Paediatric Examination Handbook

4th Edition

Taso Papadopoulos
Class of 2007

Kevin Schwartz
Class of 2007

Illustrators
Desmond Balance Sherry Lai
Ardis Cheng Adrian Yen

Supervisor
Dr. Julie Johnstone
ASCM II Paediatric Preclerkship Coordinator
 2015 Taso Papadopoulos & Kevin Schwartz and the University of Toronto

Written permission to copy any part of this material must be obtained from
Taso Papadopoulos & Kevin Schwartz and the University of Toronto,
Faculty of Medicine, Undergraduate Medical Education, (416) 946-7009.
TABLE OF CONTENTS

1.1: GENERAL HISTORY ................................................ 3

1.2: GENERAL PHYSICAL EXAMINATION .................... 7

SECTION 2:
2.1: INFANT/CHILD EXAM .............................................. 9
2.2: NEONATAL EXAM .................................................. 22
2.3: ADOLESCENT EXAM ............................................. 31

SECTION 3:
3.1: SCREENING FOR DEVELOPMENTAL ABNORMALITIES ... 33

APPENDICES ................................................................ 36
Appendix 1: Vital Signs .............................................................. 37
Appendix 2a: Congenital Heart Disease .................................... 38
Appendix 2b: Cardiac Murmurs .................................................. 39
Appendix 3: Common Dermatologic Lesions Of The Neonate .. 40
Appendix 4: Primitive Reflexes................................................... 41
Appendix 5: Apgar Scoring......................................................... 43
Appendix 6: Common Congenital Disorders .............................. 44
Appendix 7: Developmental Milestones ..................................... 46
Appendix 8: Current Immunization Schedule ............................. 48
Appendix 9: Assessment Of Severity Of Dehydration ................ 49
Appendix 10: Tanner Staging ..................................................... 50
Appendix 11: Feeding Schedule ................................................ 54
Appendix 12: Growth Charts ...................................................... 55

REFERENCES ............................................................... 63

1
ABBREVIATIONS USED IN THE HANDBOOK
BP blood pressure
CAS children's aid society
CHF congestive heart failure
CVS Chorionic Villus Sampling
DM Diabetes Mellitus
EMG electromyogram
EtOH ethanol
GBS Group B Streptococcus
GI Gastrointestinal
GTPAL Gravida, Term, Preterm, Abortion, Living
GU Genitourinary
HEENT Head Eyes Ears Neck Throat
HR heart rate
HTN Hypertension
ICP intracranial pressure
LLQ left lower quadrant
LMN lower motor neuron
LUQ left upper quadrant
MCL midclavicular line
MSS Maternal Serum Screen
MVA motor vehicle accident
NICU neonatal intensive care unit
NTD neural tube defect
PPH persistent pulmonary hypertension
RAPD relative afferent pupillar defect
Rh rhesus
RLQ right lower quadrant
RR respiratory rate
RUQ right upper quadrant
SIGECAPS Sleep, Interest, Guilt, Energy, Concentration,
Attention, Psychomotor Retardation, Suicide
TM tympanic membrane
TMJ temperomandibular joint
TORCH Toxoplasma, Other (Syphilis), Rubella, CMV,
Herpes/HIV/HBV/HCV
U/S ultrasound
UMN upper motor neuron

2
SECTION 1.1: GENERAL HISTORY
Please note that this section provides a thorough approach to a paediatric
history. This is not meant to be a strict script for every patient encounter, as
not all questions will be required for every patient. Clinical judgment is
required.

TIP: Often the history is appropriately taken from a third party,

such as a parent, but whenever possible engage the child in
questions that are at their level. For example, even young
children can provide information on their age and what's
hurting them. Help engage them now and build your report
for the physical exam to come!

Identifying data
age, sex,
gestational age at birth
who is accompanying the patient and what is their
relationship with the patient.

Chief Complaint/Reason for Referral

History of Present illness

onset of symptoms, duration, timing (intermittent vs.
constant)
Progression of illness over time
Associated symptoms
Exacerbating & alleviating measures
Similar episodes in the past
o Treatment, outcome, complications
What the family has done so far to manage (i.e. meds
given? Other MDs visited?)
Review of systems (as clinically indicated)
o General changes in behaviour, fevers, growth
parameters
o HEENT Hearing changes, visual
concerns/complaints, head or neck masses,
sore throat
o Respiratory cough, nasal congestion,
shortness of breath, chest pain
o Cardiac cyanosis, palpitations, diaphoresis
o Abdominal/GI nausea/vomiting, diarrhea,
constipation, abdominal pain, abdominal
distension, fecal incontinence, toilet training
o Genitourinary
3
 dysuria, hematuria, urinary
incontinence, frequency, urgency,
caliber of urine stream, flank pain
external genitalia (size, shape, edema,
lesions, skin integrity), pruritus,
discharge
o Reproductive age of menarche, regularity,
duration, sexually active
o CNS seizures, headaches,
weakness/paralysis
o Dermatological rashes, lesions, loss of skin
integrity, birth marks.
Pregnancy History:
1) Mother
a) History of previous pregnancies/mothers health:
o GTPAL
o Maternal Systemic Illness HTN, DM, Thyroid
d/o, seizures d/o, cardiac disease, metabolic
d/o, psychiatric d/o (depression)
b) History of current pregnancy
o gestational age
o Antenatal course, bleeding, Rh status
o prenatal screening results (TORCH, GBS,
MSS), U/S results, amniocentesis/CVS and why
they were done.
o Mothers meds during pregnancy
o mothers smoking history, alcohol history, illicit
drugs, and how much during current pregnancy.
c) History of congenital diseases/consanguinity/maternal age
at delivery
o DM, thyroid, metabolic diseases, cystic fibrosis,
muscular dystrophy, Downs.
2) Labor History
o Duration (from rupture of membranes)
o Vaginal or C-section, and if C-section why?
o Any complications? Presence of meconium
o Use of medications during labor (analgesics,
type, route)
o Maternal fever and need for antibiotics
3) Post-natal
o birth weight
o Apgars (1 and 5 min) and if points lost, for what?
Appearance
Pulses
Grimace
4
 Activity
Respirations
(See appendix 5 for further detail)
o Was resuscitation necessary? If yes, what and
for how long?
o Hospitalization > 72 hours Why?
o jaundice, cardiorespiratory, etc
o NICU stay
duration, treatment, complications
Past Medical and Surgical History
Acute Illnesses
o Onset, duration, frequency, treatment,
complications
Chronic Illness
o Diabetes, asthma, cancer, congenital heart
disease
Past surgeries
Emergency room visits

Medications
current medications, purpose, start date, dose, duration.
any medications in the past 4-6 months
any medications that were taken for an extended period of
time but have been stopped.

Allergies
Drug
o medication used, type of reaction (?anaphylaxis)
Environmental/seasonal/food

Immunizations: (see Appendix 8)

TIP: up to date is not sufficient, need to ask specifics!

