Children and adolescents

General examination

If the child appears unwell then the ABCDE approach should be used for assessment (https://www.resus.org.uk/resuscitation-guidelines/abcde-approach/). If not, then proceed as follows.

Note the state of nutrition. Are there any obvious rashes to be seen? Are there any naevi or other skin anomalies? Look at the colour of the child’s lips: is there cyanosis or pallor? Listen to the child. Are there any audible noises such as stridor, wheeze or stertor? Is the speech appropriate for the age of the child? Has the child come with any pieces of equipment, such as a feeding pump or portable oxygen? Are there any obvious devices to be seen, such as a central venous line, gastrostomy tube, suprapubic catheter or ventriculoperitoneal shunt? Is the child interacting with the parent and with you as expected for his age? If not, why not? There could be a sensory deficit or a behavioural problem as a reason for this.

The head, face and neck

Look at the child’s face and ask the following questions:

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  Does it look normal? If not, try to identify which features seem unusual and describe them. Many syndromes are diagnosable by particular facial features.

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  If the baby looks dysmorphic, then do not forget to look at the parents to correlate with any family traits. If the appearance is still not clear, ask who the baby looks like.

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  Does the child have a large or protruding tongue?

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  Are the ears in the normal position, or are they low set and abnormal in any way?

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  Are the eyes small (microphthalmus)? Are they set close together or wide apart (hypo- or hypertelorism)?

Next note the shape of the head. This needs to be done by viewing the child’s head from the front, sides and from above. It may be small if the baby is microcephalic; globular if the baby is hydrocephalic, sometimes with dilated veins over the skin surface; or brachycephalic (flattened over the occiput), for example in trisomy 21 (Down’s syndrome). It is often asymmetrical (plagiocephalic) in normal infants who tend to lie with their heads persistently on one side ( Fig. 6.1 ). This is now much more common because babies are placed on their backs to sleep in order to reduce the risk of sudden death in infancy. It becomes much less noticeable as the child grows older.

Having gained the child’s confidence you can now feel his head for fontanelles and sutures. The anterior fontanelle is normally small at birth, enlarges during the first 2 months, and then gradually reduces until final closure at around 18 months. It can close much earlier and has been reported as staying open in a few normal girls until 4 years of age. Delayed closure may be seen, however, in rickets, hypothyroidism and hydrocephalus. An assessment of the tension of the anterior fontanelle is important. In health, it pulsates and is in the same plane as the rest of the surrounding skull. A tense, bulging fontanelle indicates raised intracranial pressure, but it also becomes tense with crying. A sunken fontanelle is a feature of severe dehydration. The posterior fontanelle is located by passing the finger along the sagittal suture to its junction with the lambdoid sutures. It should normally be closed after 2 months of age. Sometimes, when passing the finger along the sagittal suture, a small notch is felt over the vault of the cranium. This is the third fontanelle and, although it can be normal, it is seen in some chromosome abnormalities and in congenital infections such as rubella. While feeling the head, any ridging of the sutures should be noticed, suggesting premature fusion (craniosynostosis). In the neonatal period, the sutures tend to be separated, and there is sometimes a continuous gap from the forehead to the posterior part of the posterior fontanelle. Sutures close rapidly and are normally ossified by 6 months of age. Leave the measurement of the head circumference until near the end of the examination, because some babies find this a little threatening and may start crying.

Having assessed the skull, the neck can be checked, paying particular attention to the presence of lymph nodes. It is common in childhood to feel small lymph nodes in the anterior and posterior triangles of the neck. They can persist for some years and change in size in response to local infections such as tonsillitis (reactive lymphadenopathy). Lymph nodes of greater than 2 cm diameter or rapidly increasing size may indicate significant pathology and should be investigated. Examination of other lymphatic areas can be carried out at a later stage of the examination—the inguinal nodes when the nappy area is checked, and the axillary nodes when the chest is examined. In young babies, the sternomastoid muscles should be checked for the thickened area known as a sternomastoid tumour. This is a benign lesion occurring usually as a result of birth trauma, but it can lead to difficulties with neck movement and an abnormal head and neck posture. Torticollis, a potentially more sinister sign, can be associated with posterior fossa tumours, vertebral osteomyelitis and urinary tract infections.

The limbs

The feet need to be checked for a variety of problems, such as minor varus deformities, overriding toes or flat feet. Genu varum (bow legs) is common in toddlers and usually the legs straighten with age; however, it could be a sign of rickets caused by vitamin D deficiency. It is helpful to feel the surface of the legs with your hands to detect muscle wasting or tenderness. Note any bony abnormalities and examine the movements of the knee and ankle. Feel for any swelling or warmth of the joints, which may be suggestive of an arthropathy. At the same time, an assessment of the muscle tone can be made. This part of the examination may be made easier as part of a game. It is easy to notice at the same time whether the skin is dry or lichenified (as in eczema) and to note any skin lesions. All the time the child’s reactions should be watched. Is the child still friendly? Be prepared to stop the examination if the child seems to be getting upset, and spend a few minutes trying to re-establish the previous rapport.

