You should be able to conduct a complete examination of all organ systems in all infants/toddlers using an age appropriate approach. Specific maneuvers that are a part of the infant/toddler examination include:
Ask about hearing concerns• Inquire about infant’s response to
• Observe an older infant’s/toddlers speech pattern
Inspect the ears
• Assess the shape of the ears
Determine if both ears are well formed
•Assess the positionExamine the child from the front, with the child’s head held erect and the eyes facing forward.
Draw an imaginary line between the inner canthi and extend it around the head.
This line should be at or above the top of the pinnae
Palpate the tragus and posterior auricular area
Otoscopic exam including insufflation
•Position the child for an ear examination
This part of the exam can be examined either on the examination table or in the caregiver’s lap. The head should be stabilized to prevent movement during otoscopy. A parent or assistant can assist with the examination by folding the child’s wrists and arms over the child’s abdomen with one hand and then holding the child’s head against the parent’s/assistant’s chest with the other.
•Visualize the external canal
Gently hold the tragus and insert the otoscope while visualizing the canal. In contrast to adults, gentle posterior traction may help you visualize the canal and eventually the tympanic membrane.
•Visualize the tympanic membrane
Identify the landmarks starting with long handle of the malleus then moving to the “cone of light” in the pars tensa
Carefully visualize the pars flaccida
courtesy of M. Whipple, MD
•Perform pneumatic otoscopy
Hold the otoscope and bulb with one hand and retract the pinna with the other
Gently apply a small “puff” of air to the tympanic membrane
Normal movement: medially (away from you) with the application of air and laterally (toward you) when the bulb is released
Any delay in language acquisition or loss of language milestones should prompt a referral for formal hearing testing
Hearing impairment is estimated to occur in 1-2/1000 live births
Some etiology of hearing loss in childhood
Sensory neural: cochlear malformation, damage to hair cells (due to noise, disease, ototoxic agents) or 8th nerve damage
Conductive: (most common)—ear canal atresia, cerumen impaction, otitis media with effusion
Position/Shape of the ears
Malformed external and middle ears may be associated with serious renal or other craniofacial malformations
Tenderness to palpation of the tragus is indicative of otitis externa.Tenderness to palpation and/or redness in the posterior auricular area may suggest mastoiditis.
You will also typically see white cheesy material in the external auditory canal. Treatment is aural toilet and topical antibiotics
Areas of retraction in the pars flaccida may represent a cholesteatoma and should be further evaluated. A cholesteatoma acts as a benign tumor causing local bone destruction and is a nidus for bacteria to grow and cause chronic infections.
The most common reason for an immobile tympanic membrane (TM) with pneumatic otoscopy is a poor seal between the otoscope and ear canal
You must assess the movement of the TM to determine if a patient has otitis media. In addition to pneumatic otoscopy; acoustic tympanometry can be used.
Changes in the appearance of the TM that are highly suggestive of acute infection include: bulging or purulent material visualized behind the tympanic membrane. Guidelines for the diagnosis and treatment of otitis media: www.aap.org
Removal of cerumen is difficult but sometimes necessary to adequately see the TMs. The external auditory canal bleeds easily with minor trauma so ask for help if you need to clear out cerumen. It can be done by gentle irrigation with warm water, H2O2 or with direct visualization and use of a wire/plastic loop.
Save the mouth exam for the very last in young children
Ask child to open their mouth and show you their teeth (appropriate for an older toddler/child). If this doesn’t work, be prepared to be fast with your tongue blade.
An alternative is to be flexible and look in the mouth when the child is crying for some other reason!!!
Inspect the teeth
Count the number of teeth and note position
Note any defects or discolorations
Inspect gums, mucosal surfaces and posterior pharynx
Inspect the buccal mucosal and gums looking for ulcers, candida or trauma
To see the posterior pharynx, you may have to use the tongue blade and gag the child. Alternative tricks you can use include asking the child to “roar like a lion”, “pant like a dog”, have their parents model what you would like to child to do or have the child look in your mouth.
The numbering system for primary teeth is different than the system used in adults.
There are 20 primary teeth
Time for first tooth eruption is variable; delayed eruption maybe familial or associated with other syndromes/conditions (like hypothyroidism)
There may be developmental anomalies associated with tooth development
Dental caries is the most common chronic illness in the United States. More than ½ of children within the U.S. have dental caries. Steptococcus mutans is associated with the development of dental caries.
Early childhood caries may occur on the smooth surfaces if upper/lower incisions because of prolonged exposure to sugar containing substances.
Site for caries in children include pits/fissues of biting (occlusal) surfaces in older children (> 3 yo)
Using a tongue blade in this population is challenging. Inserting it along the side of the mouth and then gagging the child will allow for an unobstructed view of the posterior pharynx in most children.
The size of tonsils are described in the following way
1 Visible between the tonsillar pillars
2 Easily visible outside of the tonsillar fossae
3 Enlarged and occupying >75% of posterior pharynx
4 Touching in the midline occupying all of the posterior pharynx
The diagnosis is streptococcal pharyngitis is a laboratory, not clinical diagnosis. Other infections that can cause tonsillar exudates include EBV infections, CMV infections, S. aureus infections, adenoviral infections.
The approach the pediatric heart examination is the same as in an adult. Included here is a brief discussion of MURMURS in children.
As the pulmonary vascular resistance decreases, flow through the Patent Ductus Ateriosus or Patent Foramen Ovale stops as these structures close. Some murmurs heard shortly after birth will disappear.
However, as the pulmonary vascular resistance decreases, this may allow left to right shunting and new murmurs may appear (such as seen with a VSD)
Presence of central cyanosis is an important clue for congenital heart disease. Those lesions associated with cyanotic heart disease are the “Ts”: Tetralogy of Fallot, Tricuspid Atresia, Transposition of the Great Arteries, Total Anomalous venous return & Truncus arteriosus (there are others but these are easy to remember)
Beyond the newborn period
50% of children have innocent murmurs
Non-pathologic murmurs include:
Peripheral Pulmonary flow murmur:
Soft (1-2/6) systolic ejection murmur heard in L upper sternal border with radiation to the axilla and back
Soft (1-2/6) continuous murmur heard in 1st or 2nd ICS)
Soft (<3/6) early systolic murmur heard along the L sternal border between the 2nd/3rd or 4th/5th. Intensity varies with position & might be heard with the bell. “Vibratory/blowing/musical” in quality.
Hemic murmur (flow murmur)Heard in states with increased physiologic need (fever,anemia). Heard at base of the heart, soft (<3/6) and often associated with tachycardia
Observe the child closely; noting in particular range of motion and limb use
An excellent time to get this information is before the examination while the child is playing or interacting with their parents.
Inspect the joints for redness or swelling
Start with the hands or some non-threatening part of the examination; examine the affected joint last.
Palpate methodically and in a systematic manner the involved area and all other areas that influence the involved area.
Note muscles, bony prominences, other important landmarks, and joints of the involved body part.
Be observant for pain or warmth
Assess Active and Passive Range of motion for each major joint.Young children may not cooperate with this part of the examination; you may have to range their joints and gauge how much they resist you to judge function.