Development: (see Appendix 7)

Diet:
Typical intake per day
Breast vs. formula, restrictions (why?), supplements

Family History:
genetic diseases, infant deaths, consanguinity
for more detail refer to the congenital anomalies section.
5
 Ages, health, names, occupation of parents
Ages, health, names of siblings

Social History:
inhabitants in home, daycare, parental employment, CAS
involvement, support systems
current stressors at home
observe family interactions as well as what they report

6
SECTION 1.2: GENERAL PHYSICAL EXAMINATION
Please note that this is an overview of the general physical examination in
paediatrics and that subsequent sections will provide more detail for the age
specific examinations.
FOR MORE DETAILS OF THE SPECIFIC MANEUVERS PLEASE ALSO
REFER TO THE ASCM I GENERAL PHYSICAL EXAMINATION
HANDBOOK AS THEY WILL ALSO APPLY TO THE PAEDIATRIC EXAM.

TIP: The paediatric exam is opportunistic. If the child is quiet ,

feel the abdomen and auscultate first and perform
distressing maneuvers last (ears, throat, BP, head
circumference, etc.), but perform a complete exam and
document it in an organized manner.

General:
Vitals: HR/ RR/ BP (see appendix 1), Temp (>38
rectal/aural, >37.5 oral, >37.3 axillary);
Overall appearance, well vs. toxic looking
Height, weight, and head circumference.

HEENT:
Head: shape and symmetry, fontanelles, dysmorphism
Ears: shape, hearing, otoscopic exam
Eyes: acuity (>3 years), lids, pupils, fundus, strabismus
Mouth: Mucous membranes, teeth, uvula, tonsils, tongue,
frenulum, palate
Neck: stiffness, lymph nodes, thyroid

Respiratory:
Inspect for Respiratory rate and signs of distress (indrawing)
Palpate and percuss chest if indicated
Auscultate all lung fields

Cardiovascular System:
Inspect for Distress or Cyanosis
Palpate chest and peripheral pulses comparing brachial and
femoral, thrills, heaves
Auscultate heart

Genitourinary: Age appropriate exam for boys and girls

Inspect genitalia and signs of puberty (see Tanner Staging in
Appendix 10, pg 51)

7
Gastrointestinal:
Inspect abdomen
Auscultate for bowel sounds
Percuss and palpate for tenderness and masses

Musculoskeletal:
Look, Feel, and Move all joints including spine

Neurological:
(For a detailed outline of the neurological examination
please refer to the ASCM I handbook written by Ari
Greenwald.)
Age appropriate exam for Higher cortical function and
development, cranial nerves, power, tone, reflexes, sensory,
and cerebellum function

Dermatological:
Full body inspection for rashes, bruises, caf-au-lait spots,
and hemangiomas

8
SECTION 2.1: INFANT/CHILD EXAM
History:
A complete history should be obtained following the general
outline in section 1.1.

Physical Examination:

TIP: To keep the child as cooperative as possible, the physical

exam should be done in a playful manner. Numerous techniques
can be used, but here are some tips that may be helpful:
Blowing out the otoscope like a candle (let the child do it too)
Transilluminate your finger and the childs finger making it
look red.
Tongue depressors can be magical for occupying little
curious hands that like to grab at your stethoscope.
1. HEENT:

TIP: Brain Growth is the prime determinant of head size

Head: Fontanelles: Posterior is closed or extremely

small at by 6 weeks of age.
Anterior closes at 18 6 months; bulging (e.g.;
meningitis/ICP) vs. flat (normal) vs. sunken
(dehydration)

Auscultate over temples for bruits; Presence may

indicate an AVM
Eyes:
o Lid: Inspect for ptosis,
o Sclera: for colour (red - conjunctivitis, blue -
osteogenesis imperfecta, yellow - jaundice),
o Nystagmus/EOM,
9
 o Cornea; large or cloudy eyes (congenital
glaucoma),
o Light reflex: looking for strabismus, Cover-
uncover test

o Pupils: pupillary reactions, RAPD

o Fundi: for red reflex, papilledema
o Visual Acuity: Use a Snellen chart for a
child >3yrs
Ears:
o Inspect for low set
o Palpate pinna and tragus for pain which
could represent otitis externa
o Otoscope:
st
Examine asymptomatic ear 1
Positioning:

OPTIONS: Positioning for Otoscopic Examination

1) Have the parent/guardian accompanying the child
hold the child in their arms with the childs chest
against their chest (i.e. facing each other)
2) Have the parent/guardian put their arms around the
child so that they are holding the childs arms to
his/her side.
3) For the right ear, have the parent/guardian put the
child up on their LEFT shoulder.
4) Turn the childs head to the RIGHT, so they are
facing away from the parent/guardians head.
5) Hold the childs head against the shoulder of the
parent/guardian (firmly if necessary) and conduct
the otoscopic examination. Apply gentle caudal and
posterior traction to the childs ear in order to
straighten the external auditory canal and better
view the tympanic membrane.
6) Repeat the same procedure on the opposite side.
7) If all else fails, with the child supine ask parent to
stand at the head of the table holding their childs
hands down above their head. Position yourself with
your arm over the abdomen of the child ensuring
their legs cannot get under your arm. You now have
2 free hands to position the head, retract the pinna
and examine

10
 Tympanic Membrane;
o Colour (pearly gray is normal, erythema
can be caused by infection, fever, or
crying);
o Landmarks (Malleus and cone of light;
distortion of these may indicate fluid
behind TM; this is a better indication of
infection than erythema);
o Perforation, note any fluid in ear canal

TIP: Ear-tugging can be the only symptom of an acute otitis

media in infants, particularly those that are not verbal.

Mouth: Same principles of positioning apply to looking at the

pharynx as the ear when a tongue depressor is necessary

TIP: Using the tongue depressor

Hold the tongue depressor in your dominant
hand and the otoscope turned on in your non-
dominant hand.
With the child supine and the arms held by the
parent guardian, place the tongue depressor in
the childs mouth and move laterally along the
dentition until the tip is just past the molar (or the
gingiva if the molars are not yet erupted).
Angle the tip of the tongue depressor toward the
middle of the oropharynx toward the uvula while
remaining above the tongue.
As the child opens his/her mouth move further
centrally to the depth of the uvula and depress
the childs tongue. This should give you a good
view of the oropharynx.

11
 o Lips: Inspect for cleft, cyanosis, and herpes
lesions
o Gingiva and teeth: hygiene, thrush, herpes,
lower incisors come in ~6 months, but varies
o Tongue for strawberry appearance associated
with GAS/Kawasakis disease; white coating

TIP: To differentiate milk from candidiasis scrape with tongue

depressor, if the coating comes off it is milk

o Palate for cleft, petechiae (GAS),

o Tonsils for size, colour, presence of
exudates, and symmetry (Asymmetric tonsils
may be a sign of peritonsillar abscess or
malignancy).

TIP: Central Incisor or bifid uvula may be a sign of incomplete

midline facial development associated with hypopituitarism

Nose:
o nasal flaring, patency, deviated septum,
polyps
Sinuses:
o Maxillary and ethmoidal sinuses present at
birth. Pain on palpation is associated with
sinusitis.
o Frontal sinuses begin to form around age 7.
Neck:
12
 o Nuchal Rigidity; with child supine lift head from
under occiput and flex neck.
o Inspect and palpate lymph nodes
o Inspect thyroid gland with neck extended and while
swallowing. In children rest thumbs (or 2 fingers
from behind) over thyroid and have child swallow;
describe masses in terms of size,
consistency, tenderness, mobility and
matted.
o Lymph nodes up to 1cm in size, soft, and mobile are
typically normal.

