? When did he first smile with meaning? When did


eb

eb

he sit unsupported, etc.? The modern mother may well have


e

filled these developmental milestones in her baby’s book or


m

diary. If so, ask to look at it.


151
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5 SYSTEMS EXAMINATION

co

c
e.

e.
If a mother presents her infant with a possible develop-

re

fre
mental or neurological problem remember our primary:
f
ks

s
•   she’s usually right

ok
•   her worries often commenced well before attending doctors
oo

•   her instincts are sharper than your observations.

o
eb

eb

e
m

m
Some alerting statements made by mothers
‘He was an unusually good baby’ (this may mean he cried or moved
very little, but merely slept and fed).
‘He was always different from the others.’
m

m
‘He was okay till 9 months of age then he seemed to stop.’
o

co
‘He seems to have gone backwards.’
.c

e.
e
re

fre
Infants with perinatal insults tend to be abnormal in their
f
ks

ks
behaviour from the beginning. Babies with neurodegenera-
tive disorders, for example, may develop normally for a
oo

oo

period and then stop, or indeed, regress.


eb

eb

Neurologists, above all specialists, are obsessive in

e
their demand for a good history. When did the problem
m

m
begin? What was the child like before that? What exactly
happened? What has been the sequence of events
since then? Giving a history of a convulsion to a neurolo-
m

gist as an intern is akin to being cross-examined in court


co

co

by a querulous senior counsel. So learn the art before you


qualify. Be confident, be complete and choose your words
e.

e.

carefully. In other words, take a good history, or risk being


fre

fre

‘hammered’.
ks

ks
oo

oo

Examination techniques
eb

eb

We plan merely to highlight some skills and certain signs


e

particular to paediatrics. For detailed description of neuro-


m

logical examination refer to your text of clinical signs.


152
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SYSTEM EXAMINATION 5

co

c
e.

e.
Tendon reflexes

re

fre
The fingertip is sometimes used to elicit knee jerks in
f
ks

s
neonates; this is acceptable practice. After the newborn

ok
period we recommend the use of a small reflex hammer.
oo

When striking a tendon with the hammer, be a swinger

o
eb

eb
not a stabber – in other words allow the hammer to have

e
a free flowing stroke. The knee jerk is best tapped with the
m

m
hammer held in a pengrip and parallel to the leg.
The use of the side of the stethoscope’s diaphragm
to elicit tendon reflexes is sloppy practice and not
m

m
recommended.
o

co
Deep tendon reflexes may be arbitrarily graded for record
.c

purposes as follows:

e.
e

0 = absent
re

1+ = weak response
fre
f
ks

ks
2+ = normal response
3+ = exaggerated response
oo

oo

4+ = very brisk response


eb

eb

Exaggerated responses are characteristic of upper motor

e
neurone (pyramidal) lesions, reduced reflexes occur with
m

m
muscle weakness, and absent reflexes suggest a peripheral
neuropathy (lower motor neurone).
m

Funduscopy
co

co

In infants and toddlers, funduscopy requires the patience of


e.

e.

Job and a fair amount of skill. Funduscopy can at times be


fre

fre

akin to seeking a passenger in a train rushing by. Do your


best. Don’t be depressed if you fail – we all do (see p. 188
ks

ks

for more detailed discussion).


oo

oo

Neonate
eb

eb

We will only briefly mention the newborn, whose neuro-


m

logical examination is detailed in Chapter 4. Observe the


153
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5 SYSTEMS EXAMINATION

co

c
e.

e.
posture adopted by newborn babies and infants. Observe

re

fre
limb movements and in particular whether symmetrical
or not. Note the normal flexed position of the well infant.
f
ks

s
See the ‘frog position’ of the floppy infant. Look for neck

ok
oo

extension in infants with ‘cerebral irritation’ or with severe

o
meningism. Look for spontaneous movement and for abnor-
eb

eb
mal movements.

e
m

m
Normal newborn findings:
•   tremulousness
•   mass responses
m

m
•   extensor plantar response
o

co
•   unsustained ankle clonus.
.c

•   Babinski response may be upgoing (extensor) to the age of 8

e.
e

months.
re

fre
f
ks

ks
Infant
oo

oo

How does the infant handle? This is an important observa-


tion. Does he resent handling (as, for example, infants with
eb

eb

meningism)? Is he floppy – does he tend to slip through

e
m

m
your hands in upright suspension? Is he stiff – does he tend
to move ‘in one piece’? Is muscle tone decreased?
m

Cranial nerve examination


co

co

Full formal cranial nerve examination can be difficult in


infants and toddlers. However, observation of everyday
e.

e.

activities such as smiling, crying, sucking, looking, rumi-


fre

fre

nating and chewing can be very instructive. Examination of


ks

ks

the 1st cranial nerve is almost impossible in preschool chil-


dren; fortunately it seems rarely involved in neurological
oo

oo

disorders. Table 5.10 lists activities requiring normal cranial


eb

eb

nerve function for perfect performance.


e

The commonest cranial nerve problems in infants include


m

squint (paralytic or concomitant) and facial nerve palsies


154
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SYSTEM EXAMINATION 5

co

c
e.

e.
Table 5.10  Activities requiring normal cranial nerve function

re

fre
Activity Cranial nerves used Comment
f
ks

s
Smell   1 Impossible

ok
Visual acuity   2 Can he see?
oo

Eye movement   3 Up, medially, down, in

o
Eye movement   4 Down and out
eb

eb
Chewing   5 Or rooting

e
Eye movement   6 Lateral
m

m
Crying, smiling   7 Facial expressions
Hearing   8 Startle reflex, formal
testing
m

m
Sucking   5, 7, 9 Serious if absent
Swallowing   9, 10, 11 Coordinated?
o

co
Phonation   9 Or test gag reflex
.c

Phonation 10 Observe palatal

e.
e

Head turning 11 movement


re

Tongue protrusion 12
fre
f
ks

ks
oo

oo

(congenital or acquired). Poor or absent sucking in a term


eb

eb

e
infant is a serious neurological sign. Failure of appearance
m

m
of a social smile at 6 weeks warrants worried observation.
Mothers are intimately tuned into their infants and usually
acutely aware of social responses such as looking, hearing,
m

smiling and cooing. The mother may often better elicit these
responses than you can, but do try and do learn. Please
co

co

remember that infants and toddlers respond best to friendly,


e.

e.

smiling human faces in preference to lights, pens, toys or


fre

fre

other inanimate objects.


At the end of the neurological examination it will
ks

ks

be helpful to arrive at a broad general conclusion as


oo

oo

follows:
eb

eb

1.  Definitely normal in all respects.


e

2.  Probably normal but shows a few minor discrepancies. Check


m

again.
155
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5 SYSTEMS EXAMINATION

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e.

e.
3.  Probably abnormal. Definite deviations from normal, such as

re

fre
absence of social smile, weak suck, or reduced movement.
Repeat examination.
f
ks

s
4.  Definitely abnormal. Definite findings such as absence of

ok
oo

visual fixation, persistent primitive reflexes, altered tone

o
(usually floppy), etc.
eb

eb

e
Neurological and developmental examinations are inte-
m

m
grally interrelated and require lots of skill and practice.
Students should confine themselves to the extremes – dem-
onstration of normality and detection of major abnormality.
m

m
The subtleties in between will accrue with postgraduate
o

co
time and practice.
.c

We believe that sensory examination of infants and tod-

e.
e

dlers is too subtle and too subjective for undergraduate


re

fre
students and will not discuss it further. Pain is easy to elicit
f

but we would suggest that our primary premise – first do


ks

ks
no harm – takes precedence. Fortunately, most neurologi-
oo

oo

cal insults in infants and toddlers involve the motor system


rather than the sensory system. Absence of sensation can be
eb

eb

demonstrated in the flaccid lower limb paraplegia associ-

e
m

m
ated with myelomeningocele and in ascending polyneuritis
(Guillain–Barré syndrome).
Disappearance of primitive reflexes with appearance of pos-
m

m
itive skills is part of the developmental sequence (Table 5.11).
Persistence of primitive reflexes is neurologically sinister.
co

co
e.

