SECTION TWO

65
Children and adolescents

the child is walking, the gait should have been Box 5.8 Primitive reflexes
observed. Look for toe walking (spasticity), wide Rooting reflexes
based gait (seen in cerebellar ataxia but normal in
toddlers) and limping (antalgic gait or henmiplegia). On touching a baby's cheek, he will turn his head towards
Hemiplegia may become more obvious on running the [Link] itself is a reflex, and failure of the
sucking response beyond the 36th week of gestation
as the affected upper limp is brought up closer to suggests significant neurological impairment.
the body.
Note any abnormal movements. Tics or habit Palmar and plantar grasp
spasms are repetitive but not purposeful move Afinger placed across the child's palm or plantar surface
ments, such as shrugging of the shoulders or facial of the foot will cause flexion and grasping of the finger.
grimacing. Choreiform movements are involuntary, Lost by 2 months of age.
purposeless jerks that follow no particular pattern. Stepping reflex
Athetoid movements are writhing and more pro
nounced distally. Fits may be seen as lip smacking or When lowered verticallyonto a hard surface, the foot
flickering eve movements. presses down and the other leg flexes at the hip and knee
Take the opportunity to check for spinal abnor in a stepping movement. As this response is alternated
from one leg to the other, the baby makes a walking
malities such as scoliosis or kyphosis or any evidence movement. Lost by 2 months of age.
of spina bifida such as atuft of hair. Be careful to
pick up on any signs of a neurocutaneous disorder The Moro reflex (see Fig. 5.11)
such as cafe au lait spots or telangiectasia. On dropping the heada few centimetres, the upper limbs
Coordination can best be checked by watching a abduct and extend symmetrically and then flex. Lost by
child at pla. It is useful to have toys available that 6 months of age.
require adegree of coordination, such as a toy farm
or garage. Otherwise, a modification of the inger
nose test using a toy held in the hand can be used.
If the child is old enough, vatching him dressing extensor response beyond the age of 2 years indi
whether
or dong up shoelaces is a good way to assess cates an upper motor neurone lesion. Note
coordinatior primitive reflexes have persisted (Box 5.8) indicat
Check muscic he if this has not already been ing significant neurodevelopmental dysfunction.
done P k the tii p if there is still a fricndly
relationshin Thi s agooi idea of the feel of a The eyes
child and o tic mcle ton it ie child is hypot The eyes should now be checked. Inspect them for
onic, it w as chough ie or she is slipping
thrcuglhsnds. Muscle o; is difhcult to ptosis, conjunctivitis, cataracts or congenital defects
check:hhiloren extipr watcling playing such as colobomata. Watch for spontaneous nystag
habits, cit ssess02 [Link] tv ai01lity at a variety of mus or roaming eye movements which may indi
cate a visual impairment. It is very important to
liftirg gimes i s rememor io check for neck
stift:ess olinp istance to passive neck flexion check for squints, as immediate ophthalmological
referral is necessary, however voung the infant.
rather than bstarng Ior Kernig's sign.
Squints are checked for by shining a light in the
Testu t sessotin 1s difhcult in young children, strong eyes from in front of the fae; the light reflex should
and is rohalih hst omitied unless there is a be at thesame position in each cornea. A cover test
suspic ot neurological disease.
should then be used (see Ch. 14), using a doll or
Testirs the cranial nerves takes a little ingenuity.
a toy some other appropriate toy on whih the child can
Eye movcments are relatively easy using the baby's focus his gaze. Pupillary accommodation and light
moved in different directions in front of
reactions can be noted at the same time. Examina
face. Young infants will often copy poking out the
check the twelfth tion of the fundus is particularly dithcult in intants
tongue at them, which will
cranial nerve. If the child can be made to
smile. and and will require dilatation of the pupils. It should
facial move be possible to see the red reflex which, if absent.
even if he is crying, any asymmetry of to bite on a is suggestive of a corneal, lens or vitreous opacity,
ments can be seen. If a child is
able
probably such as cataract or retinoblastoma. Usually, enough
wooden spatula, the trigeminal nerve is of the dis (an be seento detet papilloedema. The
intact.
testing of vision in young children is included in the
Getting achild's limbs intothe correct position to
they section on developmental screening examination
test tendon reflexes may take some time. Often (see p. 72).
finger rather than a patellar
can be elicited by using a With the possible exception of the eye examina
infants tend to
hammer. Tendon reflexes in young tion, nothing so far should have upset a baby unduly
plantar
be brisk, and up to 18 months of age the of an The following examinations should be carried out at
The persistence
responses are extensor.
 SECTION TWO
67
Children and adolescents