2. Respiratory Examination:

TIP: For infants and toddlers, this examination may be more

easily performed with the child sitting on the parents lap.

Inspect: General appearance

o Respiratory Rate (appendix 1)
o Allergic Shiners and the Allergic Salute where the
child repeatedly rubs the tip the nose with the palm
or back of the hand.
o Colour: central vs peripheral cyanosis
o Nasal flaring
o Accessory muscle use: sternocleidomastoids,
scalenes, and abdominal muscles
o Retractions: suprasternal, supraclavicular, lower
sternal, and intercostals
o Chest wall shape: Barrel (chronic small airway
obstruction), pectus excavatum (cosmetic), pectus
carinatum (may be associated with chronic
cardiorespiratory disease), kyphoscoliosis.
o Clubbing: Loss/decrease of angle at skin-nail
junction; seen in Cystic Fibrosis, bronchiectasis,
cyanotic heart diseases, GI diseases, and familial.
o Listen and describe cough (without
stethoscope), snore, stridor, wheeze, grunt

Palpation:
o Palpate for tracheal position with 1 finger in
small children and 2 fingers in older kids
o Chest expansion
o Percussion

13
 Auscultation:
o All lobes, compare sides
o Characterize breath sounds and describe any
adventitious sounds (crackles, wheezes, rubs)

TIP: Placing bell of stethoscope in front of childs mouth can help

differentiate between extrathoracic sounds (i.e.; stridor heard
in epiglottitis, croup, laryngomalacia, tracheomalacia) and
intrathoracic sounds (ie; wheezes heard in foreign body
inhalation, bronchomalacia, asthma)

3. Cardiovascular:

Inspection
o Dysmorphic features: many congenital heart
lesions associated with chromosomal disorder.
o Cyanosis: check hands and lips for
acrocyanosis; check frenulum for central; Is the
cyanosis asymmetrical?
o Prominent left thorax is associated with both
right and left ventricular failure
Palpation
o Pulses: compare femoral and brachial pulses for
rate, rhythm, and volume (decreased or absent
femoral pulses associated with coarctation)
o Blood pressure: All 4 limbs (decreased leg BP
associated with coarctation)
o Impulses: Depress thorax with first and second
fingers just left of the Xiphoid process. A forceful
impulse implies an enlarged heart. Palpate in
the suprasternal notch for pulsations and thrills
o Palpate valve areas for thrills
o Palpation for an enlarged liver is an important
sign for heart failure
o Palpate periphery for capillary refill and cold
extremities

Auscultation

TIP: S1 = MITRAL/tricuspid; S2 = AORTIC/pulmonary; S3 = rapid

filling in early diastole (can be normal in children); S4 = late
diastole due to poorly compliant ventricle (abnormal)

14
 o Listen for S1/S2 in all 4 areas with diaphragm;
S3/S4 with bell
st nd
o Systolic murmurs between 1 and 2 heart
nd st
sounds; diastolic murmurs between 2 and 1
o Describe murmurs in terms of Intensity I-VI,
quality, timing, radiation, changes with
movement. (see appendix 2b for differentiating
physiological from pathological murmurs)

** Don't for get to check for an enlarged liver, ascites, edema, jugular
venous distension, respiratory distress, or pallor/cool extremities as
signs of potential heart failure.**

4. Gastrointestinal/Abdominal Examination:

TIP: This examination should always include measurement of

growth parameters, as these may be the only signs that
there is a gastrointestinal abnormality on examination.

TIP: Abdominal pain is a common complaint in acute tonsillitis

and pneumonia

Inspection
o look for scars, masses, skin lesions, asymmetry,
visible pulsations
o scaphoid versus distended abdomen
it is normal in the newborn period and
infancy to have some distension of the
abdomen, and this will normally flatten out
with age.

TIP: Marked distension with shiny skin appearance is always

abnormal regardless of age.

o bulging flanks
o abdominal muscle use during breathing
o Sequelae of liver disease and associated
encephalopathy*
Hands
Teres Nails, Thenar wasting,
Palmar erythema, Asterixis*
clubbing
Chest
Spider nevi
15
 Petechiae
Gynecomastia
Abdomen
Caput medusa
Umbilical hernia, outie
Other
Loss of male pattern hair
Testicular atrophy
Fetor hepaticus

Auscultation
o listen in all quadrants or until bowel sounds are
heard as they will transmit throughout the entire
abdomen

TIP: To define bowel sounds as being absent, must listen for two
straight minutes.

o listen to the right and left of the umbilicus for any

renal/aortic bruits
o Auscultate over the right and left upper
quadrants for any hepatic or splenic bruits

TIP: An audible bruit in the abdomen is very difficult to localize

due to the transmission of sound throughout the abdominal
cavity.

Percussion
o Percuss in all four quadrants of the abdomen.
Should normally be tympanic percussion note.
o LUQ Traubes space with both expiration and
deep inspiration (dullness with inspiration = a
positive Castells Sign)
o RUQ Percuss in the mid-clavicular line
starting from the level of the anterior superior
iliac spine and moving up to find the lower liver
edge. Then percuss down from the clavicle in
the midclavicular line (MCL) to find the upper
liver edge.
Normal = 6-10 cm in children
TIP: Scratch Test with the stethoscope over the RUQ start to
lightly scratch first up from the RLQ and then down from the
clavicle in the MCL. When the liver edge is reached you will

16
 clearly hear a scratching sound. This can help discern liver
span if you have difficulty doing so by palpation.
o Fluid wave, shifting dullness, flank dullness
Palpation

TIP: If the child is ticklish, get them to press their hand on top of
yours while you are examining them and magically the
ticklish feeling often stops.

o 2 step process for the general abdominal exam.

Both should be performed in all four abdominal
quadrants. Watch childs face for wincing.
Superficial/light palpation
Feel for any superficial masses or large
intra-abdominal masses that can be felt
at the surface
It can be helpful to palpate with stethoscope
while child is relaxed
Deep palpation
Deeper masses
Pulsatile masses in the midline,
characterize size if present

TIP: Ask if the child/adolescent is experiencing any pain

currently. If the answer is affirmative get them to point to
that area and leave it to palpate last as this could very well
be the end of your patients cooperation with the physical
exam.

Palpate for the spleen in the LUQ and the liver

in the RUQ by moving finger tips as child
breathes. Start in RLQ for both liver and
spleen exam
Normally liver edge is palpable
throughout childhood and adolescence,
just below the costal margin
The spleen is palpable in up to 30% of
newborns and gradually decreases to
<1% by adolescence.

Kidney ballottement

Peritoneal signs
17
 on auscultation with placement of
stethoscope on abdomen
guarding with light palpation or on
percussion
rebound tenderness*
shake tenderness*
*Often unnecessary and causes needless pain if other
signs are present.

TIP: Peritoneal irritation (e.g. appendicitis) can be elicited in

children by having them puff up their tummy or by jumping
up and down.