e.
fre

fre

Table 5.11  Primitive reflexes: appearance and disappearance


ks

ks

Reflex Appearance Disappearance


Stepping Newborn 2 months
oo

oo

Moro Birth 3–5 months


Palmar grasp Birth 2 months
eb

eb

Plantar grasp Birth 8–10 months


e

Asymmetric tonic neck Newborn 1–6 months


m

156
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SYSTEM EXAMINATION 5

co

c
e.

e.
Feeling the fontanelle

re

fre
If the eye is the window of the soul, the fontanelle is a
f
ks

s
window on the infant’s brain.

ok
The tension of the anterior fontanelle is an important
oo

sign in deciding whether or not an infant has raised the

o
eb

eb
intracranial pressure and in determining the presence and

e
degree of dehydration. The fontanelle must preferably be
m

m
palpated (gently!) when the infant is quiet or sitting upright.
Fullness and elevation of the fontanelle over the surround-
ing skull is evidence of increased intracranial pressure. The
m

m
usual causes of this will be meningitis or hydrocephalus. No
o

co
comment should be made if the infant is crying.
.c

A systolic bruit is frequently audible over the anterior

e.
e

fontanelle in the presence of meningitis. This usually disap-


re

pears in 2–3 days.


fre
f
ks

ks
oo

oo

Delayed closure (beyond 18 months) of the


anterior fontanelle
eb

eb

e
Delayed closure (beyond 18 months) of the anterior fontanelle is
m

m
associated with:
normal variation
hydrocephalus
Down’s syndrome
m

hypothyroidism
co

co

bone disorders
some syndromes
e.

e.

arteriovenous malformation.
fre

fre
ks

ks

A rapidly enlarging head may be a cause of concern.


oo

oo

Serial measurements of head circumference are important.


eb

eb

If a large head is accompanied by a full fontanelle and


e

spread sutures, raised intracranial pressure is the likely


m

cause.
157
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co

co
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om
5 SYSTEMS EXAMINATION

co

c
e.

e.
Some causes of large head

re

fre
familial macrocephaly (measure parents’ heads)
f
hydrocephalus
ks

s
space-occupying lesion

ok
storage diseases
oo

o
bone disorders
eb

eb
Sotos’ syndrome

e
m

m
m

m
o

co
.c

e.
e
re

fre
f
ks

ks
oo

oo
eb

eb

e
m

m
m

m
co

co
e.

e.
fre

fre

Fig. 5.25  Signs of hydrocephalus.


ks

ks
oo

oo

Head growth is a reflection of brain growth. However,


eb

eb

except at the extremes, head size is not related to intel-


e

ligence. When the head is small (below third centile) it is


m

microcephalic.
158
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SYSTEM EXAMINATION 5

co

c
e.

e.
Some causes of microcephaly

re

fre
normal variation
f
perinatal asphyxia
ks

s
intrauterine infection (TORCH)

ok
chromosomal disorders
oo

o
familial
eb

eb
dysmorphic syndrome

e
severe metabolic disorder
m

m
Enlarging heads can be sometimes halted; poorly growing
heads, unfortunately, usually cannot be helped.
m

m
o

co
.c

Eliciting neck stiffness

e.
e

Meningism or neck stiffness is a very important sign to elicit


re

fre
correctly. The student needs to be gentle, always to look for
f
ks

ks
active resistance to flexion before passive resistance, and to
be aware of voluntary resistance exhibited by that enfant
oo

oo

terrible, the fretful toddler. It is important to state at the


eb

eb

outset that neck stiffness, unless severe and obvious, is an

e
unreliable sign in the neonate and infant.
m

m
First, observe the infant’s position of comfort. The well-
relaxed child sleeps in a position of cuddled flexion. The ill
infant may extend. The infant with severe meningeal irrita-
m

tion may adopt the position of opisthotonos or hyperexten-


co

co

sion of the neck and trunk.


Ask the toddler to follow a light. Ask the child to flex his
e.

e.

chin onto his chest. Ask him to kiss his knee. In the sitting
fre

fre

position ask him to look at the roof. If he can do all of these


ks

ks

readily, neck stiffness is likely to be absent, or if present,


minimal.
oo

oo

Then, while supporting his occiput, gently flex his neck,


eb

eb

feeling for resistance to movement. In severe meningism the


e

child will lift up ‘like a board’. Lesser degrees of mening-


m

ism may cause him to wince or cry on flexion. Always note


159
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5 SYSTEMS EXAMINATION

co

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e.

e.
re

fre
f
ks

s
ok
oo

o
eb

eb

e
m

m
m

m
o

co
.c

e.
Fig. 5.26  Examining for neck stiffness.
e
re

fre
f
ks

ks
carefully the facial expression when looking for meningism.
oo

oo

Eliciting neck stiffness with the child sitting up with knees


eb

eb

extended is another sensitive manoeuvre.

e
Neck retraction (or extension) arch is a more reliable sign
m

m
of meningism than neck stiffness in infants.
m

Kernig’s sign (resistance to straight leg raising)


co

co

This can be elicited in children and has the same significance


as in adults. Kernig’s sign is, however, unreliable under the
e.

e.

age of 3 years. Kernig’s sign is performed by flexing the


fre

fre

hip and knee to a right angle (Fig. 5.27a) and then slowly
ks

ks

extending the leg (Fig. 5.27b). A positive sign exists when


there is pain and limitation of movement. While doing this
oo

oo

manoeuvre it is useful to feel for tightness of the hamstring.


eb

eb

The child may additionally demonstrate Brudzinski’s sign


e

by reciprocally flexing the contralateral knee in order to take


m

the stretch off his lower spine.


160
m

m
co

co
m m m
eb eb eb
oo oo oo
ks ks ks
fre fre f re
e. e .c e.

Fig. 5.27  Kernig’s sign.


co co o co
m m m m
m m m
eb eb eb
oo oo o ok
ks ks s
fre fre fre
e. e. e.
c
SYSTEM EXAMINATION

co co co
m m m om
5

m m m
e e e
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
Meningism

re

fre
Genuine meningism is likely to be associated with a shrill,
f
ks

s
high-pitched cry. The infant may be drowsy and irritable,

ok
may refuse feeds, and may wish to be left alone. Meningism
oo

does not always imply meningitis. It must be recognized

o
eb

eb
that meningism may be associated with upper respiratory

e
and other infections.
m

m
Some causes of meningism
meningitis, encephalitis
m

m
acute otitis media
o

co
severe tonsillitis
.c

cervical lymphadenitis

e.
e

pneumonia
re

retropharyngeal abscess
fre
f
ks

ks
oo

oo

Toddlers
eb

eb

In mobile children more information about tone, power,

e
coordination and movement is learned by the amateur
m

m
neurologist through informal observation than by formal
examination. So to assess motor progress, you will need to
observe:
m

}
•   walking
co

co

•   running
e.

e.

•   jumping gross motor skills


fre

fre

•   kicking
•   smacking
ks

ks

•   climbing
oo

oo

}
•   scribbling
eb

eb

•   transferring fine motor skills


e

•   picking up objects


m

•   building blocks


162
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SYSTEM EXAMINATION 5

co

c
e.

e.
You can practise on your nephews, nieces, or relations’ chil-

re

fre
dren in the appropriate 1½–4-year-old age group. Children
of this age are most willing performers who love to show off
f
ks

s
their prowess. Again, students need not concern themselves

ok
oo

with the multiplicity and subtlety of variations but rather

o
concentrate on knowing the normal and major deviations
eb

eb
therefrom.

e
m

m
Skills achieved in all of these areas will be related to
chronological and developmental age. The speed and dex-
terity with which the above motor skills are performed can
be very informative. Be prepared to get onto the floor and
m

m
observe play. Play is the all-consuming interest of inquisi-
o

co
tive toddlers and preschool children. Our neurologist col-
.c

e.
league informs us that she does much of her neurological
e

examination at floor level. A period in the ward or hospital


re

fre
playroom will be well repaid. There you can notice con-
f
ks

ks
structiveness, concentration, conversation (children often
speak to themselves when playing), coordination and curi-
oo

oo

osity. Mentally handicapped children may demonstrate


eb

eb

short attention span, poor construction abilities, lack of

e
concentration, absence of interest in other children or sur-
m

m
roundings. Beneath the apparent chaos of the playroom,
important business is being conducted.
At the bed or cot side a few bricks, pieces of Lego, or
m

simple toys are invaluable. The combination of good mater-


co

co

nal history, observation of manual dexterity and interest in


toys may help you construct the beginnings of a neurologi-
e.

e.

cal template.
fre

fre

At all ages it is important to observe:


ks

ks

•   alertness (bright eyes, bright smile, bright face)


oo

oo

•   activity
•   social adaptation.
eb

eb

Note the toddler’s gait, hand or foot preference (if deter-


m

mined) and in particular look for symmetry of movement.


