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First Nations & Inuit Health

Pediatric and Adolescent Care - Chapter 1 - Pediatric Health Assessment

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First Nations and Inuit Health Branch (FNIHB) Pediatric Clinical Practice Guidelines for Nurses in Primary Care

The content of this chapter has been reviewed August 2009

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The clinical assessment of infants and children differs in many ways from that for adults. Because children are growing and developing both physically and mentally, values for parameters such as dietary requirements and prevalence of disease, expected normal laboratory values and responses to drug therapy will be different from those observed in adults.

Health Maintenance Requirements

Healthy children should have regular health maintenance visits, often done at well-baby clinics. Such visits customarily occur at 1 and 2 weeks of age, at 1, 2, 4, 6, 9, 12 and 18 months of age, and subsequently at 1- or 2-year intervals.

At each visit, the child should undergo an appropriate history, physical examination and developmental assessment. Immunizations should also be given according to provincial guidelines. Anticipatory guidance should be provided about the following topics:

  • Appropriate nutrition
  • Safety measures (see "Pediatric Prevention Activities" in the chapter, "Pediatric Prevention and Health Maintenance")
  • Expected developmental and behavioural events

In addition, an assessment should be made of the quality of physical care, nurturing and stimulation that the child is receiving.

The most important components that should be assessed at each health maintenance visit are shown in Table 1.

Table 1: Components of Well-Child Assessments at Various Ages
Health Parameter Most Important Ages for Assessment
Height, weight Every visit, from birth to 16 years of age
Head circumference Every visit in the first 2 years of life
Growth chart plotting Every visit
Blood pressure Once in the first 2 years, then every year starting at age 3Footnote 1
Eye assessment Every visit in the first year of life, then every well-child visit
Strabismus assessment Every visit in the first year of life, then every well-child visit
Visual acuity testing Initial screening (for example, Snellen chart) at 3-5 years of age; every 2 years between 6 and 10 years of age, then every 3 years until 18 years of age
Dental assessment Every visit
Speech assessment Every visit
Developmental assessment* Every visit
Sexual development Every visit
School adjustment Every visit after child reaches school age
Chemical abuse Consider during assessments of children > 8 years of age
Immunizations According to provincial schedule: often at 2, 4, 6, 12 and 18 months and at 4-6 and 14-16 years
Hemoglobin Screen at 6-12 months
Safety counselling Every visit
Nutrition counselling Every visit
Parenting counselling Every visit
Parent/caregiver-child interactions Every visitFootnote 2

* Formal developmental testing is done only if there is a concern on the part of the parents or caregiver or the health care professional. Refer to the appropriate primary health care provider (for example, speech-language pathologist, physician, psychologist) for assessment.

The Rourke Baby Record (RBR), revised 2009, is an evidence-based health supervision guide for primary health care practitioners of children in the first 5 years of life.

The forms are available from the Next link will take you to another Web site Rourke Baby Record web site.

  • Rourke Baby Record 2009: Evidence-based infant/child health maintenance guides I-IV (birth to 5 years) and immunization record

The Next link will take you to another Web site Greig Health Record is an evidence-based child and adolescent health promotion guide for primary health care practitioners caring for children aged 6 to 17 years.

Pediatric History

Tips and Techniques

Children

Children who can communicate verbally should be included as historians, with additional details provided as necessary by parents or caregivers. Health care professionals should interact (for example, smile, coo) or play with children so as to not scare them or make them cry.

Questions, explanations and discussions occurring with children present should take into account their level of understanding. Young children may be assisted in providing details of the history by such techniques as having them play roles or draw pictures. The interviewer should gain an understanding of the child's terminology for various body parts.

Adolescents

Adolescents should be granted privacy and confidentiality.

  • Interview the adolescent alone
  • Discuss with parents or caregiver separately, with the adolescent's permission

Components of the Pediatric HistoryFootnote 3

The pediatric history includes many of the same components as the adult history, including:

  • Identifying data
  • Chief complaint
  • History of present illness
  • History of past illnesses
  • Allergies
  • Medication history
  • Tobacco, alcohol and/or drug use
  • Family history
  • Personal and social history (including grade level, family of origin, interests, lifestyle)
  • Review of systems

In addition, the pediatric history should include the following information:

  • Who the primary caregiver is
  • Who is providing the history
  • Pregnancy and perinatal history
  • Birth history, including Apgar score
  • Immunization history
  • Detailed dietary history for the first year of life, including history of vitamin supplements and fluoride use. Also include dietary intake for other age groups, including how much tea, carbonated beverages and juice are being consumed
  • Developmental history (including physical, cognitive, language, social and emotional)
  • Social history, including questions about how many people live in the home, recent separations, deaths, family crises, friends, peer relationships, daycare arrangements, progress in school, smoking in the home and secure food access for child and family
  • Physical environment at home, including presence of mold and poor heating or insulation

Physical Examination of the Newborn

Observe the entire infant at the beginning of the examination, before the assessment of specific organ systems. It is important that the infant be completely undressed and in a warm environment with adequate illumination.

General Appearance

Assess the following:

  • Level of consciousness, alertness, general behaviour and appearance (how well the baby looks)
  • Symmetry of body proportions
  • Posture of limbs (flexed, extended)
  • Body movements (for example, arms and legs, facial grimace)
  • State of nutrition and hydration
  • Colour
  • Any sign of clinical distress (for example, respiratory distress includes dyspnea, pallor, cyanosis, irritability)

Vital Signs

Average values of vital signs for newborns:

  • Temperature 36.5°C to 37.5°C
  • Heart rate 120-160 beats/minute
  • Respiratory rate 30-60/minute, up to 80/minute if infant is crying or stimulated
  • Systolic blood pressure 50-70 mm Hg

Growth Measurements

Measure and record length, weight and head circumference. If the infant appears premature or is unusually large or small, assess gestational age (see Table 3, "Assessment of Gestational Age").

  • Average length at birth 50-52 cm
  • Average weight at birth 3500-4400 g
  • Average head circumference at birth 33-35 cm (this is done only at well-child visits unless hydrocephalus is suspected)

These parameters should be recorded on gender-appropriate growth curves, which should form part of the child's health record. Printable electronic versions of the growth charts are available at:

Growth chart for boys :

Growth chart for girls:

For additional information about growth measurements, see "Growth Measurement" in the chapter, "Pediatric Prevention Activities and Health Maintenance."

