The examination of an infant or child by a physician or nurse practitioner can accomplish several goals simultaneously. With children, as opposed to adults, the physical examination often is the first direct contact between the examiner and the patient, the history having been obtained primarily from a parent. Therefore, one of the crucial outcomes of the examination is the relationship that will be initiated and continued between the physician and the child. The quality and quantity of care plans and the child's future attitude in medical settings will depend in part on this relationship. This chapter emphasizes approaches to examining children of different ages that will enhance the physician-child relationship.
The physician-parent relationship, which is initiated when the history is taken, can be enhanced further during the physical examination if the practitioner takes a relaxed, gentle approach toward the child and, no less important, performs a thorough examination appropriate to the setting and the chief complaint. Parents develop trust in physicians in a number of ways, not the least of which is the consideration the practitioner shows for the child's fears and the parents' concern about a particular symptom or sign. For each organ system discussed in this chapter, the common symptoms for which physicians are consulted are linked to a suggested level of "completeness" in performing a physical examination.
The physician must be sensitive to the potential for iatrogenic concerns initiated by his or her comments during the examination and should anticipate the child's wondering, "What's wrong with me?" and the parent's worrying, "What did I do wrong?" Reactions such as these are very common. A thorough grounding in the normal stages of growth and development of the organ systems and the body as a whole allows the examining physician to respond to such questions by emphasizing the normal physical findings, as well as by interpreting abnormal findings in the context of normal developmental patterns. The description of each organ system in this chapter begins with important stages of growth and development, particularly those steps that can be monitored by serial physical examinations. The characteristics of common physical abnormalities will be linked whenever possible to the child's age and stage of growth.
The physical examination has limited value as a screening mechanism for occult disease (see Chapter 20 [Two], The Physical Examination as a Screening Test) and has proved to be much less productive in detecting problems in schoolchildren, for instance, than is a comprehensive history. In general, the physical examination of children confirms abnormalities suggested by the history, as well as normal growth and development. When the child is examined in the presence of one or both parents, the physical examination can provide strong clues about the strength and characteristics of the parent-child relationship.
Each portion of the physical examination is discussed according to the special characteristics of each of five age groups: newborn period, infancy (1 week to 12 months), early childhood (1 through 5 years), late childhood (6 to 12 years), and adolescence (12 to 18 years).

At least one examination of the newborn infant should be performed in the presence of one or both parents to facilitate both evaluation of the parent-infant relationship and to address the parents' questions about their baby. A newborn infant is examined immediately after birth to assess the adequacy of pulmonary ventilation and the integrity of the cardiovascular system and the central nervous system (CNS). While assessing the need for resuscitation, the examiner should minimize exposure of the wet infant to cool ambient air by drying the infant with a towel and conducting the examination under a warming device.
Recovery from the birth process is measured by using the Apgar scale, with scores of 0, 1, or 2 given for degree of cyanosis, respiratory rate, heart rate, reflex irritability (reaction to a soft catheter introduced into the external nares), and muscle tone (Table 8-1). The infant is rated at 1 and 5 minutes after birth; total scores below 7 or 8 at 1 minute usually indicate some degree of CNS depression, and scores below 3 or 4 indicate severe depression requiring resuscitation. If the Apgar score is 8 or higher at 5 minutes and the baby's airway is clear, the rest of the body is surveyed briefly to identify gross congenital abnormalities and to estimate gestational age (see Figs. 45-8 and 45-9). After the baby is weighed, the weight-gestational age category is determined by using a standard gestational age growth chart (see Fig. 43-4), with certain risks predictable for each group (hypoglycemia and congenital anomalies in babies small for gestational age, hypoglycemia and infant of a diabetic mother (Atlas Fig 2-19) in babies large for gestational age). The neuromuscular part of the gestational age determination ideally is postponed until the infant is fully stabilized (12 to 48 hours after birth).
In many hospitals a second, more thorough examination is performed within 12 hours of birth to assess the degree of recovery from the birth process and to determine the presence or absence of signs of respiratory distress and the ability to feed. This examination can serve as a safety check before transferal of the baby from the "transition" nursery to the "routine" nursery. It should take place in a warmed environment with the baby undressed (Atlas Fig. 2-11) to allow careful observation of the respiratory rate, the degree of respiratory effort, as evidenced by intercostal retractions, the color, and spontaneous activity. Often, quiet babies can arouse themselves with a "startle," or Moro, response that can interfere with the examination. Giving the baby something to suck on (rubber nipple, examiner's finger, or baby's fist) and holding the baby's arms against the sides will help keep the infant as relaxed as possible; performing the examination several hours after a feeding is ideal. Although it is important to assess the intensity and pitch of the cry, as many of the painless parts of the examination as possible should be performed before fully arousing the baby. Therefore, with the baby supine and after making general observations, many examiners begin by listening to the heart and lungs, then palpating the abdomen before examining the remaining systems, leaving the usually uncomfortable abduction of the hips until last.

Examination of the undressed baby with the parents present just before discharge affords the opportunity to point out normal findings, answer questions about perceived imperfections (and sometimes allow both parents a first look at their baby's entire body), discuss care of the circumcision and umbilicus, and observe the quality of the parent-infant attachment while the baby is held or fed. Holding the baby en face (the mother's face is rotated so that her eyes and those of the infant meet fully in the same vertical plane of rotation, as shown in Fig. 8-1), smiling at the baby, responding to signs of hunger or satiation, and talking about the baby positively and confidently all are signs that strong parent-infant bonds are being formed and have been enhanced by the hospital experience.

Infants between the ages of 1 and 6 months almost always are a pleasure to examine because of their responsiveness to the examiner's face and their increasing interest in environmental objects such as tongue depressors and penlights. At this age infants can be examined successfully on the examination table, with the parent usually standing close beside the table. With the infant unclothed except for the diaper, the practitioner should observe for spontaneous activity, state of alertness, and responsiveness to both the examiner and the parent. The order of the examination varies. If the infant is asleep in the parent's lap or held upright at the breast or shoulder, the heart and respiratory rates can be obtained, and the heart, lungs, and even the abdomen can be examined without waking the baby. Again, the relatively uncomfortable abducting of the hips and speculum examination of the tympanic membranes are best left until last. Prolonged or painful procedures, such as deep palpation of the abdomen or a rectal examination, are best done while the baby is being fed. The infant should be examined as if physically attached to the parent, and the parent's response, especially to painful procedures, should be noted. Sometimes the parent may appropriately thank the examiner for removing an irritable, crying baby to the examining table (or to another room if on a house call), but the physician must never be lulled into thinking that the isolated examination of the infant is a complete examination. With a chronically hospitalized baby, a continuous care nurse may substitute for an absent parent during the examination.
Infants 6 to 12 months of age are increasingly difficult to examine because of their normally developing anxiety about faces other than their parents' and the perceived separation from the parent. Offering interesting objects or allowing infants to sit and reach for objects or to walk or crawl around the office can help distract them. Direct eye contact with the strange face of the examiner can be especially frightening to the baby. Examination at these ages usually is easier if the baby is held in the parent's arms or on the parent's lap. In many clinical situations, direct observation of breast-feeding or bottle-feeding is extremely useful and can help in identifying problems such as improper feeding techniques, weak sucking movements, and dysfunctional swallowing.

With children 1 to 5 years old, the most effective initial approach is to form a supportive relationship with the parent or an older sibling, who, it is hoped, will become the physician's ally in the examination of the child. This alliance is aided by identifying the parent's emotional state and anxiety level during the history and then "tuning in" nonjudgmentally. For instance, if the parent appears both anxious about the child's symptoms and guilty about having had to bother the physician, the physician might say, "I know it can be frightening to hear a baby cough like that, and I'm glad you brought him in to be examined." A parent who appears angry sometimes can be "defused" by a remark such as, "I know how aggravating it must be to have to bring your child in for so many ear infections." Tired, worn-out parents will work with a physician who is sympathetic, but they can be distracting and even disruptive if they receive nonverbal and verbal messages that they are dressed improperly, somewhat less than adequate as parents, or a general nuisance to those who practice medicine.
In most situations, children in this age group are easiest to examine while being held by the parent, (Atlas Fig. 22-1B) a position that also is comforting to the child when the history is initiated. A few toys and books on a low table, colorful photographs and children's drawings on the walls, and the absence of a white coat on the examiner often lead children to relax and encourage them to leave the parent and explore the office. It can be helpful to offer the child a piece of examining equipment such as a stethoscope or percussion hammer to handle while the history is being taken. The examiner often can alleviate fear by showing the child the otoscope and demonstrating its use before using it on the child. (Atlas Fig. 22-1C,D) Observing the child's handling of objects and interest and confidence in exploring a new environment, as well as the parent's reaction to the child's curiosity or fear, gives the examiner information important to understanding the child's developmental status and anticipating the parent's ability to cope with any problems the child may have.