Routine measurements
Height and weight
Childhood is a period of growth, the pattern of
which may be adversely affected by many distur
bances of health as well as social deprivation. Serial
measurements of height and weight are therefore
essential in the examination of children. In children
able to stand, height can be measured against a wall
mounted gauge. Younger children can be measured
ove
lying down on special measuring boards. Measure
ments should be made under standard conditions,
and children should be weighed unclothed. If the
child keeps any clothes on, this should be noted
against the weight so that subsequent weights can
be taken with the child wearing the same quantity
Figure 5.5 How to hold a baby to allow the mouth and throat to of clothing. Heights and weights should be compared
be examined. The baby faces the examiner, with the mother with those of healthy children of similar sex,age and
holding him firmly with one hand on the forehead and the other build on percentile charts. Figures 5.6 and 5.7 show
holding both arms. standard height, weight and head circumference
charts for UK boys and girls from birth to 4 years.
The corresponding charts for children aged 4-18
years are in development at the time of writing
inspected. Look carefully for the light refles, which full-size versions of the current charts for 0-20years
can be lost if the child has chronic secretory otitis are available in clinical settings in the meantime.
media ('glue ear). In acute suppurativeotitis media, Comparison should also be made against the
the drum may be bright red and bulging. parents' height by calculating the mid-parental
The mouth and throat can be examined by encour height. This is done by adding together the height
aging a cooperative child to 'show me your teeth'; of the father and mother (cm) and dividing by two.
an open mouth will then allow alear view of the Add 7 cm for a boy and take away 7 cm for a girl.
mouth and tau es if uncooperative, the child will Plot the final value in centimetres at the final adult
need to be heidas shown in Figue 5.5. Someies height line (either at 18 years or 20 years depending
it is not to0disestrous if the hild ries at this pont, on the chart used) to find the child's expected
as this will ive a very cdear view of the teeth, the centile. A child who fails to grow at an appropriate
tonsils and someumes even tÉe cpiglottis. A spatula velocity (growth rate) needs to be investigated
is a terrifving instrument to the average daild,causing further. The term failure to thrive' is used to denote
most to lamp thu tecth shut If this happens, the children whose weight gain is below that expected
spatula should be advanced to the bakof the tongue (fallen across two centiles on the chart). He will
to nduce a gag reflex. Look tor the presence of the need a very careful history and examination to be
white patches of candida infectiOn, ulcers seen in carried out. It is important to pick up any markers
Crohn s discase and the Kopliks spots seen in of potential disease (such as chronic diarrhoea,
measles recurrent chestiness). There are as yet no satistactory
The general physical examination has now ben growth charts for children of Asian origin borm in
completed his to be hoped that the child is still the UK, who tend to be smaller than Caucasian
friendly. Once the child is dressed, the examiner children at leastin the fhrst few ycars of life. As a
should stt with the parents and explain what has roughguide, the mean percentile tor an Asian child
been found. It is always best for the child to have is the 25th percentile on the standard UK charts.
finished dressing before talking to the parents: they There are speial growth harts for children with
are more likely to listen and take in what you have Down's syndrome and lurner's syndrome The
to say if they are not worrying about buttons or meaning of the ten 'l0h percentile' is that |0% of
shoelaces. Always involve an older child in the dis all normal hildren are respectively lighter or shorter
cussion, as they have every right to know what is at the age concemed Slghtly different standards are
wrong. Even young children can be told that they applicable in ditferent races and in different coun
will be all right. Never under any circumstanes tries. Preterm infants should be plotted according to
deceive a child. The eventual truth will lose their their corrected age (chronological age minus the
confidence at that time and with later medical number of weeks born early) up until the age of
attendants. 2 years.
 SECTION TWO
73
Children and adolescents
head up before he can sit unsupported). It
also
requires the loss of primitive reflexes (see Box 5.8) developmental skills and will refer to a doctor babies
at the appropriate age to progress (a about whom there is any suspicion. There is always
transfer objects between his hands if child cannot
he still has
an assessment at 6 weeks and at 8 months of age.
The 18- and 24-month tests are now focused on
a grasp reflex). Developmental progress can
aftected by emotional difhculties, environment be 'at-risk' children and are more selective.
lack of stimulation due to neglect) and illnesses. (e.g. Head control
All infants should have a simple
developmental
screening examination at regular intervals. By 4 months, babies can normally keep their head
Table 5.1 in line with the trunk when pulled from supine to
lists the important milestones. Detailed develop
mental assessment is a specialist subject, but it sitting and, when held in the sitting position, will
important for all those who examine children to beis keep their head upright. Before this age, the head
able to carry out asimple developmental screening lags behind the trunk (Figs 5.8 and 5.9).
examination, and to be aware of all the basic
milestones. Testing vision
It is usual to consider development under four Much willbe learned about a child's vision by obser
main headings: vation. Note whether the child is looking around the
1 Movement and posture. room and at particular toys,or staring at nothing in
2 Vision and manipulation. particular, especially if there are random or nystag
3 Hearing and speech. moid eye movements, the latter suggesting that the
4 Social behaviour.
child is unable to see. When he picks toys up, is
accommodation normal? The routine examination
Screening for developmental delay involves testing of the eye has been dealt with in the first part of this
the child's performance of a few skills in each of the chapter.
four felds of development, and comparing the Checks of visual acuity are not easy in young
results with the average for children of the same age. babies. By 6 weeks of age, babies should be following
The range of normal developmental progress is wide,
and the milestornes shon in Table 5.1 are those of
an average normal baby Delay in all ields of devel
opment is more signiñcant than delay in one only,
and severe delar 1s more meaningfu! than slight
delay. Alew ance must always be made for those
intants whowereburn prmaturcv. at lesst until the
age of e2r by which time they should have
caught
By 18 months oi age covious deviations from
normaopment shoul beom apparent.
Beyondis age sclopme tel tesungis more spe
cial1zed nd beyond the spe cithis chapter. A
baby whe epnears te have delaved deveiopment on
sCreening n turther sprciali/ed asssSrnent to
establhs! tlese and subsquent imananement. Figure 5.8 Head control at 6 weeks of age.
Technigu6s uSed
The s uls apply to the techniques used in
developunestal screening as to those of general phys
ical exarunstion As with all parts of the examnina
tion, muh more is learned by simply watching a
child play and watching his reactions to the sur
roundings. Time has to be spent gaining the friend
ship of the child. For example, when offering a
10-month-old baby a smalltoy, watch to see how he
grasps it and reacts to it. Let the baby play with the
toys and bricks while sitting on the mother's lap, and
if the child remains suspicious, get the mother to
offer the various objects.
In the UK, developmental screening is usually
carried out by a health visitor who is trained in Figure 5.9 Head control at 4 months of age.