163
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5 SYSTEMS EXAMINATION

co

c
e.

e.
re

fre
f
ks

s
ok
oo

o
eb

eb

e
m

m
m

m
o

co
.c

e.
e
re

fre
f
ks

ks
oo

oo
eb

eb

Fig. 5.28  Toddler standing on tiptoes.

e
m

Children with a hemiplegia tend not to want to use the


hand on the affected side. Hemiplegia may delay the onset m
m

of walking; he drags the leg or limps. All gaits are unsteady


co

co

for a while after acquisition of walking. Persisting unsteadi-


ness, frequent falls and dropping of objects may suggest
e.

e.

ataxia. Observation of play is imperative in determining


fre

fre

coordination.
ks

ks

It is worth observing the gait of any child with a sus-


pected neurological disorder. Children usually acquire the
oo

oo

skill of independent walking between 10 and 18 months.


eb

eb

The initial gait is unsteady and broad based; confidence


e

and coordination are rapidly gained. Failure to walk inde-


m

pendently by 18 months warrants an explanation (familial,


164
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co

co
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SYSTEM EXAMINATION 5

co

c
e.

e.
obesity, bottom-shuffler?) and an examination to establish

re

fre
normality or determine the cause.
Certain characteristic gaits are worth noting and if possible
f
ks

s
videorecording:

ok
oo

1.  Gait of muscular dystrophy is of a waddling nature, the hips

o
eb

eb
being thrown from side to side.

e
2.  Ataxic gait – usually wide based, unsteady and poorly
m

m
coordinated.
3.  Hemiplegic gait – tendency to drag and to circumduct the
leg with extended foot, which scrapes the ground.
m

m
4.  Lower limb weakness results in the foot being dragged and a
o

co
slapping gait.
.c

5.  Toe-walking gait is not in itself abnormal and has been noted

e.
e

in infants born prematurely.


re

fre
6.  Possible causes of a limping gait are mentioned on
f

pages 175–176. Remember that a late or missed congenital


ks

ks
dislocation of the hip may not be apparent until the child
oo

oo

walks.
eb

eb

e
m

m
Schoolchild (5+ years)
The cooperative schoolchild will usually allow you to carry
out a complete formal neurological examination as appro-
m

priate. This is described in your text on clinical methods so


co

co

we will not duplicate here. One will always have to make


allowance for the child’s confidence, cooperation and com-
e.

e.

prehension of what is required of him. The examiner will


fre

fre

need to be patient, expedient and to be prepared to try again.


ks

ks

Testing of children’s sensation is not often required but


when performed needs clear explanation to the child of the
oo

oo

answers being sought (children are very obliging creatures


eb

eb

and may give false answers for fear of disappointing you!).


e

In the schoolchild the following are the best tests of


m

coordination:
165
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5 SYSTEMS EXAMINATION

co

c
e.

e.
•   one leg stance

re

fre
•   hopping
•   walking on tiptoes
f
ks

s
•   walking on heels.

ok
oo

The child aged 5 years or more who can hop is well coor-

o
eb

eb
dinated. In our country little girls will often demonstrate

e
their dexterity by dancing a simple jig or reel. In these cir-
m

m
cumstances, formal neurological tests such as straight line
walking or running the heel along the leg, are stupid and
superfluous.
m

m
In addition you may wish to observe the child writing,
o

co
kicking a ball, tying his shoelace, clapping, catching a ball,
.c

buttoning his shirt. By the age of 5 years hand dominance

e.
e

is determined – most children are predominantly right-


re

handed, right-footed and right-eyed.


fre
f

The neurological examination is not complete without a


ks

ks
clinical comment on:
oo

oo
eb

eb

e
m

m
m

m
co

co
e.

e.
fre

fre
ks

ks
oo

oo
eb

eb

e
m

Fig. 5.29  One leg stance.

166
m

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co
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SYSTEM EXAMINATION 5

co

c
e.

e.
•   vision

re

fre
•   speech
•   hearing
f
ks

s
•   intelligence.

ok
oo

o
eb

eb

e
m

m
Come to terms: odd movements
chorea = coarse, involuntary, purposeless movements
athetosis = slow, writhing, incoordinate movements
tic = repeated bizarre movements; habit spasms
m

m
tremor = constant small movements
o

co
fasciculation = random contractions of groups of muscle fibres
.c

myoclonus = sudden, single, shock-like contraction of muscles

e.
e
re

fre
f
ks

ks
oo

oo

Determination of tone
eb

eb

Tone implies resistance to passive movement and its assess-

e
ment is related to age. In the newborn and infant, tone is
m

m
best assessed by neck traction, by ventral and upright sus-
pension, and passive movement of limb joints. Tone may
be normal, reduced (hypotonic or floppy), or increased
m

(hypertonic, spastic). The infant (post neonatal) who ‘slips’


co

co

through your hands in upright suspension is hypotonic.


Hypotonia may be caused by muscle weakness or wasting
e.

e.

(as in malnutrition, myopathies, cerebellar lesions and


fre

fre

neuropathies). Wrists and ankle joints may be unduly floppy


ks

ks

and muscles may feel flabby. Shaking of wrists and ankle


joints is a useful index of tone in infants.
oo

oo

The characteristics of spasticity are increased tone of the


eb

eb

muscles and exaggerated deep tendon reflexes. One has to


e

work harder to flex and extend the joints involved. Rigidity


m

may be of the ‘lead-pipe’ variety (the same throughout the


167
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5 SYSTEMS EXAMINATION

co

c
e.

e.
range of movement), ‘clasp-knife’ (stiff initially, but gives),

re

fre
or ‘cogwheel type’ (jerky throughout).
f
ks

s
ok
A selection of CNS signs
oo

o
1.  Cracked pot note is the hollow, cracking note one obtains on
eb

eb
percussing the skull in the presence of raised intracranial

e
pressure and closed fontanellae. The examiner’s ear is applied
m

m
directly to the head and the skull percussed with one finger.
In older children with space-occupying lesions and spread
sutures a ‘hollow note’ may be elicited. The sound is quite
m

m
different from the solid note of the sound skull. The sideroom
o

co
technique of skull transillumination has been rendered
.c

superfluous by the advent of cranial ultrasound.

e.
e

2.  Setting sun sign is when the sclera is visible above the iris. It is
re

fre
seen in hydrocephalus with raised intracranial pressure. It is
f
ks

ks
also seen in normal ‘pop-eyed’ infants.
3.  Head tilt is an interesting and important sign. It may be
oo

oo

evidence of torticollis and is seen in children with strabismus


eb

eb

and ptosis. Rarely it has been described as an early sign of an

e
occipital tumour.
m

m
4.  Doll’s eye reflex is where the eyes move in the opposite
direction to that of the head.
m

Cerebral palsy
co

co

Definition: a disorder of movement and posture presenting


e.

e.

in infancy and characterized by one or a combination of


fre

fre

hypotonia, spasticity, ataxia, involuntary movements.


The common types of cerebral palsy are:
ks

ks

•   hemiplegia
oo

oo

•   quadriplegia – spastic


eb

eb

•   diplegia
e

•   ataxia
m

•   dyskinesis – choreoathetosis, dystonia.