In general, older children in this age group are increasingly able to communicate verbally with the examiner. A conversation that starts about the child's cat or siblings can lead to a description of what is about to be done. Continuing to describe what is being done ("I am now listening to your heart beating") can soothe even the child who starts off by screaming and kicking. With a frightened child, the parent may interpret prolonged silence on the examiner's part as disapproval or anger with the child or parent. Also, a continuing conversation with the parent and the child during the examination signals to the child that the examiner is on the parent's side, and this may increase the child's confidence that nothing too drastic will be done.
It is best to have the child remain dressed until just before the examination, some of which can be accomplished by only partly removing pieces of clothing. Even before having the parent undress the child, important general observations about the child can be made, such as the activity level, gross and fine motor coordination, receptive and expressive language function, skin color, respiratory rate, and ability to cope with a foreign environment. Some specific portions of a developmental assessment, such as throwing and catching a ball or drawing a circle, often can break the ice and help the child into a gamelike atmosphere that can be continued throughout the examination.
Again, the order of the examination should be flexible; painful procedures (ears, throat) and frightening ones (anything that requires lying down) should be postponed until last. A steady pace, coupled with gentle but firm anticipatory statements ("Now I'm going to have you lie down so I can listen to your tummy"), enhances a relatively brief encounter, which in turn keeps the parent on the practitioner's side.
It often is necessary to restrain the child, for instance, to accomplish an adequate examination of the tympanic membranes. This can be done in a number of ways, all enhanced by continuing the descriptions and discussions calmly. The parent usually is the best assistant. The child can be restrained by holding the outstretched arms against the child's head or against the child's abdomen while the examiner's body and one elbow immobilize the lower half of the child's body. The parents should be reassured that struggling is a normal response to an examination in this age group, but that it can be aggravated if the parents berate or threaten the child. The examiner's goal should be to evaluate the child's health and illness while maintaining the trust and confidence of both the child and the parent. Achieving this goal requires long hours of practice, the flexibility to ask other professionals for help when the examiner's (or the parent's) patience is about to run out, and, most important, an enjoyment of the diversity, unpredictability, and spontaneity of children.

Children 6 to 12 years old usually are a pleasure to examine and rarely present any problems. A key ingredient for a successful examination is a relaxed conversation with the child about subjects such as school, hobbies, or favorite friends, interspersed with brief comments about the examination itself. Occasionally a child who had an unpleasant experience with a physician as an infant will need more time for the preparatory description of the examination. School-age children usually prefer to wear a simple drape over their underpants, and they also prefer that siblings of the opposite sex be kept out of the room, particularly when the genitalia are examined. The order of the examination can be the same as for adults (vital signs, then head to foot leaving the genitalia, perineal, and rectal [when required] until last), with care taken to anticipate any painful manipulations or procedures. As with younger children, the examiner can make the following critical observations without the actual "laying on of hands": activity level, ability to follow simple directions, ability to read passages of varying difficulty and to write, clarity of articulation, mood, level of neuromaturational functioning as tested by tasks such as hopping on one foot and rapidly alternating hand movements, and the relationship with the parent.

Most adolescents (12 to 18 years) prefer being examined without their parents in the room. They respect a straightforward, uncondescending approach, and parents respect the examiner who approaches adolescents as though they were adults. Decisions about who will be present and the issue of confidentiality should be discussed before the examination. With the parent out of the room, the examiner can review pertinent history or concerns directly with the adolescent. Most pubertal boys and girls have concerns about what is happening to their body, and a physical examination allows the examiner to explain and try to alleviate these concerns. Some special clinics for adolescents use brief, self-administered questionnaires so that the examiner can tune in to the adolescent's present concerns more quickly. While performing the examination, the examiner can reassure the pubertal child about normal developmental stages such as unilateral gynecomastia in boys, rapidly enlarging feet, the beginning of acne, and the interrelationships of the adolescent growth spurt and sexual development. The examiner's ability to approach the child's emerging sexuality factually or nonanxiously will help adolescents view themselves, at least briefly, with objectivity. Instruction in breast and testicular self-examination can help in this regard.

Just as general observation of a child's behavior can give important clues about the child's general level of functioning, measuring vital signs and the characteristics of somatic growth often provides the basis for decisions about the child's overall health or illness. An abnormal vital sign or physical measurement often is the only outward indication of a problem in a child. Interpretation of vital signs and physical measurements depends on a knowledge of the normal biological changes of the growing infant, child, and adolescent. One principal characteristic of human growth is that different organ systems mature at different rates and times throughout fetal life, infancy, and childhood. Fig. 8-2 compares the longitudinal growth of the body as a whole with three component tissues: lymphoid, neural, and genital.

Body temperature usually is measured rectally in infants and in children up to 3 or 4 years of age (because rectal temperatures have been used in clinical studies to determine the significance of temperature levels in infants and young children vis a vis management of potentially life-threatening infectious illnesses) and tympanically in older children. Oral temperatures also can be taken but are less reliable. The axillary temperature sometimes is measured, especially in infants whose bottoms are excoriated or in small premature infants. This reading generally is 2° F lower than the rectal temperature. The rectal temperature usually is measured with the infant or child held prone on the parent's lap (Fig. 8-3). The buttocks are separated, and the lubricated thermometer is inserted through the anal sphincter at an angle of about 20 degrees above the horizontal for a distance of 1-1/2 inches. The thermometer is held in place for approximately 1 minute, either by the examiner or by the parent. Because of the relative thermal instability of newborns, especially prematurely born babies, the ambient temperature often is measured and recorded at the same time and sometimes can explain an abnormally elevated or depressed rectal temperature. Newborns' temperatures normally are higher than those of older children, averaging approximately 99.5° F (37.5° C) during the first 6 months of life. The temperature falls below 99° F (37.2° C) after age 3 and reaches 98° F (36.7° C) by age 11. A circadian rhythm of body temperature is observable by age 2 and is well developed by age 5, with increasingly higher temperatures during the daylight hours and a fall in temperature during the night (Fig. 8-4). In infants and children there often is little relationship between the degree of temperature elevation and the severity of illness. In fact, hypothermia sometimes develops in infants who have profound infection, and children can have rectal temperatures as high as 101° F (38.3° C) after vigorous activity. It is not uncommon for children admitted to the hospital for elective procedures to have elevated temperatures initially, probably because of transient anxiety.

The heart rate is measured by palpating the peripheral pulse (femoral, radial, or carotid arteries), by observing the pulsating anterior fontanelle, or by palpating or auscultating the heart directly. The pulse can be increased significantly in normal infants and children by anxiety, fever, and exercise before or during the examination, as well as by inflammatory illnesses, shock, and congestive heart failure. Major changes occur in the resting heart rate with increasing age, probably reflecting increasing functional control by the vagus nerve (Table 8-2). A circadian rhythm in the heart rate is observed by age 2, with a fall of 10 to 20 beats/min during sleep; an absence of this rate slowing with sleep can be helpful in diagnosing acute rheumatic fever or thyrotoxicosis.
The examiner also should assess the rhythm of the heartbeat; equal spacing between consecutive beats is recorded as regular sinus rhythm (RSR). The cardiac rhythm more commonly is irregular than regular, especially in early and late childhood, reflecting sinus arrhythmia and increasing vagal control. Extrasystoles, appearing as irregularly spaced beats with or without a compensatory pause, are common in healthy children; usually can be abolished by exercise; and rarely occur as the only physical finding of underlying heart disease. Heart rates above 180 beats/min (especially if rigidly regular) in infants beyond the neonatal period may indicate atrial tachycardia.Other arrhythmias in children are rare and occur mostly in those who have underlying heart disease (e.g., congenital heart disease, rheumatic fever, and Kawasaki disease). Tachycardia with shock in infants and children usually is associated with a weak pulse and cold, sweaty extremities. Tachycardia caused by congestive heart failure usually coexists with significant tachypnea, with or without hepatic enlargement. Heart block can occur in children who have Lyme disease with myocardial involvement.