5. Genitourinary:

TIP: Show children the same respect and privacy you would for
adults

Inspect external genitalia for abnormality, signs of abuse, or

infection
Boys:
o Inspect meatus for hypospadias and epispadias
o The penis should be >2.5cm, palpate both testis
(5ml using an orchidometer indicates puberty
o Tanner stage of pubic hair(see appendix 10)
o Puberty begins between 10.5 and 16 years
Girls:
o Inspect vagina for discolouration, enlarged
clitoris, or fused labia minora may be indicative
of androgenization
o palpate labia majora for gonads
o Tanner stage of pubic hair (see appendix 10)
o Breast budding is usually the first sign of puberty
o Puberty begins between 6 (African American), 7
(caucasian) and 14 years

TIP: Early puberty is frequently pathological in boys and

constitutional in girls
Late puberty is frequently pathological in girls and
constitutional in boys

TIP: To rule out a pathological cause to short stature ask:

1) Was the child intrauterine growth restricted?

18
 2) Is the child disproportional?
3) Is there abnormal growth velocity?
4) Is the bone age abnormal?

-If the answer is YES to any question search for pathology

6. Neurological Examination:

TIP: Neurological exam will vary depending on age

Observation:
o ability to speak and answer questions (intellect)
o Gait: walking, running, heel-to-toe, walk on
heels, walk on toes (Gross motor, spasticity, and
cerebellum)
o Useful screening exam tricks include playing
ball; observe children throwing and kicking a ball
with each hand/foot
o Skin for caf-au-lait spots (neurofibromatosis)

TIP: Cranial nerves I-XII (Make a game out of it and observe

closely)
III, IV, VI use a light or toy to assess EOM
V, VII, XII Simon says or having infants imitate
you can be useful

Power: It is important to test individual muscle groups if

screen is abnormal looking for asymmetry.
Tone:
o Flexibility differs among age groups (ie; a
normal child <12y should be able to touch his
nose with his toe with no discomfort, whereas a
spastic child cannot)
o Ankle clonus >2-3 beats in abnormal
Coordination: finger-to-nose & heel along shin tests
Reflexes: symmetry, absent (0), decreased (1+), normal
(2+), increased (3+), increased with sustained clonus (4+),
delayed relaxation (seen in hypothyroidism),
o Test; knees, ankles, biceps, triceps, and
brachioradialis.
o Others: Babinski (upgoing toes normal up to 1yr),
abdominal, cremasteric, anal wink

19
 Sensory: Pain and vibration tests if age appropriate

TIP: For a younger child; while playing slowly move a wheel up a

leg until child becomes aware of sensation. If a reproducible
spot of awareness can be elicited, further studies
(EMG/nerve conduction) may be warranted.

7. Musculoskeletal

TIP: Acute monoarthritis with severe pain and fever = septic

arthritis until proven otherwise

Observation:
o Watch gait closely
o Have the child squat and walk like a duck joint
pathology unlikely if no pain
o Observe standing from duck position if difficult
check for primary muscle disease (e.g.;
dermatomyositis)

TIP: A good screening exam involves a game of Simon says:

put 3 fingers in your mouth (TMJ)
hands above your head (shoulder)
put your hands together like youre praying (wrists)
make a fist (fingers)
touch your shoulders(elbows)
squat like a duck (knees/hips)
bend down and touch your toes (back)
Look up, down, side-to-side (neck)

Spine:
o Sacral dimples should be level to rule out leg length
disparity
o tuft of hair, midline nevi, angioma, lipoma, central
dimple (associate with underlying spinal cord or
vertebral abnormality)
o Kyphoscoliosis scapulas should be even, check
for curve when bending
o Range of Motion (ROM)
bend forward
bend back
slide hand down leg
rotate to side while sitting for ROM
o test power and reflexes in upper and lower limbs
20
 Peripheral joints:
o May sit on parents lap
o Inspect for swelling, redness, and deformity
o Palpate for tenderness, synovial thickening, and
effusions
o active and passive range of motion

8. Dermatologic Examination:

This is a full head to toe examination with the child fully

exposed
Identify all lesions and describe:
o Position
o Morphology
Primary
(macule/patch, papule/plaque,
vesicle/bullae, pustules,
wheals/urticaria, comedones,
burrows, telangiectasia)
Secondary
Crust, scale, excoriation,
erosion/ulcer, atrophy, scar
Pigmentary changes
o Nails
o Mucosa
Oral, nasal, vaginal
o Scalp and hair

21
SECTION 2.2: NEONATAL EXAM
History:
A complete history as per the general layout with particular
focus on the pregnancy and antenatal/delivery/postnatal
history.

The Physical Examination:

1. Observe
have the mother or father undress the infant. This exam is
preferably done in a warm room with good lighting.
Does the baby look normal or abnormal?
o body proportions, face, head and neck
o If there are deformities document them
o Dont forget to also look at mom and dad for any
similar features.
Respiratory effort
o intercostal or sternal indrawing, tracheal tugging,
tachypnea, stridor/expiratory grunting, cyanosis
Activity
o spontaneous, elicited, hypotonic
Skin
o peripheral/central cyanosis, jaundice
o dermatologic lesions (refer to appendix 3)

TIP: Dont forget to look at the baby from the back side as well,
lesions can be anywhere. To do so, support the babys
head and neck and gently roll them to one side. Inspect the
spine for any NTD, the skin for any lesions and the anus for
patency.

2. Listen
sounds consistent with laboured breathing
strong and loud cry or weak cry
raspy cry
grunting
can the baby be easily consoled

TIP: With experience the clinician can get a lot of information

from a cry.

22
 3. Vitals
Heart rate, respiratory rate, temperature, oxygen saturation,
and blood pressure (4 limbs to rule out coarctation if
suspected) (See appendix 1).
Height, Weight, Head Circumference.

TIP: BP is not done by auscultation in children <3 years of age. If

indicated, the Doppler US method should be used.

4. HEENT
Head
o fontanelles, overriding suture lines (with vaginal
deliveries) shape of head, cephalohematomas,
caput succedaneum, hemangiomas
Eyes
o red reflex in both eyes, scleral icterus
o visible hemorrhages of the subconjunctiva sclera
usually benign (resolve in 2-4 wks)
o coloboma or iris heterochromia

TIP: The eyes should open spontaneously if the infant is held up

and tipped gently forward and backward.

Ears
o external ear fully formed and cartilaginous
o Level relative to lateral epicanthal folds
o Patency of the external auditory canal
Nose
o Cartilage/bony deformities
o Patency of nasopharynx
Throat/Mouth
o Cleft lip/palate
o neonatal teeth

23
 Neck
o Tone
o attempt to palpate the thyroid by lifting the baby up
from the scapula keeping the occiput resting on the
table, to expose the neck and palpate in the area of
the thyroid gland.

TIP: A palpable thyroid in newborns is always abnormal.

5. Chest
kyphoscoliosis, chest wall deformities
tracheal deviation/tugging
intercostal indrawing.
Inverted nipples, widely spaced nipples, shield chest.

TIP: Breast hypertrophy is common in both boys and girls at birth

and is completely benign.