168
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
Hemiplegia (commonest type)

re

fre
The upper limb is more involved than the lower limb. There
f
ks

s
is marked thumb adduction, fisting and increased prona-

ok
tor tone. Contractures may occur and limb growth may be
oo

retarded.

o
eb

eb

e
m

Quadriplegia

m
In this situation all four limbs are involved, particularly the
upper. The predominant sign is hypertonia, demonstrable
m

m
at the wrists and elbows, and also in the ankles, knees and
o

co
hips.
.c

e.
e

Diplegia
re

fre
f

The lower limbs are more severely involved with a sym-


ks

ks
metrical distribution. Clinical presentation coincides with
oo

oo

development of extension in the lower trunk and hips. Typi-


cally the infant drags himself around the floor with flexed
eb

eb

e
arms and extended legs. Extensor spasticity at the hips and
m

m
knees results in the classic signs of extension and scissoring
of lower limbs.
Orthopaedic deformities may result from the altered
m

tone, including:
co

co

•   kyphosis of the thoracic spine


•   lordosis of the lumbar spine
e.

e.

•   dislocation of the hips


fre

fre

•   equino varus or valgus feet.


ks

ks
oo

oo

Ataxia
eb

eb

•   Diplegia (as described above)


e

•   Cerebellar involvement


m

•   Initial hypotonia


169
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
•   Intention tremor

re

fre
•   Stamping gait.
f
ks

s
ok
Dyskinesis
oo

o
This implies irregular and involuntary movements of some
eb

eb
or all groups of muscles. These movements may be continu-

e
ous or be present only when the limb is deliberately moved.
m

m
The signs of dyskinesis include hypotonia, slow and pur-
poseless movements, involvement of distal parts of limbs,
and accentuated voluntary movements.
m

m
o

co
.c

Disabilities associated with cerebral palsy

e.
e

•   Mental handicap (IQ < 70) in 75%


re

•   Visual – squint, refractive errors fre


f
ks

ks
•   Hearing – partial deafness
•   Speech – disorders of sensation, perception and language
oo

oo

development
eb

eb

•   Epilepsy

e
•   Emotional problems.
m

m
The purpose of physical and neurological examination is to
determine:
m

•   the type of cerebral palsy


co

co

•   the severity and distribution of the problem


•   the nature and extent of associated mental and physical
e.

e.

handicap.
fre

fre
ks

ks

MUSCULO-SKELETAL SYSTEM
oo

oo

In this section we have arbitrarily lumped together the limbs,


eb

eb

muscles, bones and joints, with a few words on congenital


e

malformations. A lot of interesting paediatric case material


m

is to be found on the orthopaedic ward. We propose to


170
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
highlight a few points in a chronological fashion – newborn,

re

fre
toddler and schoolchild.
A thorough examination is from head to toe. Most stu-
f
ks

s
dents are thorough in their systematic questioning and

ok
oo

systems examination. Nonetheless the untrained eye can

o
easily miss little things, which may be relevant – poly-
eb

eb
dactyly, for example, or 2nd–3rd toe partial syndactyly (a

e
m

m
common finding), or 5th finger clinodactyly. We have seen
schoolchildren with Poland’s syndrome (absence of the pec-
toralis major muscle and/or nipple) whose parents have
failed to notice this apparently obvious deformity. Scoliosis
m

m
is easily missed at any age unless one specifically looks
o

co
for it.
.c

e.
Observe the infant or child in his preferred position. If
e

mobile, watch how he moves around. Does he creep, crawl,


re

fre
bottom-shuffle? Observe the gait. Can he run? Note coordi-
f
ks

ks
nation, dexterity and symmetry of movement. Can he hop
on one foot (a good test of coordination as well as muscular
oo

oo

strength)? Can he jump? How does he get up from the sitting


eb

eb

position? Has he a limp, waddle or other abnormal gait? Are

e
the limbs symmetrical and of equal length? Parents will fre-
m

m
quently seek medical advice on normal postural variations
– intoeing (due to metatarsus adductus), bow-leggedness
(genu varum) and lumbar lordosis (producing a protuber-
m

ant abdomen).
co

co

Tiptoe walking can be normal, and is a feature of prema-


ture infants. It may additionally be an early sign of spastic
e.

e.

diplegia, due to a tightening of Achilles’ tendon.


fre

fre
ks

ks
oo

oo

Come to terms: types of abnormality


Malformation = structural defect of an organ or area
eb

eb

Deformation = abnormal form or position of a part due to compression


e

Disruption = breakdown of otherwise normal development process


m

171
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
Some simple rules when dealing with the painful, limping,

re

fre
orthopaedic or arthritic child are listed below.
f
ks

s
ok
Orthopaedic rules . . . OK?
oo

above all, don’t hurt the child

o
active movements always before passive
eb

eb
never force a joint – especially a suspected congenital dislocation of hip

e
if in doubt, don’t!
m

m
Come to terms: orthopaedic
m

m
talipes equino varus = club foot
o

co
genu varum = bow-legged
.c

genu valgum = knock-kneed

e.
e

genu recurvation = knees bent backwards


re

fre
gibbus = sharply angled kyphosis
f
ks

ks
oo

oo

The newborn
eb

eb

At this age one’s major interest is in detection of congeni-

e
tal abnormality. Are there 10 fingers and 10 toes? Any
m

m
webs? Are the limbs symmetrical? Any positional deformi-
ties? Mild positional deformities of the feet, for example,
varus (inturning) or valgus (out-turning), are common.
m

Gentle manipulation will restore the foot to its correct


co

co

position.
Fixed deformities such as club foot (talipes equino varus)
e.

e.

are frequently associated with spina bifida, and will not


fre

fre

correct on manipulation.
ks

ks
oo

oo

Developmental dysplasia of the hip (see Newborn


examination, Chapter 4)
eb

eb

The correct technique of the hip examination is important


m

to acquire – the ‘Baby Hippy’ may help in this respect. It is


172
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
vital to remember that if developmental dysplasia of the hip

re

fre
(DDH) is not detected in the newborn period, it may not be
evident until walking is attempted, at which stage curative
f
ks

s
correction is difficult. Hip examination is rewarding in the

ok
oo

first week, less so at 6 weeks, and unrewarding at 6 months.

o
After the newborn period the major sign of DDH is limited
eb

eb
abduction of the hip.

e
m

m
Come to terms: finger/toe
m

m
syndactyly = fusion of digits
clinodactyly = incurved digit
o

co
camptodactyly = flexed digit
.c

polydactyly = extra digits

e.
e

arachnodactyly = long thin digits


re

fre
f
ks

ks
oo

oo

Limb deformities
eb

eb

Limb reduction defects (of the type seen following thalido-

e
mide ingestion in pregnancy) are rare and will not be con-
m

m
sidered in detail. Proper measurement of limb length will
be valuable in suspected asymmetry. Precise measurement
of the lower limb is from the anterior iliac spine to the
m

lower aspect of the medial malleolus. Hemihypertrophy has


co

co

important associations with, for example, aniridia (absence


of the iris) and nephroblastoma.
e.

e.
fre

fre

Come to terms: limb deformities


ks

ks

amelia = absence of limb


oo

oo

hemimelia = absence of distal half of limb


phocomelia = hand or foot attached directly to trunk
eb

eb

arthrogryposis = curved joints


e

osteogenesis imperfecta = brittle bone disease (fragilitas ossium)


m

173
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
Neural tube defects are sufficiently common, particularly

re

fre
in Celtic races, to warrant mention. The defects are usually
obvious on inspection, and the associated disabilities and
f
ks

s
deformities will depend on the site and size of the lesion.

ok
oo

The length and width of the lesion should be measured.

o
The different types of neural tube defects are encephalocele,
eb

eb
myelomeningocele, meningocele, and spina bifida occulta

e
m

m
or dysraphism. In the minor and lower spinal types of spina
bifida the clinical signs may be subtle – hairy tuft overlying
the spine, ‘lipomatous’ lump or mild lower limb wasting or
weakness. There is a strong association between neural tube
m

m
defect and hydrocephalus.
o

co
Spina bifida occulta describes an incomplete fusion of
.c

e.
vertebral arches on radiographs.
e
re

fre
f

Come to terms: neural tube defects


ks

ks
spina bifida = failure of fusion of vertebral arches (synonym =
oo

oo

rachischisis)
meningocele = open vertebral arches with overlying sac
eb

eb

containing cerebrospinal fluid

e
myelomeningocele = unfused vertebral arches with exposed neural tissue
m

m
hydranencephaly = almost complete absence of cerebral hemispheres
anencephaly = congenital absence of cranial vault
encephalocele = herniation of brain through congenital skull defect
m

m
co

co

The neck
e.

e.

