What are the key components of a pediatric exam for a child of any age, including infants, young children, and adolescents, with consideration of their medical history and specific needs?

Pediatric Examination: Key Components by Age Group

A comprehensive pediatric examination must be tailored to the child's age, with specific components required for infants (birth-3 years), children (3-12 years), and adolescents (12-17 years), focusing on early detection of vision-threatening conditions, developmental delays, and systemic disease that impact long-term outcomes. 1

Essential History Components (All Ages)

Obtain a detailed history that includes:

• Demographic data: Sex/gender identity, date of birth, identity of parent/caregiver, and relationship of historian to child 1
• Chief complaint and reason for evaluation 1
• Prenatal and perinatal history: Birth weight, gestational age, infections or substance exposure during pregnancy, past hospitalizations 1
• Ocular history: Prior eye problems, diseases, diagnoses, and treatments 1
• Family history: Specifically ask about amblyopia, strabismus, retinoblastoma, congenital cataracts, congenital glaucoma, or early childhood glasses use in parents/siblings 1, 2
• Medical conditions: Down syndrome, prematurity, juvenile idiopathic arthritis, neurofibromatosis, learning disabilities, developmental delays 1
• Current medications and allergies 1
• Developmental milestones: Ask "Is there anything your child is not doing that you think he or she should be able to do?" 2
• Social history: Racial/ethnic heritage, family composition, potential trauma exposure 1, 2

Age-Specific Examination Components

Infants and Children Under 3 Years

The examination for children under 3 years must include:

• Red reflex examination (Brückner test): Perform in darkened room from 18-30 inches with ophthalmoscope at "0" power, viewing both eyes simultaneously; any asymmetry in color, brightness, or presence of white reflex is abnormal and requires immediate referral 1
• Vision assessment: Determine if each eye can fixate on an object, maintain fixation, and follow the object into various gaze positions, performed binocularly then monocularly 1, 3
• External inspection: Penlight evaluation of lids, conjunctiva, sclera, cornea, and iris for structural abnormalities (cataracts, corneal opacities, ptosis) 1, 3
• Ocular motility assessment: Evaluate alignment using corneal reflex test; normal binocular alignment should be established by 6 months of age 1, 3
• Pupillary examination: Pupils should be equal, round, and reactive to light; asymmetry >1mm suggests neurologic disorder 1
• Instrument-based screening: Attempt between 12 months and 3 years to detect amblyopia risk factors 3

Critical pitfall: Lack of cooperation or disinterest can simulate poor vision response; ensure child is awake and alert during testing 1, 3

Children 3 Years and Older

Add the following to the above components:

• Visual acuity testing: Begin at age 3 years (if cooperative) or 4 years using age-appropriate symbols (picture cards, wall charts, or optotypes); routine screening recommended at ages 4 and 5 years 1, 3
• Ophthalmoscopy: Attempt funduscopic examination 1
• Binocularity/stereoacuity testing: Use random dot E stereo test to assess depth perception 1
• Visual field testing 1
• Anterior segment examination 1

If child does not cooperate at age 3: Reattempt in 4-6 months; if age 4 or older, reattempt in 1 month 1

Adolescents (12-17 Years)

Include all components for older children, plus:

• Tanner staging for pubertal development 4
• Psychosocial assessment: Screen for trauma, behavioral concerns, and mental health 2, 4
• Cycloplegic retinoscopy/refraction when indicated 1

Critical Examination Sequence

Follow this specific order to maximize diagnostic yield:

1. Test sensory function BEFORE any dissociating techniques (such as covering an eye for visual acuity or alignment testing) 1
2. Perform binocular alignment testing BEFORE cycloplegia 1
3. Perform Brückner test BEFORE pupillary dilation (subtle red reflex differences are difficult to detect after dilation) 1

High-Risk Conditions Requiring Referral

Refer immediately to pediatric ophthalmologist if:

• Red reflex abnormalities: White pupil, dark spots, absent reflex, or asymmetry (may indicate retinoblastoma) 1
• Persistent ocular misalignment after 6 months of age (risk of amblyopia) 3
• Failed vision screening or unable to be tested 1
• Poor eye contact after 8 weeks of age 3
• High-risk medical conditions: Down syndrome, prematurity, juvenile idiopathic arthritis, neurofibromatosis 1
• Positive family history: Amblyopia, strabismus, retinoblastoma, congenital cataracts, congenital glaucoma 1, 2

Additional Screening Components

Beyond the eye examination, assess:

• Growth measurements: Height, weight, head circumference 5
• Developmental surveillance: Formal screening at 9,18, and 30 months; autism-specific screening at 18 and 24 months 5
• Hearing assessment: Inquire about response to sounds and language development 2
• Nutritional status: Diet patterns, feeding history 2, 5
• Immunization status: Review and update as appropriate 4, 5
• Safety assessment: Car seat use (rear-facing until age 2), home safety, water safety 2, 5
• Screen time: Avoid before 18 months (except video chatting); limit to 1 hour daily for ages 2-5 years 5
• Postpartum depression screening in mothers of infants up to 6 months 5

Document the child's level of cooperation, as this aids in interpreting examination results 1