Peter G Szilagyi MD MPH

Before you can effectively talk to and examine a child, you need to understand children and their development. Children are anatomically and physiologically different from adults, and many techniques for assessment, physical findings, and abnormalities in young patients differ as well. Children display tremendous variations in physical, cognitive, and social development compared with adults. This chapter opens with the section on Child Development to help you assess children at all ages and to distinguish normal from abnormal symptoms and signs.

Health promotion and counseling are central to children's health care and should almost always be addressed whenever health care providers are examining children. The section on Health Promotion and Counseling outlines some critical areas to consider.

Children change rapidly, and it is important to understand the milestones for normal development for children at any age. Normal for a 2-year-old may be abnormal for a 10-year-old. Table 17-4, Growth Charts, (pp. 742749) has key parameters of children's growth and development.

The major section of this chapter, Techniques of Examination, details the physical examination of regional systems as in the rest of the book and follows a head-to-toe sequence. The section on Approach to the Examination of Children at Different Ages provides particular strategies useful for each age group. The section is divided by age group: infancy (the first year), early childhood (years 1 through 4), and middle childhood (years 5 through 10). The physical examination of adolescents (years 11 through

20) is similar to that of adults, although cognitively and emotionally they are far from alike!

The Tables of Abnormalities (pp. 780-782) follow the order of the chapter and highlight major pediatric abnormalities.

When I approach a child,, he inspires in me two sentiments: tenderness for what he is, and respect for what he may become.

—Louis Pasteur

When I approach a child,, he inspires in me two sentiments: tenderness for what he is, and respect for what he may become.

—Louis Pasteur

H Key Principles_

Childhood is a period of remarkable growth and change, by far the greatest in a person's lifetime. During a few short years, a child will physically increase in size 20-fold, mature into an adult, acquire sophisticated language and reasoning, and develop complex psychosocial interactions. What a journey!

The first principle of child development is that it proceeds along a predictable pathway governed by the maturing brain. You can measure age-specific milestones and characterize a child's development as normal or abnormal according to established criteria. Once a milestone is achieved, the child proceeds to the next. Loss of milestones is concerning. Because your physical examination takes place at one point in time, you need to learn where the child fits within a developmental trajectory.

The second principle is that the range of normal development is wide. It is critical to recognize that children mature at different rates.

The third principle recognizes that a variety of physical, disease-related, social, and environmental factors affect child development and health. For example, chronic diseases and social problems such as child abuse and poverty can result not only in detectable physical abnormalities but in alterations in the rate and course of developmental advancement. Children with physical or cognitive disabilities may not follow the expected age-specific developmental trajectory outlined here. Tailor the physical examination to the child's developmental level.

A fourth principle, specific to the pediatric examination, is that the child's developmental level affects the nature of the medical history and physical examination. For example, interviewing a 5-year-old is fundamentally different from interviewing an adolescent—the physical examination of a rambunctious toddler who is dismantling the examination room has little in common with that of a shy teenager. Both order and style are quite different from the traditional examination of an adult. You will be faced simultaneously with adjusting your physical examination to the developmental level of the child while attempting to ascertain that developmental level. An understanding of normal child development helps you achieve these tasks.

Normal range

Social and Cognitive emotional

Milestones

Physical

Every age has its pleasures, its style of wit, and its own ways.

—Nicholas Boileau-Despreaux

H Infancy: The First Year of Life_

Physical Development. The rate of physical growth during the first year of life is the most rapid of any age. By 1 year of age, the child should triple the birth weight and increase in height by 50%. Body proportions change, and the head becomes smaller relative to the body.

The figure on p. 628 shows the amazing developmental progression from birth to 1 year of age. Even a newborn has cognitive abilities that may surprise you. For example, a newborn can fix upon and follow a human face and respond to voices. Neurologic development progresses in a central to peripheral direction. Thus, a newborn learns head control before trunk control and use of arms and legs before use of hands and fingers.

Every child is born a genius.

—R. Buckminster Fuller

By 3 months, the normal infant will lift up his head and clasp his hands. By 6 months, the infant will roll over, reach for objects, turn to voices, and may sit with support. Learning occurs through activity, exploration, and manipulation of the environment. As peripheral coordination increases, the infant learns to reach for objects, to transfer from hand to hand, to crawl, to stand by holding on, and to play with objects by banging and grabbing. A 1-year-old may be standing, exploring the environment, and putting everything in her mouth.

Cognitive and Language Development. With this exploration comes an increased understanding of the infant's self and environment. The infant learns about cause and effect (such as shaking a rattle to produce a sound), the permanence of objects, and the use of tools to explore the environment. By 9 months of age, the child may recognize you as a stranger deserving wary cooperation, seek comfort from parents during the examination, and actively manipulate objects within reach (such as your clothes). Language development proceeds from cooing at 2 months, to babbling at 6 months, to 1 to 3 words by 1 year.

Social and Emotional Development. An infant's understanding of self and family also matures. Social tasks include bonding, attachment to caregivers, and trust that loved ones will meet needs. This may result in a reluctance to play with a strange examiner. Temperaments vary greatly. Some infants are predictable, adaptable, and respond positively to new stimuli; others are less adaptable and respond intensely or negatively to new stimuli. Because social development is affected by the environment, observe the child's interactions with caretakers.

Explores room Shows wants Plays simple games

Walks

Few words Understands words Points

Stands

Feeds self Looks for toy

Monosyllable Reaches

Pulls to stand

Social/Emotional Cognitive/Language Physical/Motor

Bonds, develops trust Regards face

Responds to sounds Habituates

Fixes and follows Head control

Sits Rolls over Bears weight on legs

Infancy

Birth

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