Skin

Colour

  • Pallor associated with low hemoglobin or vasoconstriction (for example, in shock)
  • Cyanosis associated with hypoxemia
  • Plethora associated with polycythemia or vasodilation
  • Cherry red face associated with carbon monoxide poisoning
  • Jaundice associated with elevated bilirubin

Lesions

  • Milia: Pinpoint white papules of keratogenous material, usually on nose, cheeks and forehead, which last several weeks and then spontaneously resolve
  • Miliaria: Obstructed eccrine (sweat) ducts appearing as pinpoint vesicles on forehead, scalp and skin folds; usually clear within 1 week
  • Transient neonatal pustular melanosis: Small vesicopustules, generally present at birth, containing white blood cells (WBCs) and no organisms; intact vesicle ruptures to reveal a pigmented macule surrounded by a thin skin ring; spontaneously resolves by 3 months of age
  • Erythema toxicum: Most common newborn rash, consisting of variable, irregular macular patches and lasting a few days
  • Stork bite: Pink and flat nevus simplex, usually on face or back of the neck; those on face usually disappear by 18 monthsFootnote 4
  • Caf au lait spots: Irregular brown, flat macules. Suspect neurofibromatosis if there are many (more than 5 or 6) large spots
  • Mongolian spots: dark bluish/purplish patches present at birth, usually on back and buttocks but may be on limbs; common in First Nation's and Inuit children; usually fade away in first year of life

Head and Neck

Head

Check for:

  • Overriding sutures
  • Anterior and posterior fontanelles (size, consistency, bulging or sunken)
  • Abnormal shape of head (for example, caput succedaneum, molding, cephalohematomas, encephaloceles, microcephaly)
  • Bruising of head, behind the ears or periorbitally

Measure head circumference.

Eyes: Inspection

  • Check cornea for cloudiness (sign of congenital cataracts)
  • Check conjunctiva for erythema, exudate, orbital edema, subconjunctival hemorrhage, jaundice of sclera
  • Check for pupillary size, shape, equality and reactivity to light (PERRL: pupils equal, round, reactive to light), accommodation normal
  • Red reflex: hold ophthalmoscope 15-20 cm (6-8 inches) from the eye and use the +10 diopter lens. If normal, the newborn's eye transmits a clear red colour back; black dots may represent cataracts; a whitish colour may suggest retinoblastoma

Ears: Inspection

  • Check for asymmetry, irregular shape, setting of ear in relation to corner of eye (low-set ears may suggest underlying congenital problems such as renal anomalies, fetal alcohol spectrum disorder or Down's sydrome)
  • Look for fleshy appendages, lipomas or skin tags
  • Dimples may suggest a brachial cyst
  • Perform otoscopic examination; check canals for discharge and colour, and tympanic membranes for colour, brightness, perforation, effusion, bony landmarks and light reflex

Nose: Inspection

  • Look for nasal flaring, which is a sign of increased respiratory effort
  • Look for hypertelorism or hypotelorism (increased or decreased space between eyes)
  • Check for choanal atresia (posterior nasal passage blockage uni- or bilaterally), as manifested by respiratory distress. Neonates are obligate nose breathers, so first check to determine if air is coming from nostrils; if not and choanal atresia is suspected, a soft nasogastric tube can be passed through each nostril to check patency

Palate: Inspection and Palpation

  • Check for defects, such as cleft lip (some may have a membrane covering the cleft so it may not be obvious) and palate or a high arched palate

Mouth: Inspection

  • Observe size and shape of mouth
  • Microstomia (small mouth): seen in trisomy 18 and 21
  • Macrostomia: seen in mucopolysaccharidosis
  • "Fish mouth": seen in fetal alcohol syndrome
  • Epstein pearls: small white cysts containing keratin, frequently found on either side of the median line of the palate (benign)

Tongue: Inspection

  • Macroglossia: indicates hypothyroidism or mucopolysaccharidosis

Teeth: Inspection

  • Natal teeth (usually lower incisors) may be present
  • Risk of aspiration if these are attached loosely

Chin: Inspection

  • Micrognathia (abnormally small lower jaw) may occur with Pierre Robin syndrome, Treacher Collins syndrome and Hallerman-Streiff syndrome

Neck: Inspection

  • Symmetry of shape
  • Alignment: torticollis is usually secondary to sternocleidomastoid hematoma
  • Tracheal tug: can occur with dyspnea
  • Neck mass (cystic hygroma is the most common type)

Neck: Palpation

  • Palpate all muscles for lumps and the clavicles for possible fracture
  • Neck range of motion for nuchal rigidity: decreased movement may be present in meningitis
  • Lymph nodes cannot usually be palpated at birth; their presence usually indicates congenital infection

Respiratory System

Vital Signs

  • Respiratory rate

See normal values in "Vital Signs," above.

Inspection

  • Cyanosis, central or peripheral (transient bluish colour may be seen in extremities if infant is cooling off during the examination)
  • Respiratory effort, rate and pattern (for example, periodic breathing, gasping, periods of true apnea)
  • Observe chest movement for symmetry and retractions
  • Anatomical abnormalities of chest (for example, pectus excavatum)
  • Use of accessory muscles, tracheal tug, indrawing of intercostal or subcostal muscles

Palpation

  • Any abnormal masses (palpate gently)
  • Breasts may be slightly enlarged secondary to presence of maternal hormones

Auscultation

  • Breath sounds
  • Inspiratory to expiratory ratio
  • Adventitious sounds (for example, stridor, crackles, wheezes, grunting)

Percussion is of little clinical benefit and should be avoided, especially in low-birth-weight or preterm infants, as it may cause injury (for example, bruising, contusions)

Cardiovascular System

Vital Signs

  • Heart rate
  • Blood pressure in upper and lower extremities

See normal values in "Vital Signs," above.