Observations of the rate, depth, and ease of respiration begin at the first encounter with the child. The rate of respiration, like the heart rate, is influenced significantly by emotion and exercise, making it necessary to wait in some instances until a resting state is reached or to count the rate immediately if the infant or child is first encountered asleep. The rate may be counted by observing abdominal excursion in infants and thoracic excursion in children, ideally at a moment when the child is not paying attention to the examiner. In a sleeping infant, the respiratory sounds may be counted with the bell of the stethoscope held just in front of the nose.
The respiratory rate varies with age, reflecting variables such as aspirated amniotic fluid in the newborn and increasing numbers of alveoli and increasing lung compliance with postnatal growth. The rate varies between 30 and 80 breaths/min in a newborn, 20 and 40 breaths/min in infancy and early childhood, and 15 and 25 breaths/min in late childhood; the adult level of 15 to 20 breaths/min is reached by age 15. Because changes in the respiratory rate are common over short periods, the rate should be counted for at least 1 minute, especially in crying or excited infants. The respiratory rate must be observed for several minutes in newborns, especially premature babies less than 2 kg and 36 weeks of gestational age, to discover apneic episodes (absent respirations for 20 seconds or more) and periodic breathing (apneic periods lasting between 5 and 10 seconds). In early and late childhood, irregular respirations such as Cheyne-Stokes breathing are seen only in severely ill children, such as those who have overwhelming infection or severe head trauma.
Depth of respiration is determined subjectively and compared with norms observed for the patient's age group; deep breathing may be observed in states of metabolic acidosis and shallow breathing in severe obstructive states such as asthma. Ease of respiration is partly a subjective determination, as in estimating the degree of dyspnea, and is discussed in the section of this chapter on the chest and lungs.

Because of an interest in the possibility of identifying individuals who have essential hypertension before they reach adulthood, blood pressure is determined in children and in hospitalized infants more regularly. It is essential to measure the blood pressure when evaluating a child who is suspected of having congenital heart disease or chronic renal disease or who is unconscious. Blood pressure measurements in healthy ambulatory patients are compared with standard norms. The auscultatory method of determining blood pressure is useful and is practiced in children over age 5 or 6; between ages 2 and 5, some children are cooperative, but others become agitated and anxious. It is helpful to remember that the blood pressure of hospitalized children, especially those admitted for elective reasons, is higher during the first 1 or 2 days and then tends to plateau at lower levels; the blood pressure of sick, hospitalized children tends to remain constant throughout the hospitalization. Several determinations may be needed to obtain values unaffected by anxiety. Having children "watch the silver column rise" and explaining that the cuff will gently squeeze their arm usually reduces anxiety.
The size of the cuff is important because a cuff that is too small will produce falsely elevated values. The optimal cuff size is one that covers two thirds of the distance between the antecubital fossa and the acromion or between the popliteal fossa and the gluteal fold. The rubber bag inside the cuff should encircle at least 50% of the extremity. Every site where infants and children are examined should have cuffs ranging from 1 to 4 inches in width.
With the auscultation method, the point where the sounds are first heard is recorded as the systolic pressure, and the point where the sounds disappear is recorded as the diastolic pressure. When the pulse sounds cannot be auscultated, a distal artery (radial, popliteal, or dorsalis pedis) can be palpated; the point where the first pulsation is felt is about 10 mm Hg lower than the auscultated systolic pressure. The flush method can be used in infants and young children. The elevated extremity, with the uninflated cuff in place, is stroked and "milked" from the hand to the elbow. The cuff then is inflated to a point above the estimated systolic pressure, and the pressure is slowly released. A sudden flush or reddening of the extremity, compared with the color of the opposite extremity, will occur at a point approximately halfway between the systolic and diastolic pressures. Normally, the systolic pressure is higher in the lower extremities, and the diastolic pressure is the same in the arms and the legs.

Assessing somatic growth is crucial in every evaluation of an infant or a child because growth is the central characteristic of normal children and deviations from the child's norm provide an early warning of pathological processes. Several tools are available to aid in this evaluation; the most important, however, are growth charts, constructed either by longitudinal, serial measurements of a single cohort of children or by measurements of large numbers of children of different ages over a brief period. Although physical measurements of a child at a single point in time will give some useful clinical information, serial measurements over months or years provide an accurate record of the infant's or child's overall general pattern of growth, with deviations from the subject's norm indicating some intrinsic defect or environmental insult. The physical measurements used most often in assessing children are height and weight and, in infants and young children, the head circumference, as well. To be clinically useful, all these measurements should be made with care and use of a consistent technique.
Of the different growth charts currently available, the ones used most often are published by the National Center for Health Statistics. These include length for age or stature for age, weight for age, head circumference for age (to 36 months), and weight for length or weight for stature from birth to puberty. Separate charts are available for boys and girls of two age groups: birth to 36 months and 2 to 18 years (Figs. 8-5 to 8-16). The percentile lines on these charts indicate the number of normal children expected to fall above and below the index child's measurement. For instance, a 2-year-old girl whose length is 34 inches is in the 50th percentile for length; 50% of all normal 2-year-old girls will be expected to be taller, and 50% shorter.
Other growth charts indicate the mean and standard deviations from the mean by chronological age. Standard deviations (SD) are defined mathematically; for example, 1 SD above and below the mean includes about 67% of the measurements, and 2 SD above and below the mean includes about 95% of the measurements.
Velocity growth curves (Fig. 8-17) are used to measure differential rates of growth at different ages, especially among adolescents and children suspected of having endocrine disorders. These charts illustrate the two periods of rapid growth—infancy and puberty—and the differences by gender at puberty.

Standing height can be measured fairly accurately in children older than age 2 or 3 years. Some growth charts, such as Stuart's, use standing height measurements beginning at age 6 years; others, such as the National Center for Health Statistics charts, plot standing heights beginning at age 2 years. Stand-up scales with attachments for measuring height generally are inaccurate. Short of buying an expensive wall-mounted apparatus (Stadiometer), accurate measurements can be made by attaching a graduated tape or ruler to a wall and placing a flat surface on top of the head to determine the height (Fig. 8-18). This measurement should be made with the child standing in stockings or bare feet, with his or her heels back and shoulders just touching the wall.

An infant's length is measured most accurately by using flat boards placed across and perpendicular to the examining table in contact with the vertex of the head and the soles of the feet and reading the measurement from a scale attached to the surface of the table (Fig. 8-19); care must be taken, in newborns particularly, to extend the hips and knees fully.

Infants are weighed on "infant" scales, with the baby clothed only in a diaper. Children old enough to stand are weighed in their underpants on stand-up scales. Stand-up scales, because of their usually wobbly base, may be frightening to children 1 to 3 years old, and sometimes the child must be weighed by subtracting the parent's weight from the combined parent-child weight. Ideally, serial measurements are made using the same scale. In most normally growing children the height and weight measurements, when plotted on growth charts, fall within two standard percentile lines of each other (e.g., the 3rd, 10th, 25th, 50th, 75th, 90th, and 97th percentiles). Children whose measurements are either above the 97th or below the 3rd percentile require further evaluation, as do children whose height and weight differ by more than two percentile lines or categories.

The head circumference is measured and plotted on a standard growth chart during each health maintenance examination from birth to age 2 years, the period of maximum rate of brain growth. With children over age 2 years, head circumference measurements are obtained at the initial examination of any child and when any component of the growth curve has been abnormal.
The measurement is made by placing a cloth tape measure around the maximum occipitofrontal circumference, taking three separate readings and selecting the largest value. When measuring the heads of infants, it usually is necessary to have the infant supine with the arms held firmly against the body by the parent or a nurse; with children, the examiner can improve cooperation by first demonstrating the use of the measuring tape on him- or herself.

In newborns the chest circumference is compared with the head circumference, the head having a larger circumference. The chest circumference normally equals and then exceeds the head circumference during the first year of life. Chest circumference is measured at the level of the nipples midway between expiration and inspiration. Another chest measurement sometimes used in following up children who have chronic pulmonary disease is the thoracic index, obtained by dividing the anteroposterior diameter by the transverse chest diameter. This index normally decreases from 0.85 at birth to 0.74 at age 6 years because of the more rapid growth of the transverse diameter. The transverse (side-to-side) diameter and anteroposterior (sternum-to-vertebrae spinous process) diameter are measured most accurately with special calipers at the level of the nipples. Additional somatic measurements can help in the evaluation of children whose somatic growth is abnormal. The ratio of the upper half of the body to the lower half is obtained by measuring the distance from the crown to the symphysis pubis and then from the symphysis pubis to the floor (or, with an infant, to the heel) while the child is standing. This ratio changes from 1.7:1 in the newborn to 1:1 in the adult. The arm span, normally equal to the standing height, is measured from fingertip to fingertip of the third fingers with the arms outstretched. Norms for these measurements by age and by height are available in pediatric endocrinology textbooks.

