What are the recommended components of a systematic, age‑appropriate pediatric physical examination, including growth measurements, vital signs, organ‑system review, and developmental assessment?

Systematic Pediatric Physical Examination Components

A comprehensive pediatric physical examination must include age-appropriate growth measurements (weight, length/height, head circumference plotted on CDC/WHO growth curves), vital signs, systematic head-to-toe organ assessment, and developmental surveillance at every visit, with formal developmental screening using validated tools at 9,18, and 30 months. 1, 2, 3

Growth Measurements and Anthropometrics

All pediatric visits require accurate anthropometric measurements plotted on standardized growth curves to detect growth abnormalities:

• Measure and plot weight, length (or height if standing), and head circumference on CDC or WHO growth charts to identify percentiles or standard deviation scores 1, 2, 3
• Head circumference measurement is mandatory in all children under 3 years of age, as microcephaly or macrocephaly warrant further evaluation 1, 2, 3
• Mid-upper arm circumference (MUAC) can supplement weight assessment if fluid retention or other factors compromise weight reliability 1
• For premature infants, correct for gestational age when assessing growth and developmental milestones for at least the first 24 months by subtracting weeks born early from chronological age 1, 2, 3

Vital Signs Documentation

Document all vital signs at every visit, with age-appropriate normal ranges:

• Heart rate, blood pressure, respiratory rate, and oxygen saturation are crucial for assessing overall health 2, 4
• Temperature measurement should be included 4, 2
• Normal respiratory rate for a 4-week-old infant is 30-60 breaths per minute 2

General Appearance and Behavioral Observation

Observe the child's overall presentation throughout the entire visit:

• Assess overall appearance, activity level, and interaction with caregivers during the entire examination 1
• Watch posture, play, and spontaneous motor function without stressful demands of deliberate observation, as this yields critical diagnostic information, especially if the child becomes uncooperative 1
• Evaluate level of arousal and environmental interaction, as alterations may indicate systemic illness 1

Head-to-Toe Systematic Examination

Head and Neurological Assessment

• Examine fontanelles for size, tension, and closure status in infants and young children 1, 2
• Assess head shape for abnormalities or asymmetry 1
• Evaluate cranial nerves through observation: eye movements, visual confrontation response, pupillary reactivity, facial expression quality (smile and cry), and oromotor movements 1
• Assess tone and posture through ventral suspension in infants, as they should demonstrate appropriate head control for age 2
• Evaluate primitive reflexes in infants, including Moro, rooting, sucking, and grasp reflexes 2

Eye Examination

• Perform red reflex testing bilaterally to detect cataracts, retinoblastoma, or other ocular media abnormalities 1, 2, 3
• Conduct binocular red reflex (Brückner) test to assess symmetry 1, 2, 3
• Perform external inspection of ocular and periocular structures 1
• Assess fixation, following behavior, and pupillary responses 1
• Poor eye contact warrants further assessment 1

Ear, Nose, and Throat

• Examine tympanic membranes for appearance and mobility 1
• Assess nares for patency and discharge; bilateral choanal atresia can present with respiratory distress in newborns 2
• Examine oral cavity including palate integrity, tongue position, frenulum, and dentition 1, 2
• Drooling or poor weight gain may suggest oral motor weakness 1

Cardiovascular System

• Auscultate heart for rate, rhythm, and presence of murmurs 1, 2
• Many innocent murmurs present in infancy, but pathologic murmurs require evaluation 2
• Assess peripheral pulses for quality and symmetry 5
• Evaluate skin and mucous membrane color and capillary refill 5

Respiratory System

• Auscultate lungs for air entry and abnormal sounds 1
• Assess respiratory rate and pattern 1, 2

Abdominal Examination

• Palpate for organomegaly, masses, or tenderness 1
• In infants, examine umbilical cord site for complete healing and absence of infection, discharge, or granuloma 2
• Inspect umbilical area in older infants (should be fully healed by 15 months) 1

Genitourinary Examination

• Examine external genitalia for normal development and any abnormalities 1
• In males, assess for descended testes bilaterally, hypospadias, hydrocele, or inguinal hernia 2

Musculoskeletal and Neuromotor Assessment

This is a critical component requiring careful observation and specific maneuvers:

• Perform Ortolani and Barlow maneuvers in infants to screen for developmental dysplasia of the hip 2
• Assess for hip click, limited abduction, or asymmetric thigh folds 2
• Observe functional motor skills: ability to stand, cruise, walk independently, and transition between positions in toddlers 1
• Watch for Gower maneuver (inability to rise from floor without using arms to push up), which suggests proximal muscle weakness 1
• Assess muscle bulk, texture, and joint flexibility 1
• Evaluate tone through observation of posture and movement quality; increased tone may cause aberrant milestone patterns 1
• Note any asymmetry in movement, posture, or grasp, as development of handedness before 18 months is abnormal and suggests increased tone or unilateral cerebral palsy 1, 3
• Observe for involuntary movements or coordination impairments 1
• In infants, assess postural tone through ventral suspension and evaluate extremity tone by assessing scarf sign and popliteal angles 2

Skin Examination

• Inspect skin for color, perfusion, rashes, lesions, or signs of injury 1
• Examine for acanthosis nigricans or other dermatologic findings 1

Developmental Surveillance and Screening

Developmental assessment is mandatory at every well-child visit:

Developmental Surveillance (Every Visit)

• Ask parents specific developmental screening questions: "Is there anything your child is not doing that you think he or she should be able to do?" and "Is there anything your child is doing that you are concerned about?" 1
• Do not dismiss parental concerns, as parents are often the first to recognize developmental problems 3

Formal Developmental Screening (Specific Ages)

• Administer standardized developmental screening tools at 9,18, and 30 months using validated instruments such as Ages and Stages Questionnaire (ASQ-3) or Parents' Evaluation of Developmental Status (PEDS) 3
• ASQ-3 has 85% sensitivity and 86% specificity; PEDS has 75% sensitivity and 74% specificity 3
• Parent-completed tools are more practical and time-efficient in primary care settings than directly administered tools 3
• Perform autism-specific screening at 18 and 24 months 6

Critical Red Flags Requiring Immediate Referral

• Regression of any previously acquired skills suggests progressive neuromuscular disorder and requires immediate referral 3
• Asymmetry in movement, posture, or hand use is abnormal 3

Additional Screening Components

Vision Screening

• Review newborn hearing screening results if not previously documented 3
• Consider formal audiometry if concerns exist or if speech/language delays are present 3

Maternal Mental Health

• Screen for postpartum depression in mothers of infants up to six months of age 6

Physical Examination Approach by Age

Infants (Birth to 12 Months)

• Focus on primitive reflexes, fontanelle assessment, hip examination, and developmental milestones 2
• Expected milestones vary by age but include head control, rolling, sitting, and early mobility 2

Toddlers (12-36 Months)

• Emphasize walking ability, fine motor skills (pincer grasp), language development (several words by 15 months), and social interaction 1
• Formal developmental screening at 18 and 30 months is mandatory 3

Preschool Age (3-5 Years)

• One-time vision screening between three and five years of age is recommended to detect amblyopia 6
• Continue growth monitoring and developmental assessment 6

Common Pitfalls to Avoid

• Do not rely solely on informal developmental surveillance; formal screening with validated tools significantly improves detection of delays 3
• Do not delay referral when red flags are present, as early intervention improves outcomes 3
• Physicians during health care consultations often miss the opportunity to monitor growth while addressing acute issues 7
• Consider the child's age and developmental level when approaching the physical examination to maximize cooperation and information yield 8