Inspection

  • Colour: pallor, cyanosis, plethora

Palpation

  • Locate usual point of maximal impulse (PMI) by positioning one finger on the chest, in the fourth intercostal space medial to the midclavicular line
  • Abnormal location of PMI can be a clue to pneumothorax, diaphragmatic hernia, situs inversus viscerum, congenital heart disease or other thoracic problem
  • Capillary refill (< 2 seconds is normal)
  • Peripheral pulses: note character of pulses (bounding or thready; equality); any decrease in femoral pulses or radial-femoral delay may be a sign of coarctation of the aorta

Auscultation

  • Note rate and rhythm
  • Note presence and quality of S1 and S2 heart sounds
  • Assess for S3 and S4: S3 may be a normal finding in infants and children3
  • Note presence of murmurs (consider murmurs pathologic, as in congenital heart defects, until proven otherwise)

Abdomen

Inspection

  • Shape of abdomen: flat abdomen may signify decreased tone, presence of abdominal contents in chest or abnormalities of the abdominal musculature
  • Contour: note any abdominal distension
  • Masses
  • Visible peristalsis
  • Diastasis recti
  • Obvious malformations (for example, bowel contents outside of abdominal cavity [omphalocele]; this abnormality has a membranous covering [unless it has been ruptured during delivery], whereas gastroschisis does not)
  • Umbilical cord: count the vessels (there should be one vein (large and thin-walled) and two arteries (small and thick-walled); note colour, any discharge

Auscultation

  • Bowel sounds

Palpation

  • Check for any abnormal masses
  • Liver and spleen: it may be normal for the liver to be located about 2 cm below the right costal margin; spleen is not usually palpable; if it can be felt, be alert for congenital infection or extramedullary hematopoiesis
  • Kidneys: should be about 4.5-5 cm vertical length in the full-term newborn
  • Techniques for kidney palpation: place one hand with four fingers under the baby's back, then palpate by rolling the thumb over the kidneys; or place the right hand under the left lumbar region and palpate the abdomen with the left hand to palpate the left kidney (do the reverse for the right kidney)
  • Check for hernias: umbilical or inguinal

Percussion usually omitted unless a problem such as abdominal distension is noted.

Inspect the anal area for patency and for presence of fistulas or skin tags.

Genitalia

The genitalia should be carefully assessed, with particular attention to any malformation, abnormalities or sexual ambiguity.

Male Genitalia

Inspection

  • Glans: colour, edema, discharge, bleeding
  • Urethral opening: should be located centrally on the glans (in hypospadias, the opening is found on the undersurface of the penis)
  • Foreskin (prepuce): never force retraction of the foreskin
  • Scrotum: in full-term infant, scrotum should have brownish pigmentation and should be fully rugated
  • Palpation
  • Testes: ensure that both testicles are descended into scrotum. Palpate inguinal area. If one or both are not descended, consult a physician

Female Genitalia

Inspection

  • Check labia, clitoris, urethral opening and external vaginal vault
  • Whitish discharge is often present; this is normal, as is a small amount of bleeding, which usually occurs a few days after birth and is secondary to maternal hormone withdrawal
  • Hymenal tags, if they occur, are normal

Musculoskeletal System

Inspection and Palpation

Spine

  • Check for scoliosis, kyphosis, lordosis, spinal defects, a patch of hair along the spine, meningomyelocele

Upper Extremities

  • Assess the shoulder girdle for injury and the clavicles for fracture (especially if the delivery was traumatic and in large infants with a history of shoulder dystocia)
  • Assess mobility of the shoulder and extension of the elbow
  • Inspect palmar creases for assessment of gestational age (see Table 3, "Assessment of Gestational Age"): they may appear different in some hereditary syndromes
  • Count the fingers

Lower Extremities

  • Assess the feet and ankles for deformity and mobility
  • Count the toes
  • Examine foot creases for assessment of gestational age (see Table 3, "Assessment of Gestational Age")
  • Examine the hips for neonatal hip instability using Ortolani and Barlow maneuvers (see descriptions below). These tests may be somewhat unreliable depending on the examiner's experience, so further assessment may be neededFootnote 5

Ortolani Maneuver

  • Flex the knee and hip
  • Place middle fingers over greater trochanters
  • Position thumbs on medial sides of knees
  • Abduct the hip to 90° by applying lateral pressure with thumb
  • Push forward with the middle fingers that are over greater trochanters
  • If there is a "clunk," the hip may be dislocated

Barlow Maneuver

  • Flex the knee and hip
  • Place thumbs on knees
  • Place middle fingers over greater trochanters
  • Adduct the hip medially and push backward on the knee with thumbs
  • If there is a "clunk" or telescoping sensation, the hip may be dislocatable

Central Nervous System

  • Assess state of alertness
  • Check for lethargy or irritability
  • Posture: For term infant, normal position is one with hips abducted and partially flexed and with knees flexed; arms are adducted and flexed at the elbow; the fists are often clenched, with fingers covering the thumb
  • Assess tone: for example, support the infant with one hand under the chest; the neck extensors should be able to hold the head in line for 3 seconds. There should not be more than 10% head lag when the infant is moved from a supine to a sitting position

ReflexesFootnote 6,Footnote 7

Reflexes are involuntary movements or actions that help to identify normal brain and nerve activity and development. Some are present at birth and serve a variety of purposes, others develop later. Abnormal reflexes - ones that persist after an age they should disappear, or are absent at birth when they should be present - can help identify neurological or motor disease early. See Table 7, "Newborn and Infant Reflexes."

Deep Tendon Reflexes

These are not normally examined in the child under 5 years.

Apgar Store

Apgar scoring is done at 1 and 5 minutes after birth. If necessary, it is repeated at 10 minutes after birth.

Interpretation

At 1 Minute

< 7: depression of nervous system
< 4: severe depression of nervous system

At 5 Minutes

> 8: no asphyxia
< 7: high risk for subsequent dysfunction of central nervous system
5-7: mild asphyxia
3-4: moderate asphyxia
0-2: severe asphyxia

Table 2: Determination of Apgar Score*
Feature Evaluated 0 Points 1 Point 2 Points
Heart rate 0 < 100 beats/min > 100 beats/min
Respiratory effort Apnea Irregular, shallow or gasping breaths Vigorous, crying
Colour Pale or blue all over Pale or blue extremities Pink
Muscle tone Absent Weak, passive tone Active movement
Reflex irritability Absent Grimace Active avoidance

* Sum the scores for each feature. Maximum score = 10; minimum score = 0.

Assessment of Gestational Age

Gestational age can be assessed on the basis of the newborn's external characteristics.