Auscultation
o Good air entry bilaterally
o adventitious sounds.
6. Precordial
AMI, heaves, thrills, heart sounds, murmurs
Physiologic vs. Pathologic Murmurs in Children
o Please refer to Appendix 2

24
TIP: Congestive Heart Failure;
- 95% symptomatic by 3 months
- rarely present at birth
- if presents in 1st week; likely obstructive lesion or
persistent pulmonary hypertension
- if presents at 4 - 6 wks; likely Left-to-right shunt
- if presents after 3 months; likely myocarditis,
cardiomyopathy, or paroxysmal tachycardia

6. Abdominal Examination abdominal wall

malformation/hernia, masses,
hepatosplenomegaly.

7. Peripheral Vascular System

Appearance
o Cyanosis, mottling
Temperature
o If cold may be an indication of poor perfusion.
Capillary refill
o Normal < 2s
Pulses
o brachial, radial, femoral

25
8. Musculoskeletal
Spinal alignment and check midline for sacral (pilonidal)
dimple (which could indicate a spina bifida occulta)
Hips
o Barlow (Adduct hips to see if dislocatable)
o Ortolani (Abduct hips with hand over greater
trochanter, to see if hip relocatable)
o

9. Skin
make sure to examine the entire body including the scalp,
axilla, back, buttocks and genitalia
look at the spine tuft of hair may overlie spina bifida
occulta
look for any caudal dimples and see if they form a deep
open tract/sinus and thus represent a neural tube defect.

26
 10. Genitourinary
Male
o Check for hypospadias

o Check for epispadias

TIP: These patients should never be circumcised as the foreskin

will be needed for later surgical repair of anatomic anomaly.

o testicles descended
o hydrocele/hernia, spermatocele, indirect inguinal
hernia.
o Inspect for visible perineal/scrotal swelling
o Palpate any observed swelling to try and determine
if there is any bowel within the inguinal canal or if it
is only fluid
o Palpate the testes and follow the vas deferens and
vessels up the inguinal canal. If the bundle feels
thickened on one side it may be a sign of a patent
processus vaginalis.

TIP: Transillumination shine the penlight from behind a scrotal

swelling. If it is transmitted through the swelling, then this
tells you it is not a solid mass. This is a sensitive test, but
not specific and transillumination can occur with inguinal
hernias as well.

27
TIP: Do not completely retract or force foreskin to check glans
penis, only enough to ensure adequate opening for
urination.

Female
o patent vagina
o normal size clitoris (visible but not resembling a
penis)
o palpate the labia majora to ensure there are no
gonads present.

11. Neurological
(Refer to Appendix 4 for a complete review of primitive reflexes)

Tone
Power
Asymmetrical facial movements
Reflexes
o Suck
o Root
o Grasp (palmar and plantar)
o Step

28
o Moro

29
 o Spinal (Gallant) reflex

o Babinski (only useful if asymmetrical)

o upgoing toes are normal until 9-12
months of age.

30
SECTION 2.3: ADOLESCENT EXAM
History:

Leading causes of death:

1) Accidental injuries MVAs, firearms, etc
2) Homicide
3) Suicide

Leading causes of morbidity:

1) Sexually transmitted infections
2) Mental health issues
3) Substance use/abuse
4) Obesity

TIP: Respecting the below keys will greatly enhance the

interview.
1) Confidentiality
2) Autonomy Ensure that you get a chance to speak with teens on
their own once older than 14-15.
3) Understanding Intellectual capacity and overall maturity varies,
ensure you speak with teens at their level.

HEADSS Template:

H ome
How are things at home?
Who lives at home with you?
Have there been any changes at home lately?
Have you ever run away from home?

E ducation
Name of school
Current grade
Academic performance
Amount of school days missed
Behaviour at school
bullying

A ctivities
What do you do when you arent at school?
exercise/play sports
Hobbies
31
 Social groups
Do you go out to parties/clubs a lot? Part time work? How
do you pay for the things you do?

D rugs
Do you have any friends who smoke or use drugs?
What would/does your family think if they knew that? What
do you think about it?
Have you ever tried smoking or drinking alcohol? What did
you think? What about other drugs?
Have you ever gotten into trouble because of using these
substances?
S exuality:
Questions about sexual development or sexuality
Current/Past sexual activity
Age of first intercourse
Sexual orientation (M/F/B)
Number of total partners
History of STI
History of pregnancy
Contraception use
o Is it used every time and used properly
History of sexual abuse
S uicide and mental health
How is your mood? (SIGECAPS).
Suicide assessment
o Past attempts
o Protective factors
o Current plan and means to carry it out

Physical Exam:

Many adolescents present to the physician for annual well

check-ups. A general head to toe screening physical should
be conducted with focus on any problems suggested by the
history.
The structure of the physical examination will be identical to
the adult physical examination.

32
SECTION 3.1: SCREENING FOR DEVELOPMENTAL/
BEHAVIOURAL ABNORMALITIES

History:

Full history as per the outline in section 1.

o Start open ended and broad and then focus in with
the following key areas:
1) Milestones to date
2) Current performance/changes in
performance
3) Behaviour
4) Attention span
5) Neurological functioning
6) Perinatal history
Milestones:
o Screen for red flags
Gross Motor not walking by 18 mths
Fine Motor Early handedness (<10 mths),
no pincer at 1 year
Language <3 words at 18 mths
Social/Cognitive No interest in peek-a-
boo by 9 mths, not pointing by 18 months.
o Please refer to Appendix 7 for a list of many of the
major milestones. Always remember that there is a
range of normal
Current performance/Changes in performance
o School performance if applicable
Grades, teacher comments
o Plateau, delay, regression of functioning.
o Important to isolate if the child is delayed in only one
or if they are globally delayed.
Behaviour
o Focus on different situations and how the child does
Dinner time, homework, chores, line-ups.
o Always watch child behaviour throughout interview
o Hyperactivity/Impulsivity Symptoms
Fidgeting, squirming in seat
Leaves seat when should stay seated
Runs/climbs things when should not
Difficulty doing quiet activities
Described as on the go or driven by
motor
Excessive talking
33
 Blurts out answers out of queue
Can not wait own turn
Interrupts or intrudes on others
Attention Span
o Inattentive Symptoms
Difficulty with attention during tasks/play
Does not seem to listen even when spoken
to directly
Fails to finish schoolwork/chores/duties
Makes careless mistakes
Difficulty organizing tasks
Avoids/dislikes tasks that require sustained
mental effort
Easily distracted by external stimuli
Forgetful
Neurological functioning/Review of systems
o Nutritional deficiencies
o Medication in the present/past
o Neurological Assessment:
Head trauma
Seizures
Loss of consciousness
Unusual movements
Headaches
o Visual Assessment:
follow objects
hold objects close to face when playing
crossed eyes
unusual eye movements.
o Hearing Assessment
Startle to loud noises
Response to name
Past ear infections
Past formal hearing tests
Perinatal History
o Asphyxia or trauma at birth
o Neonatal Intensive Care Unit (NICU) stay
Family History
o Developmental concerns in any siblings
o Parental developmental history and any delays
o Consanguinity
Social History
o As per the general history in section 1.

34
Physical Exam:

the key is to play with the child to see how he/she interacts
and what they are able to do.

TIP: This exam often takes much longer then the standard
physical and should never be rushed.