The examination can now proceed to the rest of the body. The arms can be examined in the same way as the legs. Do the hands have a single palmar crease, as seen in children with trisomy 21? Is there any clubbing leading to suspicion of underlying cyanotic congenital heart disease or chronic lung disease, such as cystic fibrosis? Are there any limb abnormalities such as syndactyly (fusion of the digits) or polydactyly (extra digits)? Feel the wrists for widening of the epiphyses of the radius and ulna—a sign of rickets. Try to feel the pulse and count it. This is best done at the brachial pulse in a plump, young infant.

The abdomen

The abdomen can be a little difficult to examine if the child is crying, which is why it is important to have gained the child’s cooperation by this point in the examination. Most infants and toddlers will need to be examined while sitting on their carer’s lap ( Fig. 6.2 ). It is sometimes possible to quieten a crying infant by placing him over his mother’s shoulder and examining from behind. Small infants can be given a feed to quieten them. Older children can be asked if they would be happy to lie on an examination couch.

The examination needs to be structured along the three essential components of looking (observation), feeling (palpation) and listening (auscultation). Note the presence of any feeding tubes or drains, which may give you valuable information about underlying illness. Look for scars over the abdomen. A laparotomy scar will indicate major abdominal surgery, a ‘Mercedes Benz scar’ a liver transplant, lower abdominal scars may indicate previous renal surgery. During the first 3 years of life, the abdomen often gives an impression of being protuberant owing to the laxity of the rectus muscles. Causes of true abdominal distension are shown in Box 6.5 . Look for any obvious distension or for peristaltic waves (intestinal obstruction or pyloric stenosis). Note the umbilicus and whether or not there is a hernia. Palpation should be gentle initially. Always ask the child if his tummy hurts anywhere and watch his facial expression during palpation. The liver edge can be felt in normal children up to the age of 4 years; it can be anything up to 2 cm below the costal margin. When enlarged, the spleen may be felt below the left costal margin; in infancy it is more anterior and superficial than in the older child or adult. Slight enlargement of the spleen can occur in many childhood infections (EBV, CMV). Causes of hepatosplenomegaly are listed in Table 6.2 . Faecal masses can be felt in the left iliac fossa in constipated children. They often feel like a sausage that could be rolled underneath the fingertips. A full or distended bladder presents as a mass arising from the pelvis. Deep palpation of the kidneys can be carried out last. Although it would be logical to examine the groin area at this time, it is often better to do this at a later stage. If the child has cried persistently, it is still possible to examine the abdomen. When the baby breathes in and the abdominal muscles relax, the abdominal viscera and other masses, if present, can be palpated.

The chest

Examining the chest in a child takes in both the respiratory and cardiovascular systems. The basic structure remains the same: first looking, then feeling then listening with the stethoscope. It helps to have let the child play with the stethoscope at an earlier stage of the examination to alleviate any worries about this strange instrument. Observation will give much of the information required for the diagnosis, particularly in younger children and infants. On observation, check for abnormalities that are fixed and those which become obvious on movement. Static deformities in children include pectus excavatum and carinatum, which are a source of great anxiety to many parents but are not usually of any clinical importance. Fixed indentation of the lower ribs at the line of insertion of the diaphragm (Harrison’s sulcus) may be seen in obstructive airway disease, owing either to asthma or to a nasopharynx blocked by adenoidal hypertrophy or in conditions leading to increased pulmonary blood flow. Look from the side for an increased anteroposterior diameter of the chest, which could be a sign of a chronic lung disease such as cystic fibrosis. Thickening of the costochondral junction is felt in rickets (rachitic rosary). Note any scars as a result of cardiac surgery. It is important to look for the thoracotomy scar under the arms or even round the back; otherwise you will miss it ( Box 6.6 ). Central sternotomy scars usually indicate the child has had major heart surgery involving valves or closure of septal defects. Asymmetry of the chest becomes more obvious on movement (dynamic deformity) and may indicate an underlying pneumothorax or empyema. Look for any increased work of breathing. This may be indicated by seeing recession (intercostal or subcostal), tracheal tug or flaring of the nares when breathing. The infant may be using accessory muscles, such as the sternomastoids, which results in head bobbing. Count the respiratory rate ( Table 6.3 ) which, in infants, must be done over a minute to be accurate, owing to periodic breathing which is normal in babies. Listen for grunting respiration, which is audible in infants who are attempting to prevent alveolar collapse by creating their own positive airway pressure. The grunting expiration is followed by inspiration and then a pause.

Palpate the anterior chest wall for the cardiac impulse and for thrills. In children under the age of 5 years, the apex is normally in the fourth intercostal space just to the left of the mid-clavicular line. Midline shift can be assessed in this way because palpation for the trachea in the suprasternal notch can be difficult and unpleasant for the child. Vocal fremitus is of less clinical value the smaller the child. This is because of difficulty with cooperation and the small size of the precordium. Expansion is also better assessed by observation for the same reasons. The axillary nodes may now be felt in the same way as in adults.