An apparent short neck is common in the newborn. Normal


fre

fre

neck movement can be demonstrated by turning the baby’s


ks

ks

head to 90° on each side.


A fibrous nodule midway along the sternomastoid
oo

oo

muscle (sternomastoid ‘tumour’) is an occasional finding in


eb

eb

the neonate. It usually resolves spontaneously.


e

The thyroid gland is usually neither visible nor palpable


m

in the newborn. An obvious goitre suggests some form of


174
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
hypothyroidism (secondary to a thyroid enzyme deficiency)

re

fre
or transient hyperthyroidism.
Thyroglossal cysts are rare midline lesions which change
f
ks

s
position with tongue movement.

ok
oo

o
eb

eb
Toddler and preschool child

e
m

m
The normal toddler frequently has a mildly bow-legged gait.
This may convert to a knock-kneed posture in the preschool
age. Neither should cause concern unless extreme. Most
m

m
toddlers have flat feet. Intoeing is a frequent finding due
usually to metatarsus varus or to tibial torsion.
o

co
.c

e.
e

Limp
re

fre
f

Limp is a frequent clinical problem in small children and


ks

ks
will require careful examination of spine, hip, knee and foot.
oo

oo
eb

eb

e
m

m
m

m
co

co
e.

e.
fre

fre
ks

ks
oo

oo
eb

eb

e
m

Fig. 5.30  Normal lower limb variations.

175
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
The approach to the limping child will be based on (a)

re

fre
history, (b) age and (c) clinical examination. The chronol-
ogy of hip disorders in children has been well described.
f
ks

s
Inspection of the child’s position, gait and lower limb will

ok
oo

be imperative. Examination of hip, knee and ankle joint for

o
range of movement will follow. A careful search for local
eb

eb
heat or tenderness, for embedded foreign body, and for rash

e
m

m
or lumps will be necessary. Among the multiple causes of
acute limp in a child one could include the following:
•   irritable hip
m

m
•   transient synovitis
o

co
•   pyogenic arthritis
.c

•   osteomyelitis

e.
e

•   discitis
re

•   osteochondritis
fre
f

•   puncture wound, verruca, foreign body in foot


ks

ks
•   spiral fracture of tibia or fibula
oo

oo
eb

eb

e
m

m
m

m
co

co
e.

e.
fre

fre
ks

ks
oo

oo
eb

eb

Fig. 5.31  Toddler climbing steps.


m

176
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
•   rheumatoid arthritis

re

fre
•   bone tumour
•   trauma
f
ks

s
•   Perthes’ disease

ok
oo

•   slipped femoral epiphysis

o
•   anaphylactoid purpura
eb

eb
•   lymphatic leukaemia

e
m

m
•   coagulation disorder
•   inguinal hernia
•   testicular torsion.
m

m
o

co
Musculo-skeletal system
.c

e.
The term orthopaedics literally means ‘straight child’. The
e

term paediatrics means ‘child doctor’. We once heard an


re

fre
illuminating lecture entitled ‘Paediatrics as orthopaedic
f
ks

ks
medicine’, which cleverly combined the words and con-
cepts. Children are brought to doctors to have their mal-
oo

oo

formations corrected (if possible), their broken bones fixed


eb

eb

(frequently) and their aches and pains relieved. Accidents

e
and injuries are now the commonest reason for children’s
m

m
attendance at and admission to hospitals. As a result the
orthopaedic department can be the busiest in the hospi-
tal. We are firm believers that, as implied in the lecture
m

title above, orthopaedic surgeons and paediatric physicians


co

co

should work closely together.


Needless to remark, the examination of muscles and
e.

e.

nerves are inter-related exercises. Likewise, examination


fre

fre

of muscles and joints must be integrated. The subdivi-


ks

ks

sions between the chapters on nerves, muscles and joints


are somewhat artificial and arbitrary, and they should
oo

oo

best be seen as a continuum. No muscle or joint is an


eb

eb

island unto itself and lesions are often multiple rather than
e

isolated.
m

177
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
Muscles

re

fre
Muscle disorder in childhood may reflect neurological dis-
f
ks

s
eases or intrinsic muscle disease, more likely the former.

ok
oo

Early clues to neuromuscular disorder include reduced

o
intrauterine activity, postnatal respiratory distress, floppi-
eb

eb
ness, poor sucking and swallowing, and delayed develop-

e
mental milestones. Later, an affected child may be slow to
m

m
walk, poorly coordinated and clumsy, tire easily (wish to be
carried everywhere), or fall often.
Examination of muscles includes inspection, palpa-
m

m
tion, testing muscle strength and excluding neurological
o

co
disorder.
.c

e.
Muscle inspection. Here one is primarily concerned with
e

size and symmetry. Absence or hypoplasia of a muscle


re

fre
group is recognized in certain syndromes – the angle of the
f
ks

ks
mouth in congenital heart disease, the pectoralis major in
Poland’s syndrome, and the abdominal muscles in ‘prune
oo

oo

belly’ syndrome.
eb

eb

Unilateral joint disease (say of the knee) may result in

e
unilateral muscle wasting (of the quadriceps). It is well
m

m
worth noting the degree of muscle wasting which can follow
prolonged immobilization of a child’s limb in a fracture cast.
Hypertrophy of muscle groups may imply physical use
m

(swimmers have strong shoulder muscles). Some children


co

co

with certain short-limbed bone disorders look strikingly


muscular. The legs of children with hypochondroplasia
e.

e.

or achondroplasia may appear to be ‘muscular’. The calf


fre

fre

muscles may appear large, but feel rubbery, in Duchenne’s


ks

ks

muscular dystrophy.
Palpation of muscles. Muscle tenderness is indicative of
oo

oo

myositis. Acute viral myositis with refusal to walk, tender-


eb

eb

ness of the calf muscles, and little constitutional upset is


e

a recognized clinical entity. It is seen usually in children


m

aged 5–10 years. Influenza virus and Coxsackie virus infec-


178
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
tions may cause myalgia (muscle pain) in children but not

re

fre
usually myositis. Muscle pain and tenderness are well rec-
ognized features of ascending polyneuritis (Guillain–Barré
f
ks

s
syndrome) in children. Muscle tenderness is seen in der-

ok
oo

matomyositis, a rare childhood condition. We have only

o
once felt the vermiform mass of visceral larva migrans but
eb

eb
suspect it may be more common in developing countries.

e
m

m
Muscle tumours (such as myosarcoma) or bone tumours
(such as osteosarcoma or chondrosarcoma) are rare in child-
hood, but may present as masses, apparently in or adherent
to muscle groups.
m

m
Muscle strength. This can be difficult to determine in pre-
o

co
school children, but should be easily assessable in school-
.c

e.
children. Students are not expected to know the relative
e

strength of various groups of muscles at different ages. One


re

fre
arbitrary method of grading strength is shown in Table 5.12.
f
ks

ks
If the truth be told most of us ordinary mortals and pae-
diatricians require the assistance of a physiotherapist or
oo

oo

neurologist to accurately grade and gauge the strength of


eb

eb

groups of muscles.

e
A couple of simple screening tests may be helpful and
m

m
illustrative. Think of yourself – what movements would you
do if asked to test the strength of your calf muscles (stand
on your toes?), biceps (lift a litre of beer?), or abdominal
m

m
co

co
e.

e.