Table 3: Assessment of Gestational Age
External Characteristic 28 Weeks 32 Weeks 36 Weeks 40 Weeks
Ear cartilage Pinna soft, remains folded Pinna harder, but remains folded Pinna harder, springs back into place when folded Pinna firm, stands erect from head
Breast tissue None None Nodule 1-2 mm in diameter Nodule 6-7 mm in diameter
Male genitalia Testes undescended, scrotal surface smooth Testes in inguinal canal, a few scrotal rugae Testes high in scrotum, more scrotal rugae Testes descended, scrotum pendulous, covered in rugae
Female genitalia Prominent clitoris with small, widely separated labia Prominent clitoris; larger, well-separated labia Clitoris less prominent, labia majora cover labia minora Clitoris covered by labia majora
Plantar surface of foot Smooth, no creases 1 or 2 anterior creases 2 or 3 anterior creases Creases cover the sole

Screening Tests

Phenylketonuria

All newborns should be screened for phenylketonuria (PKU) by means of a capillary blood sample before discharge from the hospital.

For any newborn who undergoes this type of screening at less than 24 hours of age, the screening test must be repeated between 2 and 7 days of age.

For more information on Next link will take you to another Web site PKU

Congenital Hypothyroidism

  • All newborns should be screened by taking a thyroid-stimulating hormone (TSH) or thyroxine (T4) level by means of a dried capillary blood sample in the first week of life
  • If a child was born in hospital, verify that this type of screening was done before discharge
  • For more information on Next link will take you to another Web site congenital hypothyroidism

Other Screening Tests

For more information, see specific procedures for hemoglobin screening, developmental screening, hearing screening and vision screening under "Screening Tests" in the chapter, "Pediatric Prevention Activities and Health Maintenance."

Physical Examination of the Infant and ChildFootnote 8 ,Footnote 9 ,Footnote 10

Clinicians should be aware of the different sizes of body parts in children relative to adults: the head is relatively larger, limbs relatively smaller and, in small children, the ratio of surface area to weight is relatively larger.

Technique

Much information can be obtained by observing the child's spontaneous activities while the history is being conducted, without touching the child. For this purpose it is useful to have an age-appropriate toy available. Approach infants and young children slowly and start by playing with them to gain their trust.

For a young child, do as much of the physical examination as possible with the child either being held by the parent or caregiver or supported on that person's lap.

Generally, the least stressful parts of the exam should come first, with more intrusive or distressing parts later (for example, examination of the pharynx and/or ears with the child restrained). Allowing the child to play with the equipment can often decrease anxiety about certain parts of the exam.

One must choose the quietest moment to do the respiratory and cardiac exam. This is usually at the beginning of the exam. The order of the examination must be varied to suit the situation.

Care should be taken to select appropriate-sized equipment when examining a child (for example, blood pressure cuff width should be greater than two-thirds of the length of the upper arm).

General Appearance

Without touching the child, observe (if applicable):

  • Level of consciousness, alertness, general behaviour and appearance (how well the infant/child looks)
  • Symmetry of body
  • Posture of limbs (flexed, extended)
  • Body movements (for example, arms and legs, facial grimace)
  • State of nutrition and hydration
  • Colour
  • Any sign of clinical distress (for example, respiratory distress includes dyspnea, pallor, cyanosis, irritability)
  • Gait
  • Breathing frequency and pattern
  • Responses to sound
  • Fine and gross motor skills as the child plays
  • Lesions (for example, petechiae, eczema, impetigo)
  • Responses to parental comforting measures
  • Ability to entertain themself while the caregiver is talking
  • Quality of infant's cry or quality of child's voice
  • Interaction pattern, speech and nature of child's responses to parent(s) and health care staff

Vital Signs

Assess for:

Blood pressure measurements are influenced by sex, age and height. Therefore Next link will take you to another Web site blood pressure charts should be used to interpret the values. See printable charts on the National Institutes of Health web site, http://www.cc.nih.gov/ccc/pedweb/pedsstaff/bp.html. Blood pressure should be recorded once in the healthy child under 2 years and then annually after that.1

Table 4: Normal Pediatric Heart Rate, Blood Pressure and Respiratory Rate By Age (adapted fromFootnote 11 ,Footnote 12 ,Footnote 13)
Age Heart Rate Range (beats/minute [mean]) Lower Limit of Systolic Blood Pressure (mm Hg) Respiratory Rate Range (breaths/minute)
Birth to 6 months 80-180 [140] 60 30-60
6 months to 12 months 70-150 [130] 70 30-50
1 to 3 years 90-150 [120] 72-76 24-40
3 to 5 years 65-135 [110] 76-80 22-34
5 to 12 years 60-120 [85-100] 80-90 16-30
12 years to adult 60-100 [80] 90 12-20
 

Temperature Measurement in Children

Proper temperature measurement is essential for clinical decision making in the pediatric population. Children should be unbundled for at least 15 minutes prior to taking their temperature. One needs to be aware of the normal temperature ranges for each measurement method and use recommended temperature measurement methods in children. See Table 5 and Table 6, below.

Table 5: Normal Temperature RangesFootnote 14
Measurement Method Normal Temperature Range
Rectal 36.6 to 38°C
Tympanic 35.8 to 38°C
Oral 35.5 to 37.5°C
Axillary 34.7 to 37.3°C
Table 6: Recommended Temperature Measurement Methods in ChildrenFootnote 14
Age Definitive Method Method to Screen Low-risk Children
Less than 2 years Rectal Axillary
2-5 years Rectal Axillary
Tympanic
Older than 5 years Oral Axillary
Tympanic

Tympanic temperature measurement is contraindicated in newborns due to the shape of the ear canal and the potential for vernix or amniotic fluid in the canal.

Growth Measurements

Weight should be done at each visit for any infant under 1, those presenting for a well-child visit, at least annually for older children, and for any infant or child who presents with vomiting, diarrhea, signs of shock, or in need of a medication where dosage is dependent on weight.

Measurements of recumbent length (until 24 months old) or height, weight and head circumference (until 24 months old) should be part of every health maintenance visit. These parameters should be recorded on gender-appropriate growth curves, which should form part of the child's health record.

The Canadian Paediatric SocietyFootnote 15 recommends using the WHO Growth Charts, specific to each sex. They can be found at:

Growth charts for boys :

Growth charts for girls:

For additional information about growth measurements, see "Growth Measurement" in the chapter, "Pediatric Prevention and Health Maintenance."

Skin

Note colour, condition and lesions on all aspects of the body.