During the development of the fetus, neural crest cells, or melanoblasts, which have the potential for producing melanin, migrate from the dorsal region of the developing embryo. Under genetic control and mediated by tyrosinase, the melanoblasts produce varying amounts and shades of melanin, which make up the pigment of the skin, hair, and irides. Midline, ventral areas of defective pigmentation, such as piebaldism, (Atlas Fig. 8-109) can result from several developmental causes and sometimes are associated with defects in the development of the neural crest cells that give rise to the bipolar cells of the auditory nerve. Individuals in whom tyrosinase is absent lack pigmentation and have albinism.(Atlas Figs. 19-88, 19-89) Localized areas of depigmentation shaped like a leaf (Atlas Fig. 15-12) are seen in tuberous sclerosis. (Atlas Figs. 15-11, 15-13, 15-14, 15-15, 15-16)

The periderm is a superficial layer of epidermis with absorption properties that normally are shed before birth; persistence of the periderm is seen in the "collodion baby" (Atlas Fig. 8-86) and in forms of congenital ichthyosis. Hair follicles begin developing during the third fetal month, and skin keratinization first occurs at their openings. Sebaceous glands, whose secretions contribute to the formation of vernix caseosa, are active starting in the latter months of pregnancy; after birth, they are relatively inactive until puberty. Apocrine glands are formed in the fetus but are not developed fully until puberty. Sweat glands, which grow most rapidly between the twenty-second and twenty-fourth fetal weeks, are inactive in the fetus. They become active in the newborn after several weeks and reach a maximal rate of activity by age 2 years. Sweat gland secretion may be under some degree of cortical control, which may explain children's tendency to sweat at all times and adults' tendency to sweat more while asleep.

Adipose tissue begins to develop during fetal life and constitutes 28% of the body weight at term. The number of fat cells increases especially rapidly during the first year of life, with adipose tissue constituting 40% to 70% of the body weight at 4 months of age. Cell numbers increase at a slower rate until puberty, when a second growth spurt occurs. In adults, adipose tissue constitutes 15% to 40% of body weight in men and 25% to 50% in women. The fat content of adipose tissue in a nonobese individual increases from 40% at birth to 80% in the adult.
Examination of the skin often yields important clues to both normal and pathological systemic processes. For instance, the characteristics of the newborn's skin reflect, in part, the length of gestation, and such observations as the opacity of the skin and the distribution of body hair can help determine the gestational age. (Atlas Fig. 2-5, 2-6, 2-7) The onset, distribution, and characteristics of some exanthems are specific for certain infectious diseases of children, and a few lesions are associated with abnormalities of other organ systems, especially the central nervous system (the phakomatoses). (Atlas Figs. 15-5, 15-17) The skin, therefore, should be thoroughly examined in each newborn, each acutely ill or febrile child, and each child in whom congenital anomalies are suspected. A thorough examination of the skin involves noting the skin's color, consistency, and turgor; the distribution and type of lesions; and the characteristics of the sweat and sebaceous glands, the body and scalp hair, and the nails.

During the first minutes after birth, the newborn's Apgar score is determined partly by assessment for the presence and distribution of cyanosis. A normal, nonchilled newborn usually progresses from generalized cyanosis to generalized pinkness while normal respirations are established during the first 5 to 10 minutes of extrauterine life. Acrocyanosis, especially on exposure to a cool environment, is common in newborns for several weeks after birth, as is mottling of the skin, a latticelike pattern of pale and dark areas that appear especially on the extremities. Severe cold stress can cause generalized cyanosis. Occasionally, in newborns, transient cyanosis of an entire half of the baby (harlequin color change) or of one or more extremities is noted, presumably as the result of temporary vascular instability. Persistent generalized cyanosis usually is a sign of depression caused by maternal drugs or anesthesia, primary pulmonary disease, congenital heart disease, overwhelming infection, or hypoglycemia. Plethora in newborns may indicate high levels of hemoglobin (seen, for instance, in the twin-to-twin transfusion syndrome), and pallor in newborns may be a sign of anemia or cold stress or, less commonly, of congestive heart failure or shock.
A newborn's skin is covered by varying amounts of white, greasy, vernix caseosa, with larger amounts present in preterm babies. The newborn's skin color is determined partly by the amount of subcutaneous fat present. Premature babies have a smaller amount of subcutaneous fat and generally appear redder than full-term babies; their skin also is more transparent, and therefore subcutaneous blood vessels are more visible. Yellow staining of the vernix by meconium suggests that birth was preceded by acute fetal distress; with more prolonged fetal distress, as in the postmature baby who has placental insufficiency, the yellow (or yellow-green) staining can involve the umbilicus and nails. The skin tends to progress from being smooth to scaly, with varying amounts of desquamation and fissuring as the gestation progresses from preterm to postterm. This latter condition usually changes to normal, smooth skin without specific treatment within 1 to 2 weeks. Nonspecific edema, especially of the hands and feet, is less prominent as the gestational age approaches term. Generalized or localized petechiae, ecchymoses of the scalp or face, lacerations of the external ears, and diffuse or localized scalp edema all can be caused by physical trauma sustained during birth.
Jaundice can be expected to appear in at least 50% of normal term babies and in a higher percentage of preterm babies in the third or fourth day of life, usually indicating the presence of physiological jaundice. However, jaundice appearing at any time during the neonatal period may be an early sign of infection or of metabolic or primary hepatic disease. The early onset of jaundice also raises the question of blood group incompatibility and erythroblastosis. Clinically apparent jaundice usually indicates a serum bilirubin of at least 6 mg/dl, although the lack of subcutaneous fat in premature infants may delay its detection. Because of the variable lighting in many newborn nurseries and maternity units, clinical estimation of the bilirubin level is notoriously inaccurate, although some experienced neonatologists find that jaundice tends to progress from the head to the proximal and then distal extremities with increasing serum concentrations of bilirubin. The most consistent observations can be made by examining the skin in direct daylight. The presence of jaundice is best appreciated after pressure is applied to an area of skin over the forehead or sternum with the flat surface of a glass slide to empty the capillary bed.
The amount of melanin in the skin varies at birth. Babies of black parents may demonstrate very little as neonates. Pigmented areas over the lumbar region and buttocks, known as mongolian spots (Atlas Fig. 6-31, 8-80), commonly are present in black, darker-complexioned white, and Asian babies at birth. They become less prominent and eventually disappear during childhood. A number of other spots can be seen on a healthy newborn's skin, including the common telangiectasias (nevus flammeus) on the eyelids, bridge of the nose, upper lip, and nape of the neck, which usually disappear during infancy; red or purple strawberry hemangiomas or more deep-seated, cavernous hemangiomas; tiny white papules on the nose, cheeks, forehead, and occasionally the trunk caused by plugging of the sebaceous glands (milia) (Atlas Fig. 8-72); pinpoint vesicles with or without surrounding erythema caused by plugging of the sweat glands (miliaria) (Atlas Fig. 8-46); erythematous flares with central pinpoint white vesicles or papules, known as erythema toxicum (Atlas Fig. 8-81), which may appear and disappear over several hours during the first week of life; and areas of either decreased or increased pigmentation, café-au-lait spots (Atlas Fig. 15-5) being one example, which may occur in isolation or may be associated with generalized disease, such as neurofibromatosis.

The newborn's skin often is covered with fine lanugo hair (Atlas Fig. 2-7), more prominently seen in premature infants, which is lost after several weeks of life. Scalp hair at birth, which varies in amount, commonly is shed and replaced by permanent hair of a different degree of pigmentation. The fingernails may be long in postmature babies, and their color can be influenced by amniotic fluid staining and melanin pigmentation of the nail beds. Incurving of the lateral margins of the toenails is common and can be associated with local inflammation. Examination of the fingerprint and palmar crease patterns in newborns sometimes is useful because of the association of abnormal dermatoglyphics with certain chromosomal abnormalities and intrauterine infections.4 Magnification is essential in determining the fingerprint pattern on the distal phalanges and the position of the axial triradius of the palm. A single transverse palmar crease (simian line) (Atlas Fig. 1-13c) can occur in normal individuals but more commonly is associated with chromosomal abnormalities such as Down syndrome.

The newborn's skin should be checked carefully for defects and sinus tracts, especially over the entire length of the spine and the midline of the head from the nape of the neck to the bridge of the nose. Sinus tracts sometimes communicate with intracranial and intraspinal spaces or masses, as with dermoid cysts and encephaloceles. Preauricular sinuses may or may not communicate with a persistent brachial cleft space. A more common minor abnormality of the preauricular area is the skin tag (Atlas Fig. 1-11a), which usually has a cartilaginous core.