Table 5.12  An arbitrary method for grading strength


fre

fre

Grade Crude assessment Degree of weakness


ks

ks

0 None No movement
1 Minimal Flicker of movement
oo

oo

2 Poor Movement with gravity only


3 Fair Movement against gravity
eb

eb

4 Good Mild weakness


e

5 Normal Normal
m

179
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
muscles (do a sit-up?). Now apply your common sense to

re

fre
small children.
f
ks

s
•   Lift toddler up under his arms – tests proximal muscles of

ok
upper limbs.
oo

•   Hold toddler by fingertips – tests distal arm muscles.

o
eb

eb
•   Ask toddler to crawl up steps – tests proximal and distal

e
muscles of lower limbs.
m

m
•   Ask toddler/child to get up from sitting position. This tests
the calf muscles. Gower’s sign (where the child ‘climbs up’
his legs) is a classic sign of muscular dystrophy but is seen in
m

m
other forms of muscle weakness.
o

co
•   Ask the child to squeeze your two fingers – ‘hurt me if you
.c

can’. They usually enjoy this. Tests grip strength.

e.
e

•   Ask the child to pull your hair (with fingers only) – they
re

fre
really enjoy this! Tests small hand muscles.
f
ks

ks
We could go on but trust you have got the message. Play
games, indulge in mock fights, pit your strength against
oo

oo

theirs, be encouraging and positive:


eb

eb

e
‘Let’s see how strong you are.’
m

m
‘Come on! You can do better than that.’

Most boys enjoy these exercises and modern girls are not
far behind.
m

m
co

co

Schoolchild
e.

e.

In this section we propose to mention selectively (a) joint


fre

fre

examination, (b) arthritis and (c) examination for scoliosis.


ks

ks

The systematic examination of muscles, joints and bones


in the schoolchild is as for an adult. Limb or joint pain
oo

oo

is a common symptom seeking explanation. The term


eb

eb

‘arthralgia’ means joint pain. It is important to ascertain


e

from the parents of a child with limb pain its periodicity,


m

precipitating and relieving events and, most importantly,


180
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
whether or not they have noticed any swelling or redness

re

fre
in the affected part.
All students must be able to examine all joints, but par-
f
ks

s
ticularly (a) the hand, (b) the hip and (c) the knee, these being

ok
oo

the joints most commonly involved in arthritic process.

o
eb

eb

e
Joint examination
m

m
Arthritis, or joint inflammation, is a common phenom-
enon in paediatrics. It may occur in rubella (affecting the
knees especially), in infectious mononucleosis, in Henoch–
m

m
Schönlein syndrome (affecting the large joints), fleetingly in
o

co
rheumatic fever (which ‘licks the joints and bites the heart’),
.c

e.
in collagen-vascular disorders such as systemic lupus ery-
e

thematosus, and in the various chronic arthritides of child-


re

fre
hood. Arthritis is manifest by the presence of the classic
f
ks

ks
signs of inflammation:
oo

oo

•   rubor (redness)


•   calor (heat)
eb

eb

e
•   dolor (pain)
m

m
•   tumour (swelling)
•   functiolasia (loss of function).

Joints may also be involved in infectious processes. Septic


m

arthritis may involve hips or knees. Tuberculous arthritis


co

co

commonly used to involve hips and spines, but is no longer


common in the Western world. Meningococcaemia may be
e.

e.

accompanied by joint infection.


fre

fre

Joints may be damaged or their function disordered by


ks

ks

congenital malformation, as in arthrogryposis multiplex, or


acetabular dysplasia, now thought to be a common associa-
oo

oo

tion with dislocated hips.


eb

eb

Pain is the primary complaint in arthritis. Children are


e

brought to doctors for (a) relief of pain, (b) suppression of


m

inflammation or infection, (c) maintenance of joint position


181
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
re

fre
f
ks

s
ok
oo

o
eb

eb

e
m

m
m

m
o

co
.c

e.
e
re

fre
f
ks

ks
oo

oo

Fig. 5.32  Swollen arthritic knee.


eb

eb

e
m

and function and (d) prevention of deformity. The primary


objective in joint examination is to achieve an anatomical, m
m

pathological and functional diagnosis leading to appropri-


co

co

ate management. In simple terms, one wants to know what


joints are affected, how badly and for what reason.
e.

e.

Finally, arthralgia and arthritis may be due to trauma,


fre

fre

bleeding disorder (factor 8 or 9 deficiency), or to one of


ks

ks

the many eponymic osteochondritides, such as Osgood–


Schlatter disease. In small pre-vocal infants and toddlers,
oo

oo

joint pain may be manifest by unwillingness to move a


eb

eb

limb, or by crying when being bathed or changed. A mother


e

recently said of her infant with Still’s disease: ‘I just could


m

not touch him but he cried’.


182
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
Correct examination of any joint depends on:

re

fre
•   inspection and accurate description of observations
f
ks

s
•   palpation for heat, tenderness, swelling and crepitus

ok
•   testing range of movement.
oo

o
The basic rules of examination are look first, palpate
eb

eb
gently without hurting and always do active movements

e
m

m
before passive movements. The gait should be routinely
observed. ‘Growing pains’ are a misnomer – physical
growth is not painful, but ‘psychological growth can hurt
like hell’.
m

m
Joint inspection involves looking for the presence of
o

co
joint swelling, for loss of usual bony landmarks and joint
.c

e.
contours, and for associated muscle wasting. Joint swelling
e

may be due to synovial thickening or joint effusion or both.


re

fre
In the knee, wrist and interphalangeal joints, swelling may
f
ks

ks
be obvious. The purpuric rash of Henoch–Schönlein syn-
drome may accompany obvious arthritis of the ankle and
oo

oo

knee, making diagnosis simple. Swollen interphalangeal


eb

eb

joints produce a spindle-shaped deformity of the fingers.

e
Swelling of the wrist joint may result in a ‘dinner-fork’
m

m
deformity. Swelling of shoulder and hip joints is not usually
visible.
Joint palpation implies a search for joint heat using the
m

palm or back of one’s hand according to preference. One


co

co

must compare joint heat with its pair and with surrounding
structures. Obvious joint heat strongly suggests an inflam-
e.

e.

matory arthritis. Joint tenderness may be assessed by gently


fre

fre

pressing, compressing or squeezing the joint. Joint swelling


ks

ks

due to synovial thickening can be best appreciated at the


wrist where the thickened synovium may be palpable. Joint
oo

oo

effusion is easiest to detect at the knee joint. With a small


eb

eb

amount of fluid in the knee the bulge sign can mobilize the
e

fluid between various pouches. A large amount of fluid in


m

the knee joint is indicated by a positive patellar tap.


183
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
Joint movement. Testing joint movement requires a know-

re

fre
ledge of the normal range of movement of a given major joint
– about 180° at the wrist and 140° at the knee, for example. It
f
ks

s
is beyond the remit of this text to list ranges of movement of

ok
oo

flexion, extension, rotation or abduction of various joints at

o
different ages. An infant can get his toe into his mouth; most
eb

eb
adults can only achieve this with training or torture. You

e
m

m
should know the normal ranges at ankle, knee, hip, wrist,
elbows, shoulders and neck joints (see Table 5.13).
Finally, a word of caution. Always perform active move-
ments before passive movements. Doing things the other
m

m
way round may result in you hurting the child. If you hurt
o

co
a child during examination, and he cries – end of examina-
.c

e.
tion, upset child, angry mother, failed student?
e

The term ‘juvenile idiopathic arthritis’ (JIA) is now used


re

fre
to describe the various chronic arthritides of childhood. Sir
f
ks

ks
Frederick Still elegantly described a cluster of conditions,
emphasizing the systemic nature of the condition in the
oo

oo

young child involving skin, glands, spleen, liver and bone


eb

eb

marrow, as well as the joints.

e
m

m
m

Table 5.13  Normal range of movement at various joints


co

co

Joint Movement Normal range


e.

e.