Colour

  • Pallor associated with low hemoglobin or vasoconstriction (for example, in shock)
  • Cyanosis associated with hypoxemia
  • Plethora associated with polycythemia or vasodilation
  • Cherry red face associated with carbon monoxide poisoning
  • Jaundice associated with elevated bilirubin

Lesions

  • Stork bite: Pink and flat nevus simplex; usually on face or back of the neck; those on face usually disappear by 18 months4
  • Caf au lait spots: Irregular brown, flat macules. Suspect neurofibromatosis if there are many (more than 5 or 6) large spots
  • Mongolian spots: dark bluish/purplish patches present at birth, usually on back and buttocks but may be on limbs; common in First Nation's and Inuit children; usually fade away in first year of life
  • Acne: blackheads, whiteheads; more severe forms have papules, pustles and nodules; usually on face and sometimes on back, chest and shoulders; most common in adolescence

Head and Neck

Head and Face

  • Palpate anterior and posterior fontanelles (size, consistency, bulging or sunken) and cranium
  • Bruising of head, behind the ears or periorbitally
  • Size and shape of the head
  • Facial symmetry at rest and while crying for the infant

Eyes: Inspection

To open the infant's eyes, support their head and shoulders and gently lower the infant backward.

  • Check cornea for cloudiness (sign of congenital cataracts)
  • Check the lids and external structures; note palpebral slant
  • Assess for nystagmus
  • Check conjunctiva for erythema, exudate, orbital edema, subconjunctival hemorrhage, jaundice of sclera
  • Check for position and alignment of the eyes using cover-uncover test
  • Check for corneal light reflex and ability to track movement for cardinal fields of gaze
  • Check for pupillary size, shape, equality and reactivity to light (PERRL: pupils equal, round, reactive to light), accommodation normal
  • Red reflex: hold ophthalmoscope 15-20 cm (6-8 inches) from the eye and use the +10 diopter lens; if normal, the newborn's eye transmits a clear red colour back; black dots may represent cataracts; a whitish colour may suggest retinoblastoma
  • Inspect fundus, if possible
  • Check visual acuity in children over 3 years of age

See also vision screening procedures under "Screening Tests" in the chapter, "Pediatric Prevention and Health Maintenance" for more details.

Ears

  • Check for asymmetry, irregular shape, setting of ear in relation to corner of eye (low-set ears may suggest underlying congenital problems such as renal anomalies, fetal alcohol spectrum disorder or Down's sydrome)
  • Look for fleshy appendages, lipomas or skin tags
  • Palpate and inspect auricles
  • Perform otoscopic examination; check canals for discharge, foreign bodies and colour, and tympanic membranes for colour, brightness, perforation, effusion, bony landmarks and light reflex

See also hearing screening procedures under "Screening Tests" in the chapter, "Pediatric Prevention Activities and Health Maintenance" for more details.

Nose: Inspection

  • Determine if nares are patent. Look for foreign body
  • Look for nasal flaring, which is a sign of increased respiratory effort
  • Look for hypertelorism or hypotelorism (increased or decreased space between eyes)
  • Note nasal discharge or sneezing
  • Look at the mucosa, septum and turbinates with otoscope

Mouth

  • Inspect lips, gums, palate, buccal mucosa, tongue, palate, tonsils
  • Inspect tongue size and frenulum of tongue in infants
  • Inspect teeth for number, character, condition, position and caries
  • Palpate palate in young infants
  • Note if uvula is midline

Neck: Inspection

  • Symmetry of shape, midline trachea
  • Alignment: torticollis is often secondary to positional plagiocephaly
  • Tracheal tug: can occur with dyspnea
  • Neck mass

Neck: Palpation

  • Palpate any masses (may signify congenital cysts), trachea, lymph nodes and thyroid
  • Neck range of motion for nuchal rigidity: may be present in meningitis; in older children (over 5) Kernig and Brudzinski reflex may be helpful in assessing for meningitis
  • Palpate clavicles

Respiratory System

Inspection

  • Cyanosis, central or peripheral (transient bluish colour may be seen in extremities if infant is cooling off during the examination)
  • Respiratory effort, rate and pattern (for example, periodic breathing, gasping, periods of true apnea)
  • Observe chest movement for symmetry and retractions
  • Note any movement of the abdomen with respirations
  • Note chest size, shape, configuration and anatomical abnormalities of chest (for example, pectus excavatum)
  • Use of accessory muscles, tracheal tug, indrawing of intercostal or subcostal muscles
  • Note any nipple and breast development

Palpation

  • Any abnormal masses (palpate gently)
  • Nipples and breast tissue - it may be slightly enlarged secondary to presence of maternal hormones in infants

Auscultation

  • Breath sounds
  • Rate and rhythm
  • Inspiratory to expiratory ratio
  • Adventitious sounds (for example, stridor, crackles, wheezes, grunting)

Percussion as indicated.

Cardiovascular System

Inspection

  • Colour: pallor, cyanosis, plethora
  • Pulsations on precordial area

Palpation

  • Locate point of maximal impulse (PMI) by positioning one finger on the chest and note this location. Abnormal location of PMI can be a clue to pneumothorax, diaphragmatic hernia or other thoracic problems
  • Palpate chest wall for thrills
  • Capillary refill (< 2 seconds is normal)
  • Peripheral pulses in each extremity and femoral: note character of pulses (bounding or thready; equality); compare strength of femoral pulses with radial pulses

Auscultation

  • Note rate and rhythm
  • Note presence and quality of S1 and S2 heart sounds
  • Assess for S3 and S4: S3 may be a normal finding in infants and children3
  • Note presence of murmurs (consider murmurs pathologic, as in congenital heart defects, until proven otherwise)

Abdomen

Inspection

  • Shape of abdomen: flat abdomen may signify decreased tone or abnormalities of the abdominal musculature
  • Periumbilical area
  • Contour: note any abdominal distension
  • Masses
  • Visible peristalsis
  • Diastasis recti
  • Anal area for presence of fistulas, excoriation or fecal soiling

Auscultation

  • Bowel sounds

Percussion

  • All quadrants

Palpation

  • Note muscle tone, skin turgor and underlying organs
  • Check for any abnormal masses
  • Check for enlarged organs
  • Techniques for kidney palpation with infants: place one hand with four fingers under the infant's back, then palpate by rolling the thumb over the kidneys; or place the right hand under the left lumbar region and palpate the abdomen with the left hand to palpate the left kidney (do the reverse for the right kidney)
  • Check for hernias: umbilical or inguinal
  • Check for inguinal lymph nodes

Genitalia

Inspect the external genitalia and note stage of sexual maturity.