Start by watching the child dress and undress if age

appropriate
o Can assess many of the developmental milestones
in this way and avoid having to formally test them.
Set up games and toys with which you can get a good
screen of all the major developmental categories
o Gross motor any toys and a few simple tasks can
quickly assess gross motor functioning
o Fine motor the classic test is done using blocks or
drawing/coloring. Even if dont do anything formal,
can quickly screen with these measures to assess
fine motor function.
o Language attempt to engage the child at the
proper level. Care must be taken not to be overly
invasive with questions before the child feels
comfortable with you.
o Social assess throughout interaction. Focus on
interactions with both the examiner(s) and parent(s).
o Cognitive make sure that expectations with this
portion especially are age sensitive as asking too
much may frustrate the child and hurt the
interaction.
Exploration will they investigate new
things presented to them
Object Permanence will they uncover
toys if covered
Cause and effect relationship
Functional play
Imaginative play
Validated testing if concern

TIP: Look for strengths as well as weaknesses and focus on each

area of development to assess if there is a focal or global
abnormality as this will alter the differential diagnosis.

35
APPENDICES

36
APPENDIX 1: VITAL SIGNS
Neonate 90-160 bpm
3-12 Months 100-190 bpm
HEART
1-2 Years 90-150 bpm
RATE
3-11 Years 60-130 bpm
12-15 Years 60-120 bpm

Neonate 30-60 /min

Infant 24-40 /min
RESPIRATORY
Preschool 22-34 /min
RATE
School Age 18-30 /min
Adolescent 12-16

BLOOD PRESSURE:
There is more to the determination of blood pressure then just the
measurement itself. The definition of high blood pressure for each
age is defined at a systolic and/or diastolic blood pressure greater
th
than or equal to the 95 percentile for both age and height
percentile. Below, we have provided a general guideline of the blood
pressure ranges. You can find the complete tabulated ranges for
blood pressure in the paediatric population in The Fourth Report on
the Diagnosis, Evaluation, and Treatment of High Blood Pressure in
Children and Adolescents

Quick Reference BP Levels by age.

1 year 100/50 mm Hg
5 years 105/70 mm Hg
10 years 110/75 mm Hg
15 years 120/80 mm Hg

Tip: A back of the envelope calculation of BP ranges:

sBP = 80 + 2 X age
dBP = 2/3 X sBP

37
APPENDIX 2a: CONGENITAL HEART DISEASE

Acyanotic CHD Cyanotic CHD

Left to Right Shunt Obstructive Decreased Pulmonary Flow Increased Pulmonary Flow
Ventricular 30-50% of all CHD. Coarctation of Narrowing of aorta at Tetology of 10% of all CHD. Transposition of 3-5% of all CHD.

38
Holosystolic murmur. ductus arteriosis. Consists of VSD + Pulmonary and
Septal Defect Aorta Fallot The Great
Ranges from BP/pulse in arms > RVOTO + overriding Systemic circulations
assymtpomatic to BP/pulse in legs. aorta + RVH. Boot Arteries are in parallel. Initial
severe CHF. Treatment with shaped heart on CXR. treatment with PGE
Treatment varies from Balloon or surgical Treatment with infusion to maintain
spontaneous closure correction surgical repair PDA until surgical
to surgery. correction
Atrial Septal 6-8% of all CHD. Aortic Stenosis Ranges form Hypoplastic Left 1-3% of all CHD.
SEM LUSB. May asymptomatic to Most common cause
Defect Heart
close spontaneously CHF. SEM URSB. of death from CHD.
Treatment with Treat initially with
valvuloplasty or valve PGE to maintain PDA
replacement until surgical
correction
Patent Ductous 5-10% of all CHD Pulmonary SEM ULSB.
Arteriosis (>1/3 of VLBW). Stenosis Commonly associated
Continuous murmur with other lesions.
at left infraclavicular Treatment with
area. Closure with balloon valvuloplasty
indomethicin,
catheter, or surgical
ligation
AV Canal Variable severity.
Associated with
Defect
Trisomy 21. Repaired
surgically
*CHD=congenital heart disease, CHF=congestive heart failure, SEM=systolic ejection murmur, LUSB=left upper sternal border, URSB=upper right sternal border, ULSB=upper left sternal border,
VLBW=very low birth weight, VSD=ventricular septal defect, RVOTO=right ventricular outflow tract obstruction, RVH=right ventricular hypertrophy, CXR=chest Xray, PGE=prostaglandin E1,
PDA=patent ductous arteriosis
APPENDIX 2a: CARDIAC MURMURS

39
APPENDIX 3 COMMON DERMATOLOGIC LESIONS OF THE
NEONATE

Common Skin Lesions in Newborns

Vernix Caseosa Latin meaning cheesy varnish. It is
a greasy substance that coats the
skin in utero and may still be on skin
after birth. Normal sebaceous gland
secretions.
Skin changes in post maturity Normal to get some skin
dryness/flakiness
Angiomatous Lesions Salmon Patch - transitory macular
capillary hemangiomas of the eyelids
and neck (Angel Kiss & Stork Bite)
Milia Superficial epidermal inclusion cysts
that contain laminated keratinized
material. The lesion is a firm papule,
12mm in diameter, and pearly,
opalescent white. On the face,
gingivae and mid-palate (Epstein
Pearls)
Petechiae Commonly seen on face with vertex
vaginal delivery or on buttocks with
breech presentation. Pinpoint size,
do not blanch with pressure.
Generalized petechiae may suggest a
coagulopathy or sepsis with DIC.
Erythema Toxicum Benign rash, usually subsides after
VERY COMMON one week, contains eosinophils, on
face, trunk and extremities. Small,
white, occasionally vesiculopustular
papules on an erythematous base
Pigmented Lesions Slate blue/grey spots over the back
VERY COMMON and buttocks (in up to 50% of black,
native American and Asian infants)
Caf-au-lait spots - <5 is normal,
>5-6 may be a sign of
neurofibromatosis.
Unpigmented Lesions Tuberous sclerosis ash leaf
NOT COMMON depigmented lesion. May be the
earliest sign of disease. Using a
Woods lamp my intensify a suspected
lesion and help reveal more lesions.
Sebaceous Hyperplasia Minute, profuse, yellow-white papules
are frequently found on the forehead,
nose, upper lip, and cheeks. (cradle
cap)

40
APPENDIX 4: PRIMITIVE REFLEXES
Reflex Procedure Age at Significance of
Disappearance positive test
Palmar Grasp Press against 3-4 months Asymmetrical
the palmar suggests an
surface of the anomaly
hand and the (central or
infant should peripheral)
flex the fingers Try with
sucking as this
can help elicit,
if still absent,
more likely
peripheral
lesion.
Sucking Place finger 2- Variable Absent in
3 cm in the premature
infants mouth infants and
and they generalized
should start to CNS
suck depression.
Rooting Stroke the 2-3 months Generalized
perioral skin at CNS
the corners of depression.
the mouth and
the infant
should turn
and open
mouth to
stimulated
side.
Gallant Stroke to either 2-3 months Absent in
side of the diffuse CNS
spine and the disturbance.
infant should (e.g. Cerebral
laterally flex to Palsy)
the stimulated
side (concavity
on stimulated
side)
Moro Sudden 4-6 months Absent in
movement of serious CNS
the head disturbances
causes Asymmetric in
symmetric Erbs palsy and
abduction and clavicular
extension of the fractures.
arms followed