Careful inspection of a completely undressed infant during health maintenance checks often will reveal minor abnormalities such as cradle cap (Atlas Fig. 8-24) and diaper dermatitis, (Atlas Fig. 8-39, 8-40, 8-42, 8-43) the sometimes chronic lesions of infantile (Atlas Fig. 8-84) acne that first appear at 3 to 4 months of age, and less commonly, scattered ecchymoses of varying ages that can signal child abuse. Palpation of the skin, preferably over the lateral abdominal wall, allows qualitative measurement of subcutaneous adipose tissue during infancy and also observation of skin turgor (the rate of return to resting position after the skin is lifted and released), which is decreased with dehydration. (Atlas Fig. 10-1, 10-2)

For all children, evaluation of acute or chronic rashes is helped greatly by a careful description of the rash's major characteristics (macular, papular, pustular, vesicular, petechial, ecchymotic, oozing, scaly, exfoliative, abraded, erythematous, or pigmented), location (trunk, face, extremities, or intertriginous or hairy areas), developmental history, and temporal association with other signs and symptoms. In fact, most infectious exanthems of children are diagnosed by certain constellations of these factors. Lyme disease (Atlas Fig. 7-26, 12-23) can be diagnosed in its early stages solely by a rash (expanding, red, macular rash with or without a central mark from a tick bite) (see Chapter 227, Insect Bites and Infestations).

Examination of the skin of adolescents allows monitoring of important pubertal changes such as areolar pigmentation, pigmentation of the external genitalia, development of pubic and axillary hair, increased functioning of sweat and apocrine glands, and an increase in subcutaneous fat. The prominent signs of acne vulgaris (Atlas Fig. 8-67) on the face and trunk can be anticipated in many adolescents.

The rapid rate of brain growth during infancy and childhood explains the increased size of the head relative to body length in newborns and infants compared with that of adults. The facial contours and dimensions change considerably during the first 10 years of life, reflecting the downward and forward growth of the mandible and vertical growth of the maxilla and nasal bones. These changing proportions are best summarized by the proportion of cranium to face volumes at different ages: 8:1 at birth, 5:1 at age 2, and 2:1 by age 18. A thorough examination of the head includes measuring the head circumference and plotting the value on a standard growth chart, observing the shape and symmetry, and palpating the sutures and fontanelles; occasionally, percussion, auscultation, and transillumination are needed. The head should be examined thoroughly in clinical situations involving growth or developmental failure, suspected trauma, a seizure disorder, or fever in an infant and as part of every health maintenance examination from birth to age 2 years.
Newborn period

The newborn's skull is composed of partly calcified, bony plates that interface with each other at predictably located suture lines. The major sutures palpable at birth are the coronal, lambdoid, sagittal, and metopic sutures (Fig. 8-20). Because of overriding of one cranial bone on another after molding of the skull during the descent through the birth canal, the newborn's sutures often feel like ridges. The anterior fontanelle is located at the junction of the sagittal and coronal sutures and varies considerably in size in normal infants; it usually measures about 1 inch at its greatest diameter and is diamond shaped. The posterior fontanelle, found at the junction of the sagittal and lambdoid sutures, only occasionally is palpable at birth. Vascular pulsations, transmitted by the cerebrospinal fluid (CSF), normally can be seen over the anterior fontanelle. With normal CSF pressure and with the infant in an upright position and not crying, the anterior fontanelle is soft and flat on palpation. A bulging fontanelle is a sign of increased intracranial pressure; a depressed fontanelle is a sign of decreased intravascular volume, as in dehydration.
At birth it is common to palpate localized edema over one or more areas of the head. A palpable swelling, particularly over the vertex, that recedes after 1 or 2 days represents subcutaneous edema and is called caput succedaneum (Atlas Fig. 2-28). Swollen areas whose margins are limited to suture lines and that often require weeks to recede represent subperiosteal hemorrhage and are called cephalhematomas (Atlas Fig. 2-29). These resolve partly by calcification, which initially may feel like a mass with a heaped-up bony rim and a soft center. Other commonly seen effects of the birth process include linear or curved abraded or lacerated areas, especially over the zygomatic arches and preauricular areas, resulting from use of obstetrical forceps. The infant's face may be asymmetrical at birth because of intrauterine positioning with the chin touching one shoulder. Facial palsy (Atlas Fig. 2-34), manifested by a drooping corner of the mouth during crying, usually is caused by obstetrical forceps exerting pressure over the facial nerve in the preauricular area.

Transillumination of the newborn and infant head is useful in evaluating asymmetrical or disproportionately large heads, as well as unexplained neurological signs and symptoms. The procedure is accomplished in a completely darkened room by use of a bright light source, such as a three-battery flashlight or a special high-intensity light. If a flashlight is used, it should be fitted with a soft foam rubber collar and held against the head tangentially in such a way as to allow uniform intensity of illumination of the head around the full circumference of the light. Localized bright spots may indicate acquired problems, such as subdural effusions, or congenital defects, such as porencephalic cysts (Atlas Fig. 15-27). The entire head will "light up" in the presence of hydranencephaly. (Atlas Fig. 15-29, 15-30, 15-31)

By measuring and plotting serial occipitofrontal head circumferences, the examiner can monitor the normal growth of the brain within the normally yielding cranial bones, which are separated from each other by suture lines that remain open until brain growth is complete. A head circumference that is increasing at an abnormally slow rate may indicate either a slowly growing brain (intrinsic or acquired defect) or cranial sutures that have closed too soon (craniosynostosis). The normally proportioned small head is called microcephaly, and a small head associated with premature suture closure is labeled according to the shape distortion caused by the suture involved—scaphocephaly (closure of the sagittal suture, resulting in restricted lateral growth of the head so that it is abnormally long and narrow), plagiocephaly (closure of coronal or lambdoidal suture, resulting in a lopsided appearance to the head so that its maximum length is on a diagonal, rather than along the midline), and acrocephaly (closure of the coronal and sagittal sutures, resulting in an upward growth of the head so that it has a pointed, or conical, shape).
Craniosynostosis, a diagnosis that requires confirmation by roentgenography, often is associated with prominence or ridging of the involved suture line. A head that is growing too rapidly when compared with the rate of height and weight gain always should be evaluated for hydrocephalus and subdural effusions. Sometimes the head is just asymmetrical, with a normally increasing head circumference; this suggests either intrauterine or extrauterine positional effects, such as the flat occiput seen in babies who are left to lie on their backs for long periods and the flattening of one occipital bone and the opposite frontal bone sometimes associated with torticollis (Atlas Fig. 17-97, 21-67) (cranioscoliosis). Prominent frontal bone bossing, with or without associated saddle-nose deformity, may be a sign of the developing osteomyelitis associated with congenital syphilis. The anterior fontanelle normally is not palpable after 18 months of age and may disappear as early as 3 months of age.

Percussion of the head by directly tapping with the middle finger normally elicits a flat sound. A "cracked pot" sound may be heard in infants whose fontanelle is open or in infants who have increased intracranial pressure whose fontanelle is closed, as is seen with hydrocephalus. Auscultation of the head for localized bruits, indicating vascular anomalies, is included in the evaluation of children who have seizures or other neurological abnormalities. Up to age 5 years, however, systolic or continuous bruits may be heard over the temporal areas in normal children.
Examination of the face begins with an overall impression, which occasionally yields important diagnostic clues, such as the dull, immobile face associated with hypothyroidism; the open-mouthed expression of the child who has chronic nasopharyngeal obstruction caused by hypertrophied adenoids; the multiply bruised face of the battered child; and the small nose, open mouth, and prominent epicanthal skinfolds of the child who has Down syndrome (Atlas Fig. 1-13). Facial puffiness, or edema, especially involving the eyelids, can be an early sign of fluid retention secondary to acute or chronic renal disease or congestive heart failure. The distance between the eyes, usually measured as the interpupillary distance, can be increased as well as decreased in a number of syndromes of chromosomal origin and with other developmental anomalies.