Wrist Flexion 90°


fre

fre

Extension 90°
Elbow Flexion   0–15°
ks

ks

Extension   0–15°
Knees Flexion 30°
oo

oo

Hyperextension   0–5°
Ankle Dorsiflexion 30°
eb

eb

Plantar flexion 30°


e
m

184
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co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
Classification of juvenile idiopathic arthritis

re

fre
Definition of JIA: arthritis present for 6 or more weeks for
f
ks

s
which no other cause can be found.

ok
Subtypes
oo

o
1.  Oligoarticular onset JIA: fewer than five joints involved
eb

eb
during the first 6 months of disease.

e
m

m
Persistent: four or fewer total joints involved during the
duration of follow-up.
Extended: more than four joints involved during duration of
follow-up.
m

m
2.  Polyarticular onset JIA: five or more joints involved during
o

co
first 6 months of disease, usually involving small joints in a
.c

e.
symmetrical distribution.
e
re

Rheumatoid factor negative/positive.


fre
f
ks

ks
3.  Systemic onset JIA (formerly known as Still’s disease):
chronic arthritis associated with systemic features including
oo

oo

high spiking fevers, transient episodic erythematous rash,


eb

eb

lymphadenopathy and hepatosplenomegaly.

e
4.  Psoriatic arthritis: chronic arthritis usually with asymmetric
m

m
small and large joint involvement, and either the development
of psoriasis or other evidence of a psoriatic diathesis (family
history, nail pits).
m

5.  Enthesitis-related arthritis: previously known as juvenile


co

co

spondyloarthropathy. Chronic arthritis associated


with enthesitis (inflammation at insertion of tendons,
e.

e.

ligaments or fascia to bone), or with lower axial skeletal


fre

fre

involvement. An HLA-B27-related arthropathy. A significant


ks

ks

proportion of patients will develop sacroiliitis as adults, but


back and sacroiliac joint involvement is uncommon during
oo

oo

childhood.
eb

eb

6.  Unclassified: any form of idiopathic chronic arthritis that does


e

not fit into the above categories.


m

185
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
Come to terms: painful words

re

fre
myalgia = muscle pain
f
arthralgia = joint pain
ks

s
neuralgia = nerve pain

ok
proctalgia = rectal pain
oo

migraine =

o
unilateral headache
eb

eb
(hemi-crania = half head)

e
m

m
m

m
Scoliosis
o

co
.c

Routine examination, particularly in adolescent schoolgirls,

e.
e

should include inspection for scoliosis. Scoliosis is sought


re

by: fre
f
ks

ks
1.  Inspection from behind in the upright posture. One shoulder
oo

oo

may be elevated and the lumbar or thoracic spine may


apparently be curved. It is usual to describe the curvature on
eb

eb

the basis of its convexity (to right or left).

e
m

m
2.  Asking the child to touch her toes. The examiner should be
seated behind the child with eyes horizontal to the bent back.
A fixed scoliosis will be evidenced by a hump. A postural
scoliosis will correct on bending.
m

m
co

co
e.

e.
fre

fre

Hip ages
ks

ks

birth: CHD/DDH
oo

oo

1–3 years: transient synovitis


5 years: Perthes’ disease
eb

eb

10 years: slipped epiphysis


e

any age: inflammatory arthritis


m

186
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
re

fre
f
ks

s
ok
oo

o
eb

eb

e
m

m
m

m
o

co
.c

e.
e
re

Fig. 5.33  Inspecting for scoliosis.


fre
f
ks

ks
oo

oo

THE EYES
eb

eb

e
The eye is the window of the soul.
m

m
The eyes can tell a lot about all of us. When indulging in
the art of physiognomy (attempting to assess character from
m

m
facial features) one first looks at the eyes. So too in children.
The dull, sunken eyes in dehydration; the sad, depressed
co

co

eyes in marasmic malnutrition; the yellow sclera of jaundice;


e.

e.

the pink iris of albinism; the bright, sparkling eyes of gaiety


fre

fre

and good health.


Eye examination should include:
ks

ks

•   general inspection of the eye, pupil, iris, sclera


oo

oo

•   assessment of eye movement, with a comment on symmetry


eb

eb

or otherwise
e

•   pupillary, accommodation and corneal reflexes as appropriate


m

•   red reflex

187
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
•   retinal funduscopy (with the ophthalmoscope)

re

fre
•   assessment of visual acuity.
f
ks

s
ok
Ophthalmoscopy
oo

o
Good ophthalmoscopy is an integral part of examination
eb

eb
of any child, irrespective of age. In the newborn, assistance

e
is required to hold the head correctly in the midline. The
m

m
eyelids can be gently prised apart. Elicit the red reflex in
both eyes from a distance of 20 cm. Inspect the cornea for
clarity, seek any lens opacity and examine the fundus to
m

m
detect haemorrhages, retinopathy and appearance of the
o

co
disc.
.c

e.
Funduscopy can be very difficult in toddlers and pre-
e

school children. Keep the infant or child in his position of


re

fre
comfort – lying, sitting on his mother’s knee or sitting alone.
f
ks

ks
Darken the room if necessary. Keep the light intensity of
the ophthalmoscope down. Do not use mydriatics (without
oo

oo

permission). Try to get the child to look at an attractive but


eb

eb

distracting object. Do not force the eyes open – this usually

e
results in resistance and rejection. Be patient, approaching
m

m
slowly from a distance. Patience and perseverance may be
rewarded by the recognition of an identifiable retinopathy
(for example rubella, cytomegalovirus or toxoplasma retin-
m

opathy in a child whose handicaps were previously unex-


co

co

plained).
Other rare findings include: retinopathy of prematurity
e.

e.

(retrolental fibroplasia), hypertensive retinopathy, choroi-


fre

fre

dal tubercle, Toxocara (ocular larva migrans). Papilloedema


ks

ks

is rare in the presence of open fontanellae and sutures.


oo

oo

Funduscopy findings
eb

eb

•   rubella retinopathy = ‘pepper and salt’ appearance on retina


m

(rare)

188
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
•   toxoplasmosis =o  ne or many pigmented or atrophic

re

fre
scars (rare)
f
•   cherry-red spot = seen in a variety of rare inherited
ks

s
disorders (rare).

ok
oo

In infants and children always first ask the mother: ‘Does

o
your child see well?’ If she replies ‘yes’, ask her to tell you
eb

eb
her reasons. She’s usually right. If she thinks her child sees

e
poorly, seek the reason. The onus lies on the doctor to deter-
m

m
mine whether she’s right or wrong.
m

m
Occasional eye findings of no consequence
o

co
1.  Pseudostrabismus (pseudosquint) is the spurious appearance of
.c

e.
a squint due to broad nasal bridge or prominent epicanthic
e
re

fre
folds.
2.  Blue sclerae are usually normal in infancy. Strikingly blue sclerae
f
ks

ks
are seen in osteogenesis imperfecta, in inherited connective
tissue disorders and occasionally in iron deficiency.
oo

oo

3.  Blinking is often a form of habit spasm or tic in schoolchildren,


eb

eb

and is best ignored.

e
4.  Light reflection is useful at all ages. Light from a distant source
m

m
(the window, a light bulb, or torch) should fall symmetrically
on the pupils or iris through all ranges of movements.
m

m
co

co
e.

e.
fre

fre
ks

ks
oo

oo
eb

eb

e
m

Fig. 5.34  Light reflection is useful at all ages.

189
m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
re

fre
f
ks

s
ok
oo

o
eb

eb

e
m

m
Fig. 5.35  Ocular landmarks: A = inner-canthal distance, B =
m

m
interpupillary distance, C = outer canthal distance.
o

co
.c

e.
e

Normal values for ocular landmarks (Fig. 5.35) can be found


re

fre
in specialized texts. Hypertelorism exists when the eyes are
f

widely spaced apart.


ks

ks
The term ‘mongoloid slant’ is used when the eyes slope
oo

oo

upwards and outwards. By converse, ‘anti-mongoloid slant’


is downwards and outwards.
eb

eb

e
m

m
Observational ophthalmology
We have stressed throughout this text the rewards of careful
m

observation. A good look at the eyes is well worthwhile.


co

co

1.  Cataract may be seen. Cataracts are associated with congenital


rubella and galactosaemia.
e.

e.