Male Genitalia

Inspection

  • Glans: colour, edema, discharge, bleeding
  • Urethral opening: should be located centrally on the glans (in hypospadias, the opening is found on the undersurface of the penis)
  • Foreskin (prepuce): never force retraction of the foreskin
  • Testes: ensure that both testicles are descended into scrotum in infants. Palpate inguinal area. If one or both are not descended, consult a physician
  • If masses are present, transilluminate the scrotum

Female Genitalia

Inspection

  • Check labia, clitoris, urethral opening and external vaginal vault
  • Hymenal tags, if they occur, are normal

Musculoskeletal System

Inspection and Palpation

Spine

  • Check for scoliosis, kyphosis, lordosis, spinal defects, a patch of hair along the spine, meningomyelocele

Upper Extremities

  • Inspect and note ROM and muscle tone of the shoulder, wrist and elbow
  • Note aligment of arms and hands
  • Inspect fingers and palmar creases

Lower Extremities

  • Inspect and note ROM and muscle tone of the toes, knees, and ankles
  • Note alignment of legs, feet and toes
  • Note arch of foot
  • In infants, examine the hips for hip instability using Ortolani and Barlow maneuvers (see descriptions below). These tests may be somewhat unrealiable depending on the examiner's experience, so further assessment may be needed5

Ortolani Maneuver

  • Flex the knee and hip
  • Place middle fingers over greater trochanters
  • Position thumbs on medial sides of knees
  • Abduct the hip to 90° by applying lateral pressure with thumb
  • Push forward with the middle fingers that are over greater trochanters
  • If there is a "clunk," the hip may be dislocated

Barlow Maneuver

  • Flex the knee and hip
  • Place thumbs on knees
  • Place middle fingers over greater trochanters
  • Adduct the hip medially and push backward on the knee with thumbs
  • If there is a "clunk" or telescoping sensation, the hip may be dislocatable

Central Nervous System

  • Assess state of alertness
  • Check for lethargy or irritability
  • Posture
  • Assess muscle tone (for example, support the infant with one hand under the chest; the neck extensors should be able to hold the head in line for 3 seconds; there should not be more than 10% head lag when the infant is moved from a supine to a sitting position)

ReflexesFootnote 16 ,Footnote 17

Reflexes are involuntary movements or actions that help to identify normal brain and nerve activity and development. Some are present at birth and serve a variety of purposes, others develop later. Abnormal reflexes - ones that persist after an age they should disappear, or are absent at birth when they should be present - can help identify neurological or motor disease early. The following are some of the reflexes that should be tested in newborns and infants up to 2 years of age.

Table 7: Newborn and Infant Reflexes (adapted fromFootnote 18 ,Footnote 19 ,Footnote 20)
Reflex Stimuli Response Age Appears/ Disappears Pathology if Abnormal
Rooting Stroke cheek Head turns toward stimuli and mouth may open Birth/3-4 months (up to 12 months during sleep) May not be present if asleep; CNS disease or depressed infant
Sucking Object touching lips or in mouth Sucking to stimuli Birth/4 months (up to 7 months during sleep) May not respond well if sleeping or satisfied; If premature it may not be present; CNS depression
Tonic Neck Head turned to one side for 15 seconds while laying supine Arm and leg extension on the side the head is turned toward; arm and leg flexed on opposite side Birth-2 months/4-6 months Persistence - neurological damage; infant unable to get out of position is abnormal
Palmar Grasp Put finger onto palm from ulnar side Grasps finger strong and symmetric Birth/3-6 months CNS disease
Stepping Held upright, one foot touches a flat surface Alternating stepping movements Birth/2-4 months Absence - paralysis, depressed infant; cerebral palsy
Moro Sudden drop in position or jarring Symmetrical arm, spine and leg extension, head moves back and fingers spread; then arms flex toward each other Birth/4 months at the latest Asymmetry - paralysis or fractured clavicle; absence or persisting beyond 6 months - brainstem problem
Plantar Grasp Place thumb at base of newborn's toes Toes curl downward; should be symmetrical Birth/4-8 months Cerebral palsy, obstructive CNS lesion
Babinski Lateral sole stroked from heel up and across ball of foot Hyperextension (fanning) of toes Birth/Variable (usually by 1 year) CNS lesion, cerebral palsy
Landau Held around waist in horizontal prone position Lifts head and legs and extends the neck and trunk By 3-6 months/ 15-24 months Hypotonicity indicates motor system deficits; hypertonic arms with internal rotation, arm held at side or arm does not lift is abnormal
Parachute Held around waist in horizontal prone position and lowered quickly head first to surface Extends arms and hands to break the fall, symmetrically By 6-8 months/ Never Asymmetry indicates unilateral motor abnormality
 

Deep Tendon Reflexes

Deep tendon reflexes are not usually tested in children under 5 years of age. In older children, deep tendon reflexes may be tested. Reflexes must be symmetric. The child must be relaxed and comfortable. The reflexes include the biceps, brachioradialis, triceps, patellar and achilles.

Cranial Nerve Assessment

After 2 years of age, cranial nerves can be tested with some modifications according to the developmental stage of the child. See Table 8, "Cranial Nerve Assessment in Children."

Table 8: Cranial Nerve Assessment in Children (adapted from Footnote 21)
Cranial Nerve Number Name/Function How to Test
I Olfactory For older children, as in adults
II Optic Use Snellen chart(s) after age 3; ask parent to hold head if needed to test visual fields
III, IV, VI Extraocular movement Get child to follow (track) a light or a toy with the parent holding the child's head if needed
V Trigeminal Play a game, asking them to identify where the cotton ball touched them on the face (sensory); ask the child to clench their teeth or chew and swallow a piece of food
VII Facial Ask the child to imitate your faces
VIII Acoustic After age 4, whisper a word while covering one of the child's ears and have the child repeat it
IX, X Swallow and gag Ask the child to say "ahh" or stick their tongue and observe the the uvula and soft palate; test the gag reflex
XI Spinal accessory Ask the child to shrug, pushing your hands away, and push your hand away with their head to see how strong they are
XII Hypoglossal Ask the child to stick out their tongue

Screening

Developmental MilestonesFootnote 22 ,Footnote 23

Assessment of developmental progress should be part of each complete health assessment (well-child visit) and take place at all visits for children who do not present regularly for well-child care. Developmental assessment is done by making inquiries of the parents or caregiver and by clinical observation of the child's achievement of major age-appropriate milestones. These are in areas of gross and fine motor, speech and language, and personal and social development.

Developmental milestones are achieved at different ages in different children. See the Next link will take you to another Web site Rourke Baby Record or Table 9, "Developmental Milestones by Age and Type" for the ages by which certain developmental milestones should occur.