The Chvostek sign, elicited by tapping the cheek just under the zygoma and causing unilateral facial grimacing, sometimes is a sign of hypocalcemia or hyperventilation tetany in older children; it also can be present in normal infants and young children.
Parotid gland swelling often is difficult to distinguish from cervical adenitis. The swollen parotid gland lies mainly anterior to the angle of the mandible and often pushes the ear pinna away from the side of the head, which can be seen when the patient is viewed from behind. Swelling and tenderness below a line drawn from the angle of the mandible to the mastoid process is caused by cervical adenitis. Nonobstructive parotitis usually is viral: when acute, it usually is caused by the mumps (Atlas Fig. 12-25, 12-26) virus but can be bacterial; when recurrent or chronic, human immunodeficiency virus (HIV) should be considered (see Chapter 219, Human Immunodeficiency Virus [HIV] Infection and Acquired Human Immunodeficiency Syndrome [AIDS]).

Studies of the process of mother-infant bonding during the neonatal period highlight the functional importance of an intact visual system in babies from the first minutes after birth.4,5 Although examination of the eye is important in picking up clues to congenital and acquired systemic abnormalities, the overriding goal of examining the eyes of infants and children is to ascertain that normal functioning is taking place and that potentially remediable processes affecting visual acuity are detected early.
At birth the eye is almost full grown compared with the other organs and the body. By this time the retina is completely developed except for the central foveal region, which is fully developed by 4 months of age, as is myelination of the central optic radiations and differentiation of the optic cortex. The cornea increases in diameter from 10 mm at birth to the final adult size of 11.5 mm. The lens doubles in weight between birth and age 20 and then increases another 50% by age 80. The pupillary reflex to light is functioning by 29 to 31 weeks of gestation. At birth the globe tends to be short in relation to the focusing ability of the lens and cornea (hypermetropia), and up to age 12 to 14 years the globe gradually lengthens, with a resulting tendency for visual images to be focused in front of the retina (myopia).8 At birth, babies can respond to faces, as well as to colored and black and white objects. The fixed focal length of the newborn's eyes (20 cm), along with the aforementioned factors and distracting influences (startle reflex, hunger, temperature changes), limit the newborn's ability to respond visually for more than brief moments.
The ability to accommodate is present by 4 months of age, and the ability to follow a moving light through different planes at various angles from the face is developed fully by 6 months of age.
Examination of the eye is an important part of every examination of an infant or child. The completeness of the examination may vary according to the reason for the visit (health maintenance versus emergency head trauma) and the chief complaint (headaches versus a sprained knee). A thorough examination of the eye includes observation of the lids, including eyelashes, tear ducts, and glands; the conjunctiva; the sclera and cornea; the pupils, including reaction to light and accommodation; and the lens. Globe size and intraocular pressure should be estimated, and the extraocular movements should be tested to note any presence of nystagmus or strabismus. Examination of the fundus (Atlas Fig. 19-2) includes assessment of the optic disk, macula, retina, and central vessels; this should be done in every child who is examined because of headache, head trauma, or other suspected intracranial lesion. Assessment of visual acuity should be part of every health maintenance examination.

Several attempts may be required to examine a newborn's eyes completely because of transient edema of the eyelids caused by the birth process or by the conjunctivitis induced by antibiotic instillation soon after birth to prevent gonococcal and other bacterial conjunctivitis. The upper eyelid may have a midline notch from incomplete fusion of its embryonic medial and lateral portions. The eyelids normally are fused until the eighth month of gestation. The lids often are slippery with vernix caseosa and conjunctival exudate, which should be removed gently with a dry cloth, allowing separation of the lids with a finger placed on each lid. Occasionally, one or both eyelids will be everted after birth. Episcleral and subconjunctival hemorrhages, either focal or diffuse, commonly are present after birth and can be expected to recede spontaneously. Less commonly, hyphema (blood in the anterior chamber) may be present (Atlas Fig. 19-119). Cloudiness of the cornea can be caused by congenital glaucoma (Atlas Fig. 19-65, 19-67) and requires ophthalmological consultation. Opaque particles or strands in the lens may be cataracts or remnants of the artery that supplies the lens in its early stages of development (hyaloid artery). This iris often is less pigmented at birth; its final color develops during the first year of life. Although a ring of white specks around the periphery of the iris (Brushfield spots) (Atlas Fig. 1-13B) is present in some normal infants, it is more prominent and common in children who have Down syndrome. Defects in the iris, particularly in the ventral aspect, can be associated with parallel defects in the lens and retina (colobomas) (Atlas Fig. 19-69) and represent incomplete closure of the embryonic optic fissure.

Careful examination of the newborn's retina is difficult without the use of mydriatics. The appearance of a "red reflex," seen when the ophthalmoscope is held 10 to 12 inches in front of the eye, ascertains that no major obstructions to light and its reflection from the retina are present between the cornea and the retina, such as corneal opacities, cataracts, and retinal tumors. Funduscopic examination of the newborn is indicated in babies in whom the red reflex is absent (leukocoria) (Atlas Fig. 11-75, 19-102)(Atlas Table 19-1), in babies who have been given prolonged supplemental oxygen, and in babies in whom CNS trauma or septicemia is suspected. In some newborn nurseries every newborn is given a funduscopic examination. With the ophthalmoscope, the cornea usually can be seen at +20 diopters, the lens at +15 diopters, and the fundus at 0 diopters. The fundus is examined 30 minutes after instillation of a drop of 2.5% phenylephrine (Neo-Synephrine) ophthalmic solution in each eye, optimally with the assistance of another person who can offer the baby a sugar nipple. The physician notes the size and color of the optic disk and macula and any areas of hemorrhage or increased or decreased pigmentation of the retina. In newborns and infants, the optic disk is paler than in older children, the peripheral retina vessels are not well developed, and the foveal light reflection is absent. Papilledema (Atlas Fig. 19-105) rarely occurs before age 3 because of the ability of the fontanelles and open sutures to absorb increases in intracranial pressure.

Perhaps the most productive method for observing both the structure and function of the newborn's eyes is for the examiner to hold the infant upright, in which position the infant often opens his or her eyes spontaneously. Abnormalities in the size of the eyes should be noted, inasmuch as microphthalmia (Atlas Fig. 19-60) is a part of several rare congenital defect syndromes. Narrowing of the space between the lids may be an isolated condition, blepharophimosis, or part of Komoto syndrome (Atlas Fig. 19-33, 19-72), which also includes ptosis, epicanthus inversus, and telecanthus; unilateral eyelid droop associated with a constricted pupil indicates Horner's syndrome. Any upward or downward slanting of the axis of the eyelids (palpebral fissures) also should be noted; upward slanting is characteristic of children who have Down syndrome (Atlas Fig. 1-3A). Although inner epicanthal folds can occur in normal infants, they are common in children who have Down syndrome and in those with other chromosomal abnormalities. The setting-sun sign (Atlas Fig. 15-25A) (a portion of the white sclera is seen between the upper lid margin and the iris) occurs in some normal premature and full-term infants, but persistence suggests the possibility of hydrocephalus.

Visual acuity in the newborn is assessed indirectly by means of visual reflexes such as consensual pupillary constriction in response to a bright light; blinking in response to a bright light and to an object moved quickly toward the eyes; and opticokinetic nystagmus, which the normal infant demonstrates when a cylinder that has alternating vertical black and white lines is rotated at specified distances from the eyes.

In addition to the findings on the examination described for the newborn, a few common problems particularly affect young infants. Tears often are not present at birth but are produced by 4 months of age. The nasolacrimal duct, however, sometimes is not patent until 1 year of age, leading to a chronically tearing eye with or without purulent discharge (Atlas Fig. 19-49). Pressure over the nasolacrimal sac on the medial edge of the lower eyelid will confirm the diagnosis of nasolacrimal duct obstruction by yielding mucoid or purulent fluid. Usually there is minimal or no conjunctival inflammation, and ophthalmological consultation is not indicated unless the tearing and discharge persist beyond 12 months of age.

Although acute conjunctival inflammation with purulent exudate sometimes occurs in neonates in reaction to the routine instillation of antibiotic drops, another cause that must be considered is infection (Atlas Fig. 19-55) by Neisseria gonorrhoeae, Staphylococcus aureus, or Chlamydia trachomatis. C. trachomatis can be diagnosed by the presence of cytoplasmic material in the epithelial cells of conjunctival scrapings. An acutely red, tearing eye in infants often is caused by corneal abrasions inflicted by the infant's own fingernails; this diagnosis can be confirmed by placing a damp fluorescein strip in the corner of the eye and observing the green staining of the abraded corneal epithelium.

Unilateral or bilateral ptosis (Atlas Fig. 19-34) of the lids may be appreciated better after the immediate postbirth period; it may be a familial trait, part of a syndrome of congenital anomalies, or the result of oculomotor nerve palsy. Unilateral exophthalmos, or protrusion of the eye, can result from a retroorbital tumor or abscess.