41
 by adduction
and flexion.
Asymmetric With the infant 4-6 months A constantly
Tonic Neck supine, turn the (not present present/
Reflex (Fencing head to one until 2 weeks of persistent, well
Reflex) side, this should age) marked tonic
lead to neck reflex may
extension of the be a sign of
extremities to CNS
the side of the dysfunction.
face and flexion Absent in
of the severe CNS
extensions on insults with
the opposite hypotonia.
side.
Landau Reflex Suspend the 4-6 months Persistence
infant in prone may indicate
position, The delayed
head should lift development.
up and the
spine should
straighten.
Positive Support Stimulate the 2-3 months Lack suggests
ball of one foot hypotonia.
and this should Fixed extension
lead to co- and adduction
contraction of of legs
opposing (scissoring)
muscle groups suggests
allowing weight spasticity due to
bearing. neurologic
disease.
Stepping/Placing Dorsal surface Variable Absent in
Reflex of one foot (usually best severe diffuse
touches the seen after 4 CNS
underside of a days) disturbance
table and this (paralysis)
stimulates the **babies born
infant to place breech may not
the foot on the have this reflex.
table
Parachute Suspend the Onset: 4-6 Delay in
Reflex infant prone and months and appearance
slowly lower the does not may predict
head toward a disappear. future delays in
surface. The voluntary motor
arms and legs development.
will extend in a
protective
fashion

42
APPENDIX 5: APGAR SCORING
Apgar Evaluation of Newborn Infants
Sign 0 1 2
Heart rate Absent Below 100 Over 100
Respiratory Absent Slow, irregular Good, crying
effort
Muscle tone Limp Some flexion of Active motion
extremities
Response to No response Grimace Cough or
catheter in sneeze
nostril (tested
after
oropharynx is
clear)
Color Blue, pale Body pink, Completely pink
extremities blue
Sixty seconds after complete birth of the infant (disregarding the
cord and placenta), the five objective signs above are evaluated,
and each is given a score of 0, 1, or 2. A total score of 10 indicates
an infant in the best possible condition. An infant with a score of 0
3 requires immediate resuscitation.

43
APPENDIX 6: COMMON CONGENITAL DISORDERS:
Congenital Clinical Features
Disorder
Downs Syndrome Trisomy 21
most common autosomal chromosomal abnormality
(1:600-800); associated with advanced maternal age
Physical: upslanting palpable fissures, epicanthal folds,
flat occiput, microcephaly, small midface, speckled iris
(Brushfield spots), low set ears, prominent tongue, single
palmar crease, exaggerated gap between 1st and 2nd toes
Internal: Devel delay, Congenital Cardiac defects (AVSD),
Duodenal (GI) atresia, TE fistula, Hypotonia,
cryptochordism, leukemia, early onset alzheimers,
hypothyroidism, frequent AOM, hearing loss,
DiGeorge Syndrome 2nd most common genetic diagnosis
CATCH 22 - Cyanotic CHD - various types, most
commonly tetralogy of fallot and VSD: Anomalies;
micrognathia and low set ears: Thymic hypoplasia -
recurrent infections: Cognitive impairment:
Hypoparathyroidism - Hypocalcemia: 22q11
microdeletion
Turner Syndrome 45X (or mosaic XO/XXX, XO/XX, etc.)
Often diagnosed due to pubertal delay and/or short stature
Physical: low posterior hairline, broad chest with wide
spaced nipples, short webbed neck, prominent ears, short
4th metacarpal/metatarsal, cubitis valgus (congenital
elbow flexion, short stature
Internal: generally normal intelligence, gonadal dysgenesis
with primary amenorrhea, lymphedema in newborn, high
risk of coarctation of aorta
Rx: Education, growth hormone, estrogen at pubertal age,
gonad removal if 'Y' chromosome in mosaic
Noonan Syndrome "Male Turner syndrome" ALTHOUGH OCCURS IN
FEMALES AS WELL
Autosomal dominant
More MR than turner's, Pulmonary stenosis more
common, normal menstrual cycle in girls, boys may
require testosterone
Klinefelter 47XXY, associated with advanced maternal age
Syndrome Absent puberty, mild MR, long limbs, infertility,
gynecomastia, behavioural issues and impulse control
problems
Rx: Testosterone in adolescence

44
Fragile X Most common cause of developmental delay in boys
CGG repeats on X chromosome
Prominent jaw, forehead, and ears; long narrow face,
macroorchidism; hyperextensibility, mitral valve prolapse,
ADHD and/or autism, MR
Prader-Willi 15q11 imprinting defect due to paternal deletion or
Syndrome maternal uniparental disomy
Hypotonia, hypogonadism, Hyperphagia, obesity, short,
small hands and feet, DM 2, variable developmental delay
Angelman Syndrome 15q11 imprinting defect due to maternal deletion or
paternal uniparental disomy
"Happy puppet" (uncontrollable laughter), severe devel
delay, seizures, hypotonia, midface hypoplasia
CHARGE Coloboma, Heart disease, choanal Atresia, Retardation
Association (mental and growth), GU anomalies, Ear anomalies
VACTERL Verterbral dysgenesis, Anal atresia, Cardiac anomalies,
Association TE fistula, Renal & Radial anomalies, Limb anomalies

45
 APPENDIX 7: DEVELOPMENTAL MILESTONES
Age Gross Motor Fine Motor Language Cognitive Social/ ADLs
Behavioural
2 wks Some tone,
does not slip
through
hands
4 wks Head control Hands in Cries w/ loud Prefer to look
turns head fists noise at faces
side to side Listens to
while lying speech
down
6 wks Head control Smiles
while held up. appropriately
2 mths Extended Reaches/ Stares at spot Follows
forward bats at where object moving people
objects was placed if with eyes
quickly
removed or
covered.
3 mths Push up Grasp (4th Coos Smiles
prone on & 5th Recognizes socially and to
arms fingers) moms voice familiar voices
Turns head Brings toys
Can bear to midline
weight with
locked knees
when held
around chest
100%
4 mths Log roll (front Grasp Coos, Stares at own
Depende
back) objects if squeals, hand
nt
Sits if midline gurgles
propped up with both
by pillows hands
Stands with Whole
support at hand
hands grasp
w/out
thumb
5 mths Log rolls Reaches Laughs, Responds to
both direction for toys coos, NO
gurgles
Notices new
sounds
6 mths Sits Transfer Babbles, Uses babbles/ Raises arms
unsupported objects responds to sounds to for up
Plays w/ feet from hand- tone express Enjoys social
hand changes in emotions play.
Ulnar voices Stranger
grasp anxiety starts
7 mths Belly crawl Starts to May try to Responds to
Plays while grasp with imitate simple one
sitting thumb speech step
May attempt commands
pull to stand Gestures to
Stands on express
tiptoes when emotion
46
 supported at
hands
8 mths Full crawl Ba Da Ka Uncovers toy
Sit up on Imitates if covered by
knees something
9 mths Pull to stand Early Recognizes Games Pat-
+/- cruise w/ 2 pincer with words (e.g. a-cake
hands & body straight bottle) Peek-a-boo
semi-turned wrist Responds to Waves bye
Falls to sit name
from stand
10 Plays while Mama, Dada Shouts for
mths standing Responds to attention
Can lower simple
self to sit commands
12 Walks (or Overhand 2-3 words Imitates Use
mths very close) pincer other than during play sippy
Stands grasp w/ mama, dada cup
unsupported wrist Recognizes
extension more words
(Cheerio Imitates
test) speech
15 Walks without Scribble Jargon Points to
mths support Build 2 needs/wants
cube tower
Draw lines
18 Stairs 2 Build 3 10-20 words Pretend play Eats with
mths feet/step with cube tower Follows with object spoon
help some (but
advancing messy)
commands
21
mths
24 Stairs 2 Build 6 Combines Make believe Temper Takes off
mths feet/step cube tower words play tantrums socks
w/out help 25% Points to Parallel Play and
Runs intelligible object/ picture shoes/
Kicks ball when named. helps
dress
2.5 yrs 50%
intelligible
3 yrs Tricycle Turn book Sentences, Toilet
Stands on page one plurals training
one foot @ a time 75%
Stairs 1 Copy circle intelligible
foot/step & cross Counts to 10
4 yrs Hops on one Draw Tells stories Cooperative/
foot circles & Knows Interactive
squares colors play
5 yrs Bike Draw Knows Zippers
Skips triangles alphabet and
Future tense buttons