2.  Corneal clouding may be apparent. This is suggestive of


fre

fre

mucopolysaccharidosis.
ks

ks

3.  Nystagmus may be noted.


4.  Roving, purposeless eye movements with little visual fixation
oo

oo

are typical of the infant with visual impairment.


eb

eb

5.  Ptosis of the eyelid may be obvious.


e

6.  Males with the fragile X syndrome have cold (often blue)
m

piercing eyes.
190
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
7.  The ‘frozen watchfulness’ of the battered or abused child may

re

fre
be observed. His gaze is calculated and seems to go through
you.
f
ks

s
8.  Leukocoria = absence of red reflex. This may indicate

ok
oo

retinoblastoma, cataract or retinopathy of prematurity.

o
eb

eb

e
Come to terms: eyes
m

m
amblyopia = ‘lazy’ eye; partial loss of vision
aniridia = congenital absence of the iris
anophthalmia = congenital absence of the eye (orbit)
aphakia = congenital absence of the lens
m

m
o

co
.c

e.
A few simple points to remember about eye examination
e

are that:
re

fre
f

•   children do not like having their eyes prised open


ks

ks
•   accommodation is strong in preschool children
oo

oo

•   pupillary inequality is an occasional normal finding


eb

eb

e
m

m
m

m
co

co
e.

e.
fre

fre
ks

ks
oo

oo
eb

eb

191
e
m

Fig. 5.36  A responsive smile.


m

m
co

co
m

om
5 SYSTEMS EXAMINATION

co

c
e.

e.
•   symmetry of movement, colour and reaction is important to

re

fre
establish.
f
ks

s
Eye examination at different ages

ok
oo

Newborn

o
eb

eb
Neonates dislike strong light; however, turning to light is a

e
useful clinical test during the first month. Transitory fixation
m

m
may be elicited by bringing a red (ball) object into the visual
field at a distance of about 30–50 cm.
The newborn’s eyes are best examined with the baby
m

m
upright, and, if necessary, sucking. They will usually open
o

co
in this position. With patience and a cooperative baby you
.c

e.
may see the baby’s eyes ‘lock’ onto his mother’s.
e

At birth, examination is mainly to exclude gross


re

fre
abnormalities, evidence of possible trauma and congenital or
f
ks

ks
acquired infection. Eye movement at this stage is established
through the use of the vestibular ocular reflex, where rotat-
oo

oo

ing the baby from side to side, backwards and forwards and
eb

eb

up and down will elicit eye movements in all directions.

e
Disconjugate movements may be present in the first week
m

m
or two but are usually gone by 4 weeks. Eye size should
be checked to exclude eyes that are too big (glaucoma)
or too small (microphthalmia). The cornea should be per-
m

fectly clear within 1 or 2 days after birth. The pupils should


co

co

be equal and reactive. Always be suspicious of different


coloured eyes at this stage.
e.

e.

Assessment of alignment is best carried out with an oph-


fre

fre

thalmoscope at about a distance of 0.5 m. At this distance


ks

ks

the examiner can observe both pupils simultaneously and


compare redness and brightness of the red reflex. If inequal-
oo

oo

ity of the redness occurs, the possibility of a strabismus or


eb

eb

an opacity in the eye should be considered. Funduscopy


e

at this stage shows occasional haemorrhages, particularly


m

around the disc and posterior pole. If the haemorrhages are


192
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
extensive, an ophthalmological opinion should be sought.

re

fre
Sometimes in the first few days, oedema of the eyelids
causes difficulty in opening the eye for proper examination
f
ks

s
and in this case placing the baby in the prone position will

ok
oo

facilitate eye opening.

o
eb

eb

e
6–8 weeks
m

m
The infant is alert to moving objects although convergence
and following are jerky. An examiner can readily hold the
infant’s attention at a distance of about 30 cm and a reward-
m

m
ing smile ‘with meaning’ is elicited. By 12 weeks head and
o

co
eye movements may be demonstrated through 180°. At this
.c

e.
age lacrimal glands will show response to emotion.
e
re

fre
f

16–20 weeks
ks

ks
Hand regard develops and a 2.5-cm (1-inch) brick will cause
oo

oo

immediate fixation within a distance of 1 m. Colour pref-


eb

eb

erence develops from 20–28 weeks and hand/eye coordi-

e
nation (palmar grasp) can readily be elicited using brick
m

m
or paper. Visual acuity continues to improve dramatically
from 9 to 12 months and very small objects can be seen and
picked up using index finger and thumb. There is smooth
m

visual movement in both the horizontal and vertical planes.


co

co

At 1 year the transverse diameter of the cornea is adult size


(12 mm). Convergence is well established by 18 months. By
e.

e.

the age of 4 years visual acuity is nearly 20/20.


fre

fre

Examination of the eyes should be carried out in every


ks

ks

patient irrespective of age. Skill in the proper use of the


ophthalmoscope should be acquired early in clinical train-
oo

oo

ing. Assessment should occur in the neonatal period, at the


eb

eb

toddler stage (2–3 years) and again at 5 years (preschool).


e

Subsequently to this, assessment should be carried out every


m

2–3 years to late teens.


193
m

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5 SYSTEMS EXAMINATION

co

c
e.

e.
Strabismus (squint)

re

fre
Parents will often offer the opinion that their child has a
f
ks

s
squint. Squint may be more apparent when the child is

ok
tired. Relatives or friends may point out a squint to the
oo

parents. Students should always accept parents’ opinion

o
eb

eb
concerning squint and test the eyes appropriately. Squint in

e
the newborn is not significant so long as you can exclude a
m

m
retinoblastoma. Approach squints in the following fashion:
1.  Look for light reflection through all movements.
2.  Test eye movement and muscles in all directions. A simple
m

m
method of checking all eye movements is to draw an
o

co
imaginary ‘Union Jack’ in the air while asking the child to
.c

e.
follow your finger (Fig. 5.37).
e
re

fre
3.  Try to answer the simple question – is this squint alternating
(concomitant) or paralytic?
f
ks

ks
4.  Look for corneal opacities and cataracts.
5.  Do the cover test. Use an interesting object (toy) to hold the
oo

oo

child’s attention. The eye is covered on the visual axis to


eb

eb

make viewing of the object monocular. If the child has been

e
fixing with the eye just covered, the other eye will take over
m

m
fixation in the presence of a squint.

Any squint persisting beyond 5–6 months from birth is


m

significant and should be referred immediately to an


ophthalmologist. Pseudosquint is a common minor vari-
co

co

ation. Paralytic squint, though rare, tends to have more


e.

e.

serious connotations than alternating squint.


fre

fre
ks

ks

Come to terms: eye lumps


oo

oo

chalazion = small inclusion cyst in eyelid


hordeolum = stye in the eyelid (pustule)
eb

eb

dermoid = external angle dermoid of eye


e

pinguecula = small yellowish patch near the cornea


m

194
m

m
co

co
m

om
SYSTEM EXAMINATION 5

co

c
e.

e.
re

fre
f
ks

s
ok
oo

o
eb

eb

e
m

m
Fig. 5.37  The Union Jack.
m

m
The red reflex
o

co
.c

Shine a light at both eyes from a distance of 0.5 m. There

e.
e

should be a symmetrical red reflex. A white pupillary reflex


re

fre
will be caused by cataract, retinoblastoma and retinopathy
f

of prematurity. Absence of the red reflex is called leukocoria.


ks

ks
oo

oo

Occasional eye findings


eb

eb

e
1.  Dilated conjunctival vessels may suggest ataxia – telangiectasia.
m

m
2.  Brushfield’s spots (white spots around the outer iris) are seen in
Down’s syndrome but also in normal children.
3.  Morgan–Dennie fold is a double fold under the eye. It is seen in
m

eczematous, allergic children.


co

co

The neurological examination and interpretation of the eyes


are similar in children and adults. Pupils should normally
e.

e.

be equal, central, circular and respond to light and accom-


fre

fre

modation. Eye movements should be full in all directions.


ks

ks

Fine nystagmus on extreme deviation is a normal finding.


The corneal reflex is unpleasant and rarely needs to be elic-
oo

oo

ited. We will not detail testing of visual acuity at differ-


eb

eb

ent ages – refer to Mary Sheridan’s book (1997) or to a


e

textbook of ophthalmology. In cooperative children, visual


m

fields can be roughly assessed by confrontation tests.


195
m

m
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5 SYSTEMS EXAMINATION

co

c
e.

e.
In early infancy the following may be warning signs of

re

fre
poor visual activity
f
roving or wandering eye movements
ks

s
persistence of hand regard

ok
lack of blink to a hand thrust rapidly toward the face (‘blinking to
oo

o
   menace’)
eb

eb
nystagmus

e
m

m
Early detection and treatment of squint can prevent amblyo-
pia. Early detection of reduced visual acuity can lead to
m