Table 9: Developmental Milestones by Age and Type (should be present by this age) (adapted fromFootnote 24 ,Footnote 25 ,Footnote 26)
Age Gross Motor Fine Motor Personal/Social Language/Cognitive
Newborn
  • Reflex head turn side to side
     
1 month
  • Back completely rounded when sitting, head forward
  • Focuses gaze
  • Tracks horizontally to midline
  • Able to suck on a nipple
  • Social smile
  • Startles to loud or sudden noise
2 months  
  • Follows movement with eyes
  • Enjoys being touched
  • A variety of sounds and cries
3 months
  • Lifts up on elbows
  • Head steady when upright
  • Unfisted >50% of time
  • Eye tracks 180 degrees
   
4 months
  • Lifts up on hands
  • No head lag when pulled to sitting from supine
  • Reaches for bright object
 
  • Turns head toward sounds
  • Laughs or squeals
6 months
  • Rolls back to front or front to back
  • Sits with support
  • Follows a moving object
  • Brings objects to mouth
 
  • Babbles
7 months    
  • Has stranger anxiety
  • Plays peek-a-boo
 
9 months
  • Sits and stands with support
  • Opposes thumb and index finger
  • Reaches to be picked up and held
  • Looks for hidden toy
  • Babbles different sounds
  • Makes sound to get attention
12 months
  • Crawls or 'bum' shuffles
  • Pulls to stand or walks holding on
  • Pincer grasp
  • Shows many emotions
  • Drinks from a cup
  • Responds to own name
  • Understands simple commands
  • "Talks" making 3 different sounds
15 months
  • Crawls up stairs or steps
  • Tries to squat (picking up toys)
  • Removes socks and tries to untie shoes
  • Stacks 2 blocks
  •  Picks up and eats finger foods
  • Looks at parent/caregiver to see how to react (for example, for falls or with strangers)
  • Attempts 2 or more words (may not be clear)
  • Tries to get something by reaching, making sounds or pointing
18 months
  • Walks backward 2 steps without support
  • Feeds self with spoon and spills little
  • Removes hat/socks without help
  • Hand preference
  • Behaviour is usually manageable
  • Usually easy to soothe
  • Comes for comfort when distressed
  • Points to 3 different body parts
  • Tries to get your attention to see something of interest
  • Pretend play with toys (for example, feeds animal)
  • Turns upon hearing name
  • Imitates speech sounds regularly
  • Says 3 consonants, for example, P M B W H N
  • Says 3 or 4 words
2 years
  • Tries running
  • Puts objects into a small container
  • Copies adult behaviours
  • Develops new skills
  • Concept of today
  • At least 1 new word/week
  • 2-word sentences
  • Many words
3 years  
  • Twists lids off jars or turns knobs
  • Turns pages one at a time
  • Copies circle
  • Shares sometimes
  • Listens to music or stories for 5-10 minutes with an adult
  • Concept of yesterday
  • Understands 2-step directions
4 years
  • Stands on 1 foot for 1-3 seconds
  • Draws a person with at least 3 body parts
  • Copies "+"
  • Toilet trained during the day
  • Tries to comfort someone who is upset
  • Understands 3-part directions, if related
  • Asks lots of questions
5 years
  • Hops on one foot
  • Throws and catches a ball
  • Copies square
  • Shares willingly
  • Works alone on something for 20-30 minutes
  • Separates easily from parents
  • Dresses without assistance
  • Counts to 10 and knows common colours and shapes
  • Speaks clearly in sentences
6 years  
  • Copies triangle
  • Draws 6 part person
 
  • Well developed vocabulary, quickly retrieves words
  • May stutter
8 years    
  • Concept of right and left
  • Can follow complex directions
  • Tells jokes
10 years    
  • Has a special friend (same sex)
  • Able to discuss ideas and understand inflections and metaphors
12 years    
  • Language is a means of socializing
  • Can think about sophisticated concepts
  • Ability to express emotions
 

A developmental screening tool should be used to look at more specific developmental milestones at each well-child visit. Screening tools are not diagnostic, but help to determine when further assessment is needed. There are two broad categories of screening tools: those that rely on information from the parent or caregiver and those that rely on eliciting skills directly from the infant or child. Nurses are encouraged to use the same developmental screening tool that the majority of nurses are using in their province and/or their region and for which they have training. Some developmental screening tools that are appropriate for First Nations and Inuit children areFootnote 27:

All of these tools rely on information from parents or caregivers. Some of the tools are also a teaching tool for parents about their child's development.

More detailed assessments are indicated when it appears, or concerns are raised by the parents, caregiver or health professional, that a child is not progressing normally, according to the above measures. Any child with suspected delay(s) should be referred promptly to the appropriate primary health care provider (for example, speech-language pathologist, physician, psychologist) for assessment.

As part of each complete health assessment, attempts should also be made to assess responses to sound and ability to see. For more information, see "Hearing Screening" and "Vision Screening" in the chapter, "Pediatric Prevention and Health Maintenance."

Other Screening Tests

Routine screening should be done in infants and children for hemoglobin, development, hearing and vision. See specific procedures for hemoglobin screening, developmental screening, hearing screening and vision screening under "Screening Tests" in the chapter, Pediatric Prevention Activities and Health Maintenance."

Sources

All internet addresses are valid as of June 2010.

Books and Monographs

Behrman RE, Kliegman R, Jenson HB. Nelson's essentials of pediatrics. 16th ed. Philadelphia, PA: W.B. Saunders; 1999.

Berkowitz CD. Berkowitz's pediatrics: A primary care approach. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2008.

Bickley LS. Bates' guide to physical examination and history taking. 7th ed. Baltimore, MD: Lippincott Williams & Wilkins; 1999.

Burns CE, Dunn AM, Brady MA, Starr NB, Blosser CG. Pediatric primary care. 4th ed. St. Louis, MO: Saunders Elsevier; 2009.

Cheng A, et al. The Hospital for Sick Children handbook of pediatrics. 10th ed. Toronto, ON: Elsevier; 2003.

Frankenburg WK, Dodds JD, Fandal AW. Denver Developmental Screening Test: Manual/workbook for nursing and paramedical personnel. Boulder, CO: University of Colorado Medical Centre; 1986.

Hockenberry MJ. Wong's nursing care of infants and children. St. Louis. MO: Mosby; 2003.