47
APPENDIX 8 CURRENT IMMUNIZATION SCHEDULE

http://www.health.gov.on.ca/en/public/programs/immunization/docs/schedule.pdf
(ONTARIO)

1. Haemophilus influenzae type b vaccine is not necessary for

children older than 5 years of age.
2. Rotavirus vaccine: 2 oral (by mouth) doses should be given at
least 4 weeks apart and both doses must be given before 25
weeks of age.
3. Measles, Mumps, Rubella (MMR) vaccine: should be given on or
after the first birthday.
4. Hepatitis B vaccine: 2 doses offered to all grade 7 students
through school and community clinics.
5. Human Papillomavirus vaccine: 3 doses offered to all grade 8 girls
through school and community clinics.
6. Adults, 19 to 64 years of age, who missed their diphtheria,
tetanus, whooping cough vaccine given between 14 to 16 years of
age can get one dose as an adult to replace a diphtheria, tetanus
vaccine that adults receive every 10 years.
7. Influenza vaccine is recommended for all individuals 6 months of
age and older.
* Immunization against these diseases is required for school.

48
APPENDIX 9: ASSESSMENT OF SEVERITY OF DEHYDRATION
Mild Moderate Severe

2 years of age 5% weight loss 10% weight loss 15% weight loss

>2 years of age 3% weight loss 6% weight loss 9% weight loss

Pulse Normal Rapid Rapid, Weak

Blood pressure Normal Normal/Low Shock

Urine output Decreased Markedly Anuria

decreased

Buccal Mucosa Slightly Dry Dry Parched

Anterior Fontanel Normal Sunken Markedly sunken

Eyes Normal Sunken Markedly sunken

Skin Turgor Normal Decreased Tenting

Skin Normal Cool Cool/Mottling/

Acrocyanosis +
increased capillary
refill time

*** Be cautious as hypernatremia may mask some of the usual signs

and symptoms of dehydration.

49
APPENDIX 10: TANNER STAGING
FEMALE
1. Breast Staging
Stage 1
Prepubertal Elevation of papilla only
Stage 2
Enlargement of the areola and elevation of the breast
and papilla (Breast Buds)
Stage 3
Enlargement of the breast and areola with no separation
of contour
Stage 4
Areola and papilla form a second mound above the
breast
Stage 5
Mature Breast, even contour, no second mound.

2. Pubic Hair Staging

Stage 1
No hair, prepubertal
Stage 2
Sparse, long, straight, slightly pigmented hair along the
labia majora.
Stage 3
50
 Hair becomes darker, curlier and coarser with increased
distribution and density on pubes.
Stage 4
Adult-type hair limited to pubes with no extension to the
medial aspect of the thigh.
Stage 5
Mature distribution of inverse triangle with spread to
medial thighs.

MALE
1. Genitals (testicles and penis)
Stage 1
Prepubertal
Stage 2
Enlargement of testes (>4 mL volume) and scrotum with
reddening of scrotal skin.
Stage 3
Growth of penis, primarily in length, with further increase
in testicular and scrotal size.
Stage 4
Further increase in penile length and circumference with
development of glans, increase in testicular and scrotal
size.
51
 Stage 5
Adult size and shape.

2. Pubic Hair
Stage 1
Prepubertal
52
 Stage 2
Sparse, long, straight, slightly pigmented hair at penile
base.
Stage 3
Darker and curlier with increased distribution on pubes.
Stage 4
Adult-type hair limited to pubes with no spread to medial
thighs.
Stage 5
Mature distribution with spread to medial thighs and up
to lower abdomen.

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APPENDIX 11: FEEDING SCHEDULE

Breast is best for the first 6 months. Support breastfeeding for

up to two years or beyond, as long as mother and child want to
continue.
Supplemental vitamin D is recommended for infants and young
children who are breastfed or receiving breastmilk.
Complementary feeding, along with continued breastfeeding,
provides the nutrients and energy to meet the needs of the
older infant. Gradually increase the number of times per day
that complementary foods are offered while continuing to
breastfeed. Food that is iron-rich (such as meats, meat
alternatives, and iron-fortified cereals) should be the first
complementary foods offered
Responsive feeding promotes the development of healthy
eating skills. This means follow the child's cues, encourage self-
feeding, and encourage the use of an open cup
Iron-rich complementary foods help to prevent iron deficiency.
From one year of age, young children begin to have a regular
schedule of meals and snacks. Generally follow the advice in
Canadas Food Guide
When the child turns 12 months of age, then parents can give
homogenized milk. At 2 years of age, children can be
transitioned to the 'family milk' and no longer need the full
3.25% MF.
There is no need to delay the introduction of so-called highly
allergenic foods such as peanuts, eggs and fish.

Reference:

http://www.cps.ca/en/documents/position/nutrition-healthy-term-
infants-6-to-24-months

54
APPENDIX 12: GROWTH CHARTS

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 References

Behrman, Richard E. Nelsons Textbook of Paediatrics, Saunders,

2003

Bickley, Lynn S; Szilagyi, Peter G.; Bates' Guide to Physical

th
Examination and History Taking, 8 edition, Lippencott, 2002

Butalia, S.; Ko, H.;Lam, C. Tan, J; Essentials of Clinical Examination

Handbook, The Medical Society, Faculty of Medicine, University of
Toronto, 2002

****Goldbloom, Richard B. Pediatric Clinical Skills, Saunders (W.B.)

Co Ltd., 2002

Heng, M., Greenwald, A. Toronto Notes 2007, Type and Graphics,

2007

Schwartz, M. William 5-Minute Pediatric Consult, Lippencott,

Williams and Wolcott, 2005

www.cdc.gov/growthcharts

www.health.gov.on.ca/english/providers/program/immun/pdf/schedule.pdf

www.uptodate.com

**** Suggested reading for more in depth elaboration of the

paediatric history and physical examination.

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