After the neonatal period and up to 3 to 5 years of age, visual acuity continues to be determined by the observations of the parents and the examiner. By 4 weeks of age, the infant can fixate on an object; by 6 weeks, coordinated movements in following an object are seen. By 3 months, the infant can follow an object moving across his or her midline, and convergence of the eyes is present. Beginning at 4 to 5 months the infant can reach for and grasp objects. Increasing recognition of familiar objects and faces by 5 to 6 months of age confirms normally developing cortical and visual systems. Between 1 and 3 years of age the infant responds to and uses brightly colored toys and children's books and can circumnavigate the examiner's office. Standardized tests of visual acuity for children under age 3 years have been developed. These tests require the child to "match" a toy or ball with small "test" objects that the examiner holds. These tests, which are not widely known or used, may offer the child health worker a useful screening tool.
Infants and children who fail to perform according to the tests outlined here should be examined further for blindness or mental retardation. Besides instances of blindness that are genetically determined or caused by perinatal insults, amblyopia (or reduced visual acuity) results from suppression of one or two unequal images in the visual cortex. Its importance is that it can be reversed only if diagnosed early enough (by age 6 years at the latest) to allow treatment of the underlying cause. There are two major categories of causes of amblyopia: obstructive amblyopia secondary to a cataract, corneal opacity, or severe ptosis and amblyopia ex anopsia secondary to uniocular squint (strabismus) or refractive (anisometropia) error. Strabismus is detected by using the corneal light reflection (Hirschberg) (Atlas Fig. 19-27) test and the cover-uncover test. The symmetry of the corneal light reflections is observed while the child focuses on a penlight 12 inches from the eyes; asymmetry indicates esotropia or exotropia. In the cover-uncover test (Atlas Fig. 19-28, 19-29), with the child focusing on the penlight, the visual axis of one eye is interrupted by the examiner's hand; any movement of the uncovered eye indicates strabismus. Similarly, when the examiner's hand is removed, the original uncovered eye moves back to its original position.

Loss of visual acuity in one eye detected during a screening evaluation often is the first indication of amblyopia. Vision is screened by using the Snellen illiterate E chart for children between the ages of 3 and 5 years and the Snellen E chart for children 5 years of age and older (see Chapter 20 [Eleven], Vision Screening).
The most common abnormalities of children's eyes seen in an ambulatory setting are swelling and redness of the eyelids and a red, tearing eye. Swelling and redness of the eyelids occur with obstruction of the nasolacrimal duct (Atlas Fig. 19-49), blepharitis, hordeolum (Atlas Fig. 19-42), and chalazion (Atlas Fig. 19-43, 19-44). Edema, tenderness, and warmth of the eyelid, usually indicative of periorbital cellulitis (Atlas Fig. 22-60, 22-61), can be caused by infection resulting from local trauma or insect bites, or they can be associated with upper respiratory tract infections and otitis media. Orbital cellulitis (Atlas Fig. 22-62) is characterized by marked lid edema, proptosis, chemosis, reduced vision, and decreased motility with pain on movement of the globe (see Chapter 248, Periorbital and Orbital Cellulitis). A red, tearing eye can be caused by acute conjunctivitis (Atlas Fig. 19-55, 19-56), subconjunctival hemorrhage (Atlas Fig. 19-59), keratitis, acute iridocyclitis, and acute glaucoma. Conjunctivitis characterized by prominence of the conjunctival blood vessels is one of the signs of Kawasaki disease. Evaluation of children who have sustained head trauma or who are suspected of having an overwhelming infection requires careful, repeated testing of the extraocular movements in the six cardinal fields of gaze and of the pupillary light reflex and observation of the conjunctivae and fundi, looking for unilateral abnormalities, hemorrhage, and papilledema. For example, lateral rectus muscle palsy often is the earliest sign of increased intracranial pressure (see Chapter 290, Increased Intracranial Pressure). Retinal hemorrhages can be seen in infants who have the shaken baby syndrome (Atlas Fig. 19-98).

The inner ear develops early in the first trimester of pregnancy, and response to sound can be shown in the twenty-sixth fetal week. At birth the cochlea and vestibule are anatomically mature.
Successful examination of the ears in infants and children, a skill that requires years of practice to develop, is extremely important because of the high incidence of middle ear abnormalities in children. The student should approach the use of the otoscope and the almost universal presence of ceruminous impediments to visualization of the external auditory canal in children with patience and a willingness to ask for confirmation of findings as often as needed. The practitioner should include a thorough examination of the ears in every physical examination, noting the characteristics of the external ear, external canal, and tympanic membrane and assessing hearing acuity.

The external ear is flat and shapeless until 34 weeks of gestation; once folded, it may remain so unless placed back in the flat position. Between 34 and 40 weeks of gestation, an incurving of the periphery of the pinna develops, along with an increasing ability to return spontaneously from the folded to the flat position. Minor anomalies in the shape of the external ear should be noted, including the occasional preauricular skin tags (Atlas Fig. 1-11A) or preauricular sinuses (Atlas Fig. 2-40, 22-18). The position of the upper attachment of the external ears should be noted in relation to a line connecting the inner and outer canthus of the eye. Attachments that fall below this line sometimes are associated with other congenital abnormalities, including renal agenesis. Patency of the external auditory canals can be determined by direct observation after pulling the pinna away from the side of the head. The tympanic membrane is coated with vernix caseosa for several days after birth and usually cannot be visualized.

Auditory screening in neonates begins with identifying those at risk for hearing loss because of a familial hearing disorder; intrauterine viral infection; hyperbilirubinemia, with bilirubin levels above 20 mg/dl; previous treatment with an ototoxic drug (e.g., gentamycin); or defects of the ear, nose, or throat. Neonates with any of these factors should be screened for hearing loss. In some states, all newborns are screened routinely for hearing acuity. Their subsequent language development should be monitored closely, and they should be referred to an audiologist for any signs suggesting hearing loss (see Chapter 20 [Nine] Language and Speech Assessment and Chapter 20 [Ten] Auditory Screening).

Several techniques can help the practitioner visualize the tympanic membrane. The infant's head should be stabilized to prevent painful jamming of the speculum into the ear canal. This sometimes can be accomplished by having the parent or a nurse hold the infant against his or her chest with the infant's head on one and then the opposite shoulder. The head usually is stabilized best by laying the infant supine on the examining table and having the parent or a nurse hold the baby's arms against the body or extended on either side of the head. Providing some type of visual distraction, as well as verbal reassurances, while positioning the infant usually affords the examiner a brief, struggle-free period for performing the otoscopic examination. Varying amounts of resistance are almost universal, however, and a rapid examination is desirable for the infant, the parents, and the examiner. One hand is used to grasp the ear pinna and gently pull it laterally and posteriorly to straighten the lumen of the external canal. In infants, the external canal tends to be perpendicular to the temporal bone, with a slight upward angle (further growth of the skull will give the canal a slightly anterior and downward direction). If the otoscope is held upside down, the infant's head can be stabilized further by the hand holding the ear pinna and the ulnar edge of the hand holding the otoscope (Fig. 8-22).
The examiner can further stabilize the infant's body by leaning across the chest and abdomen. The ear speculum then is introduced into the external canal and gently advanced to the point where the bony portion of the canal prevents further entry. Cerumen, which can be soft, firm, or flaky and varies from white to dark brown, may have to be removed. A flexible, wire-loop ear curette can remove small to moderate amounts of soft cerumen and poses less risk of abrading the canal wall or tympanic membrane than does a rigid curette. Curetting is done most safely through the otoscopic head. Larger amounts of hard, inspissated cerumen may require irrigation with warm water and sometimes prior treatment with softening agents such as hydrogen peroxide. An ear canal filled with purulent exudate usually indicates acute otitis media with perforation or otitis externa (the latter is accompanied by pain when the pinna is moved); irrigation usually is unsuccessful and may be dangerous, especially with perforation of the tympanic membrane. Several sizes of specula should be tried to find the largest size that fits into the ear canal, thus allowing visualization of the largest area of tympanic membrane. The otoscope usually must be rotated to view all the important landmarks.
A normal tympanic membrane (Fig. 8-23) (Atlas Fig. 22-21) is semitransparent, roughly cone shaped, and inclined away from the examiner. The light reflex in the anteroinferior quadrant often is the first landmark seen, with its origin at the central umbo. The examiner, moving the light superiorly from the umbo, can see the long process of the malleus through the membrane, which ends in a bony protuberance that marks the junction of the pars tensa inferiorly and the pars flaccida superiorly. Vague outlines of the incus sometimes can be seen in the posterosuperior quadrant. Air insufflation, by means of a diagnostic otoscopic head fitted with a small bulb, permits direct observation of the eardrum's movement as positive and then negative pressure is applied gently (pneumatoscopy) (Atlas Fig. 22-22, 22-23).

