What are the key components of a physical exam for a 9-month-old patient, including developmental assessments and preventive care measures?

9-Month Physical Examination

At the 9-month visit, the infant must demonstrate rolling to both sides, sitting well without support, and motor symmetry—absence of these skills signifies developmental delay requiring immediate action. 1

Developmental Assessment

Motor Milestones (Critical at 9 Months)

Gross Motor:

• Rolling over supine to prone 1
• Sitting without support 1
• Pulling to stand 1
• Coming to sit from lying 1
• Crawling 1
• Motor symmetry must be present 1

Fine Motor:

• Reaching for cubes and transferring objects 1
• Raking small objects with 4 fingers 1
• Picking up small objects with 3 fingers 1
• Note: 2-finger pincer grasp is NOT expected until 12 months 2

Red Flags Requiring Immediate Referral

• Regression of any previously acquired motor skills (suggests progressive neuromuscular disorder) 1, 2
• Asymmetry in movement or hand use (suggests unilateral cerebral palsy) 2
• Failure to sit without support 1, 2
• Absence of rolling to both sides 1
• Hypotonia or feeding difficulties 2

Standardized Developmental Screening

The 9-month visit is one of three mandated ages for formal developmental screening using a standardized tool (others are 18 and 30 months). 1, 2

Physical Examination Components

Growth Parameters

• Measure and plot head circumference, weight, and length on CDC or WHO growth curves 1
• Microcephaly or macrocephaly warrant further evaluation 1
• Poor weight gain may suggest oral motor weakness 1

Neuromotor Examination

Cranial Nerves:

• Eye movements and visual confrontation 1
• Pupillary reactivity 1
• Red reflexes (must be detectable and symmetric) 1
• Facial expression quality, smile, and cry 1
• Oromotor movement observation 1
• Tongue fasciculations (suggests lower motor neuron disorder) 1

Tone and Strength:

• Assess postural tone through truncal positioning when sitting 1
• Evaluate extremity tone using scarf sign and popliteal angles 1
• Observe antigravity movement and quality of body posture 1
• Assess muscle bulk, texture, and joint flexibility 1
• Check for atrophy 1

Reflexes:

• Primitive reflexes should be diminishing 1
• Protective reflexes should be present (asymmetry or absence suggests neuromotor dysfunction) 1
• Deep tendon reflexes (diminished/absent suggests lower motor neuron disorder; increased with abnormal plantar reflex suggests upper motor neuron dysfunction) 1

Ophthalmologic Assessment

Vision Screening:

• Fixation testing using developmentally appropriate targets (toys, faces, hand-held lights) 1
• Observe ability to gaze steadily and follow targets horizontally and vertically 1
• Corneal light reflex assessment for eye alignment (reflexes should be symmetric and centered on pupils) 1
• Cover testing for strabismus (more accurate than corneal light reflex) 1
• Instrument-based vision screening (photoscreening/autorefraction) is useful for this age when cooperation is limited 1

External Examination:

• Assess eyelids, eyelashes, lacrimal system 1
• Note facial anatomy including epicanthal folds and nasal bridge 1
• Observe head position (tilt, turn, chin posture) 1

Pupillary Examination:

• Assess size, shape, symmetry in dim light (>1mm difference is clinically significant) 1
• Test reactivity to light 1
• Swinging-light test for relative afferent pupillary defect 1

Hearing Assessment

• Formal audiogram with tympanometry should be performed 1

Nutritional Assessment

• Evaluate feeding, swallowing, and growth 1
• Screen for gastroesophageal reflux and constipation 1

Surveillance Questions for Parents

Ask specifically about: 1

• "Is there anything your child is not doing that you think he or she should be able to do?"
• "Is there anything your child is doing that you are concerned about?"
• "Is there anything your child used to be able to do that he or she can no longer do?" (regression)
• "Is there anything other children your child's age can do that are difficult for your child?"

Immediate Action for Delays

If motor delays are identified:

• Refer immediately to early intervention services (do not wait for diagnosis) 2
• Refer to pediatric physical therapy while diagnostic investigations proceed 2
• Consider pediatric neurology consultation for comprehensive neuromotor evaluation 2
• Schedule close follow-up at 12-month visit to reassess milestones 2
• Instruct parents to return immediately if child loses any motor skills or develops new concerns about strength, respiration, or swallowing 2

Prematurity Correction

For infants born before 36 weeks gestation, correct for prematurity when assessing developmental milestones for at least the first 24 months. 2, 3