Mandleco BL. Growth & development handbook: Newborn through adolescent. Clifton Park, NY: Thomson Delmar Learning; 2004.

Morris A, Mellis C, Moyer VA, Elliott EJ, editors. Evidence-based pediatrics and child health. London, England: BMJ Books; 2004. p. 206-14.

Rudolph CD, et al. Rudolph's pediatrics. 21st ed. New York, NY: McGraw-Hill; 2003.

Ryan-Wenger NA, editor. Core curriculum for primary care pediatric nurse practitioners. St. Louis, MO: Mosby Elsevier; 2007.

Internet Guidelines

Canadian Pediatric Society. (2010, March). Next link will take you to another Web site Greig Health Record.

Canadian Task Force on Preventive Health Care. (1994). Next link will take you to another Web site Well baby care in the first 2 years of life.

Gesell Institute of Human Development. (n. d.). Next link will take you to another Web site Gesell developmental observation.

Next link will take you to another Web site Nipissing District Developmental Screen. (2007).

Paul H. Brookes Publishing. (2009). Next link will take you to another Web site Ages and stages questionnaires.

Rourke L, Rourke J, Leduc D. (2009). Next link will take you to another Web site Rourke baby record. Evidence-based infant/child health maintenance guide.

Footnotes

Footnote 1

Gulati S. Next link will take you to another Web site Measuring up: How to take children's blood pressure. Canadian Journal of Continuing Medical Education 2004;10:97-101.

Return to footnote 1 referrer

Footnote 2

Comley L, Mousmanis P. (2003). Next link will take you to another Web site Improving the odds: Healthy child development. p. 32-34.

Return to footnote 2 referrer

Footnote 3

Engel J. Mosby's pocket guide to pediatric assessment. 4th ed. St. Louis, MO: Mosby Inc; 2002.

Return to footnote 3 referrer

Footnote 4

Berman K. Next link will take you to another Web site Stork bite. Medline Plus.

Return to footnote 4 referrer

Footnote 5

Carey TP. Next link will take you to another Web site Current concepts in the treatment of DDH (developmental dysplasia of the hip).

Return to footnote 5 referrer

Footnote 6

Ryan-Wenger NA, editor. Core curriculum for primary care pediatric nurse practitioners. St. Louis, MO: Mosby Elsevier; 2007. p. 144-45, 237-39.

Return to footnote 6 referrer

Footnote 7

Mandleco BL. Growth & development handbook: Newborn through adolescent. Clifton Park, NY: Thomson Delmar Learning; 2004. p. 55-61.

Return to footnote 7 referrer

Footnote 8

Bickley LS. Bates' guide to physical examination and history taking. 8th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2003. p. 645-53.

Return to footnote 8 referrer

Footnote 9

Ryan-Wenger NA, editor. Core curriculum for primary care pediatric nurse practitioners. St. Louis, MO: Mosby Elsevier; 2007.

Return to footnote 9 referrer

Footnote 10

Jarvis C. Physical examination & health assessment. 4th ed. St. Louis, MO: Saunders; 2004. p. 843-51.

Return to footnote 10 referrer

Footnote 11

UptoDate Online 17.1 Pediatric normal vital signs by age. Available by subscription: http://www.uptodate.com

Return to footnote 11 referrer

Footnote 12

Hazinski MF, sr. editor. PALS provider manual. Dallas, TX: American Heart Association; 2002. p. 33-34.

Return to footnote 12 referrer

Footnote 13

Ryan-Wenger NA, editor. Core curriculum for primary care pediatric nurse practitioners. St. Louis, MO: Mosby Elsevier; 2007. p. 75-76.

Return to footnote 13 referrer

Footnote 14

Canadian Paediatric Society. (2007). Next link will take you to another Web site Temperature measurement in paediatrics. Available: http://www.cps.ca/english/statements/CP/cp00-01.htm

Return to footnote 14 referrer

Footnote 15

Canadian Paediatric Society: Nutrition Committee. (2004). Next link will take you to another Web site The use of growth charts for assessing and monitoring growth in Canadian infants and children. Canadian Journal of Dietetic Practice and Research 2004;65(1):22-32.

Return to footnote 15 referrer

Footnote 16

Ryan-Wenger NA, editor. Core curriculum for primary care pediatric nurse practitioners. St. Louis, MO: Mosby Elsevier; 2007.

Return to footnote 16 referrer

Footnote 17

Mandleco BL. Growth & development handbook: Newborn through adolescent. Clifton Park, NY: Thomson Delmar Learning; 2004.

Return to footnote 17 referrer

Footnote 18

Ryan-Wenger NA, editor. Core curriculum for primary care pediatric nurse practitioners. St. Louis, MO: Mosby Elsevier; 2007.

Return to footnote 18 referrer

Footnote 19

Mandleco BL. Growth & development handbook: Newborn through adolescent. Clifton Park, NY: Thomson Delmar Learning; 2004.

Return to footnote 19 referrer

Footnote 20

Burns CE, Dunn AM, Brady MA, Starr NB, Blosser CG. Pediatric primary care. 4th ed. St. Louis, MO: Saunders Elsevier; 2009.

Return to footnote 20 referrer

Footnote 21

Bickley LS. Bates' guide to physical examination and history taking. 8th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2003. p. 734.

Return to footnote 21 referrer

Footnote 22

Ryan-Wenger NA, editor. Core curriculum for primary care pediatric nurse practitioners. St. Louis, MO: Mosby Elsevier; 2007. p. 286-91.

Return to footnote 22 referrer

Footnote 23

Hockenberry MJ. Wong's nursing care of infants and children. St. Louis, MO: Mosby; 2003. p. 233-38.

Return to footnote 23 referrer

Footnote 24

Berkowitz CD. Berkowitz's pediatrics: A primary care approach. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2008. p. 93.

Return to footnote 24 referrer

Footnote 25

Burns CE, Dunn AM, Brady MA, Starr NB, Blosser CG. Pediatric primary care. 4th ed. St. Louis, MO: Saunders Elsevier; 2009.

Return to footnote 25 referrer

Footnote 26

Rourke L, Rourke J, Leduc D. (2006). Next link will take you to another Web site Rourke baby record. Evidence-based infant/child health maintenance guide.

Return to footnote 26 referrer

Footnote 27

Stout M, Jodoin N. Prepared for the Maternal Child Health Program, First Nations Inuit Health Branch. (2006, July). Maternal Child Health Screening Tool Project: Final Report. p. 32-35.

Return to footnote 27 referrer