As acute otitis media develops (Atlas Fig. 22-25), the tympanic membrane becomes increasingly opaque and erythematous, usually progressing superiorly to inferiorly, with progressive outward bulging and eventual loss of the outlines of the malleus and of the light reflex. Air insufflation will demonstrate decreasing mobility and sometimes the changing menisci of fluid levels within the middle ear. As the condition heals, these changes resolve inferiorly to superiorly; final resolution of opacity, limited motion, and fluid levels sometimes requires several months.

Bullous myringitis (Atlas Fig. 22-26) appears as a bubblelike swelling that can almost fill the bony portion of the external ear canal. Blood behind the eardrum, either red or purple, is a sign of basilar skull fracture and should be looked for in children who have suffered head trauma. White plaques on the eardrum are scars from old infections (Atlas Fig. 22-33). A white mass in the posterosuperior quadrant may be a cholesteatoma, which is present with chronic obstructive middle ear disease. When examining acutely ill children suspected of having a middle ear infection, the mastoid process should be inspected for overlying swelling and erythema and palpated for tenderness—signs of acute mastoiditis (Atlas Fig. 22-10).

In infants, auditory acuity is screened directly and indirectly. The indirect method is based on the effect of normal hearing on language development. Normal infants make cooing sounds (semipurposeful vocalization of vowel sounds) by 6 weeks of age, laugh out loud by 3 months, babble (repetitive sounds, such as "baabaa") by 6 months, echo sounds made in their presence by 9 months, and say their first meaningful word between 12 and 15 months. An infant who fails to progress beyond any of these developmental stages or who regresses should be examined further for hearing loss, as well as for mental retardation.
Hearing can be assessed qualitatively by noting the infant's response to a nearby sound, which is made without visually distracting the infant and without producing vibrations of the air or the surface on which the infant is lying. Responses often are difficult to interpret but include blinking the eyes in a neonate, momentarily ceasing body movements at 1 to 2 months, and turning the eyes or the head toward the sound by 3 to 4 months (Atlas Fig. 3-24). The test sounds can be made by snapping the fingers or ringing a bell. With older infants, tongue clucking produces a test sound with the frequencies of normal speech (500 to 2000 Hz). Asking the parents about the infant's responses to sounds may be as reliable as simple office screening.

For children 1 to 5 years of age, normal hearing is necessary for language development beyond the one-word stage. Hearing can be screened by whispering, as softly as possible, a number into the child's ear and asking the child to repeat it or by asking the child if he or she can hear a ticking watch held a few inches from either ear.
Audiometric testing is indicated for any infant or child who fails any of these qualitative tests, and formal testing should be a routine procedure for children before they start school. Because of the high incidence of middle ear infections among infants and preschool children, hearing screening is routine in many offices and well-child clinics, both in following up known infections and as an annual procedure (see Chapter 20 [Ten] Auditory Screening).

The tympanic membrane in this age group usually can be examined without resistance, with the child sitting. If the child has ear pain or has had a previous painful examination, the supine position will make head stabilization easier. A qualitative hearing test for children in this age group can be accomplished by using tuning forks, particularly those with frequencies in the human voice range of 500 to 2000 Hz. The examiner's own acuity, presuming that it is normal, can be compared with the child's. Comparing bone and air conduction (Rinne test) and testing for lateralization of bone conduction with the handle of the tuning fork held against the midforehead (Weber test) can distinguish qualitatively between conductive and nerve hearing loss; with conductive loss, air conduction is less than bone conduction, and there is lateralization to the affected ear. Audiometric screening for this age group is routine in many schools. Some children who have chronic middle ear disease have fluctuating hearing loss that can be missed on a single puretone screening. In such cases, pneumatoscopy, impedance audiometry, and tympanometry (Atlas Fig. 22-7) can provide the definitive diagnosis.

The relative size and shape of the nose normally are influenced by the downward and forward growth of the maxillary bones and, to a lesser extent, by the increase in the bizygomatic width during childhood. The bony orbits are nearer adult size in the newborn than are the other facial bones, and the palate grows most rapidly during the first year of postnatal life. The paranasal sinuses are represented only by the centrally placed ethmoid sinuses at birth; the maxillary sinuses develop from birth and usually are apparent on roentgenograms by 4 years of age and the sphenoid sinuses by age 6. The frontal sinuses usually have reached the level of the roof of the orbits by age 6 to 7. The nose humidifies incoming air and traps bacteria and noxious materials in its continuous mucous blanket, moving them toward the pharynx by ciliary action. Olfactory function appears to be present at birth and to increase with age.
A thorough examination of the nose involves inspecting the external form, the condition of the external nares, the mucous membranes of the septum, and the turbinates and floor of the nose, as well as noting any exudate present. The nose should be examined in all newborns and in all children who have upper respiratory tract symptoms, noisy breathing, epistaxis, head trauma, headache, and fever.

In examining the newborn's nose, it is important to rule out the presence of unilateral or bilateral choanal atresia (Atlas Fig. 22-35, 22-36), which can produce severe respiratory distress, inasmuch as most newborns are unable to breathe easily through their mouths. This examination is performed by introducing a soft No. 8 feeding tube into each external naris and advancing the catheter to the pharynx. Advancing the feeding tube farther into the stomach rules out esophageal obstructions such as atresia and allows aspiration of the amniotic fluid from the stomach. A simpler technique for testing choanal patency is to close one and then the other nostril while holding the mouth closed. When choanal atresia is present, the infant will struggle for breath when the patent nasal airway is occluded. Obstructed nasal breathing sometimes is seen briefly after birth because of inhaled blood and amniotic debris, which can cause moderate to severe distress, especially in those few infants who have congenitally narrow nasal cavities. A profuse, purulent nasal discharge in the neonatal period could suggest the presence of congenital syphilis.

By elevating the tip of the child's nose and using a nasal speculum, the practitioner can inspect the membranes covering the nasal septum, floor of the nose, and inferior, middle, and superior turbinates in the lateral nasal wall for signs of inflammation and bleeding points. The nasal septum occasionally is deviated to one side, sometimes obstructing breathing on that side. The fairly common occurrence of intranasal foreign bodies should be anticipated when examining any child who has chronic nasal discharge, with or without associated bleeding (Atlas Fig. 22-41). Epithelial polyps of the nasal mucosa are rare in children and usually indicate underlying cystic fibrosis (Atlas Fig. 22-42, 44-43) or chronic allergic rhinitis. A pale, swollen, boggy nasal mucosa indicates allergic rhinitis, whereas with viral rhinitis the nasal membranes are red and bleed easily. Sinusitis should be suspected whenever purulent exudate appears from beneath any of the three nasal turbinates, especially in a child who has a history of chronic nasal congestion, chronic tracheobronchitis, recurrent otitis media, and fever. Transillumination of the paranasal sinuses in younger children is of limited value to physicians other than otorhinolaryngologists because of the variable development of the sinuses before ages 8 and 10. After 10 years of age the frontal sinuses can be transilluminated in a darkened room by holding a bright light source (transilluminator attachment for an otoscope-ophthalmoscope handle) against the superomedial aspect of the orbit; the maxillary sinuses can be transilluminated by holding the light against the lateral aspects of the hard palate within the closed mouth.

Clear fluid draining from the nose after head trauma should be tested for sugar, which is present with a CSF leak. In a child who has a history of epistaxis, the anteroinferior portion of the septum is a common location of prominent blood vessels (Kiesselbach plexus) (Atlas Fig. 22-47) that bleed easily, especially when aggravated by local inflammation and self-inflicted abrasions.

Swelling around the bridge of the nose can be caused by a cavernous hemangioma or, less commonly, a nasal encephalocele (Atlas Fig. 22-37). Erythematous swelling that involves the lateral portion of the bridge of the nose and adjacent eyelids can be a sign of orbital or periorbital cellulitis (Atlas Fig. 22-60, 22-61, 22-62), which requires immediate intensive investigation and treatment.

Primary care physicians often are asked to examine a child who has suffered trauma to the nose. Consultation with a subspecialist should be sought immediately if the child has prolonged bleeding from the nose after an injury, there is evidence of a septal hematoma (Atlas Fig. 22-46), or there is any question of depression of the base of the nose or of deviation from the nose's normal straight-line vertical axis.