Chest percussion is useful in older children, but in young children and infants it is rarely of value. Tell the child ‘I am going to make you sound like a drum’. Percuss very lightly in babies, directly tapping the chest wall with the percussing finger rather than using another intervening finger. The chest is more resonant in children than in adults.

A stethoscope with a small bell chest piece is suitable for auscultation of the child’s chest. Do not use adult-sized chest pieces, because it is impossible to localize added sounds accurately with a chest piece covering such a wide area in a small child. Often it is less threatening to examine the back of the chest first, and much more information about the lungs can be acquired in this way. Listen for the breath sounds and adventitious sounds. Because of the thin chest wall, breath sounds are louder in children than in adults, and their character is more like the bronchial breathing of adults (puerile breathing). Upper respiratory tract infections in children often give rise to loud, coarse rhonchi, which are conducted down the trachea and main bronchi (transmitted upper airway sounds) ( Table 6.4 ). All is not lost if the child is crying, as this is accompanied by deep inspiration giving an opportunity to listen for the character of the breath sounds.

When you are auscultating the front of the chest, the child’s immediate instinct is to push the stethoscope away. You can ask the parent to hold the child’s hands or try to distract the child with toys held in the hand ( Fig. 6.3 ). It is a good idea to examine a doll or teddy bear first if the child is playing with one. The normal splitting of the first and second sounds is easier to hear in children than in adults. Venous hums and functional systolic flow murmurs are often heard in normal children ( Box 6.7 ). If the murmur does not fit into this classification, remember that most cardiac problems in children occur as a result of congenital heart disease and not acquired as in adults ( Table 6.5 ). Count the heart rate in young children (see Table 6.3 ). Arrythmias are uncommon in children unless they have had cardiac surgery.

Neurological examination

The neurological examination can usually be carried out in the normal way in older children, but in younger children the extent of the neurological examination will depend on the child’s age and willingness to cooperate. Although a great deal should have been learned already from initial observations, still look at the child’s static and dynamic posture. Asymmetry may indicate a hemiparesis. A hypotonic child may sit on his back rather than his bottom and an infant may display a ‘frog leg’ posture when lying down. Children with cerebral palsy may have a characteristic ‘windswept’ posture (quadriplegic) or have uncoordinated continuous movements (ataxic or dyskinesic). If the child is walking, the gait should have been observed already. Look for toe walking (spastic diplegia), wide-based gait (seen in cerebellar ataxia, but normal in toddlers), limping (antalgic gait) and unilateral sweeping (hemiplegia). Hemiplegia may become more obvious on running as the affected upper limb is brought up closer to the body.

Note any abnormal movements. Tics or habit spasms are repetitive movements, such as shrugging of the shoulders or facial grimacing. Choreiform movements are involuntary, purposeless jerks that follow no particular pattern. Athetoid movements are writhing and more pronounced distally. Fits may be seen as lip smacking or flickering eye movements or as tonic–clonic spasms. Note if they are generalized or focal and if associated with loss of consciousness.

Take the opportunity to check for spinal abnormalities, such as scoliosis or kyphosis, or any evidence of spina bifida, such as a tuft of hair. Be careful to pick up on any signs of a neurocutaneous disorder, such as café-au-lait spots or telangiectasia.

Coordination can best be checked by watching a child at play. It is useful to have toys available that require a degree of coordination. Otherwise, a modification of the finger–nose test using a toy held in the hand can be used. If the child is old enough, watching him dressing or doing up shoelaces is a good way to assess coordination.

Check muscle tone if this has not already been done. Pick the child up if there is still a friendly relationship. This gives a good idea of the feel of a child and of his muscle tone. A hypotonic (floppy) infant will feel as though he is slipping through your hands. Hypertonia may be regional or generalized, depending on the cause. It will be difficult to move the limbs passively and there may be fixed flexion deformities owing to contractures around the joints. Muscle power is difficult to check in young children, except by watching playing habits and assessing power by ability at a variety of lifting games. Always remember to check for neck stiffness by testing resistance to passive neck flexion rather than by testing for Kernig’s sign.

Testing of sensation is difficult in young children and less likely to yield useful information. Touch can be tested by observing the reaction when the skin is touched with a cotton wool ball. In older children the approach to assessing sensation is the same as in adults.

Testing the cranial nerves takes a little ingenuity. Eye movements are relatively easy using a toy moved in different directions in front of the baby’s face. Young infants will often copy poking out the tongue at them, which will check the 12th cranial nerve. If the child can be made to smile, and even if he is crying, any asymmetry of facial movements can be seen. If a child is able to bite or grimace, the trigeminal nerve is probably intact.

Getting a child’s limbs into the correct position to test tendon reflexes may take some time. Often they can be elicited by using a finger rather than a patellar hammer. Tendon reflexes in young infants tend to be brisk, and up to 18 months of age the plantar responses are extensor. The persistence of an extensor response beyond the age of 2 years indicates an upper motor neurone lesion. Note whether primitive reflexes have persisted ( Box 6.8 ), which indicates significant neurodevelopmental dysfunction.