• Vital signs within normal limits for age and gender
• See Heart and Respiratory Rate for Age Category table
• See Blood Pressure for Age and Gender
• Elevated temperature may indicate an internal cause such as infection or may be caused by environmental heat such as sitting or riding in an unairconditioned car during hot weather
• Subnormal temperature may be due to illness or environment; note that newborns commonly have subnormal temperatures in response to infection or sepsis
• Elevation or decrease of other vital signs may indicate organ malfunction or may occur in response to fever or hypothermia

• CNs: Motor and sensory functions intact

Note that some CNs have both sensory (detect sensation or taste) and motor (movement) functions; when possible, both should be assessed

• DTRs brisk

• Newborn reflexes within normal limits
• Moro reflex limbs form symmetrical embrace when startled
• Tonic neck—extends arm and leg on side to which supine infant is turned
• Roots or searches for nipple when cheek is stroked
• Grasps finger or object that is placed into hand
• Asymmetrical Moro reflex may indicate nerve damage or clavicular fracture

• Age-appropriate developmental milestones attained; see Developmental Milestones

• Findings within normal limits as determined by testing standards

• Clean and intact, without lesions or parasites
• Redness may indicate infection or burn
• Pallor (paleness) may indicate anemia or poor arterial blood supply
• Lesions may indicate local or systemic disease
• Dimpling or sinus tract at lower spine may indicate underlying spinal disorder or risk for future pilonidal cyst
• Punctate lesions on the dorsal side of the finger webs or linear “burrows” under the skin on other parts of the body may indicate scabies, a mite that lives under the skin and causes pruritus (itching); in teenagers, scabies may occur in the genital area
• Velvety dark color of skin in the axilla or on the back of the neck (acanthosis nigracans) may indicate insulin resistance

Table

• Nail beds pink; capillary refill brisk after blanching
• Pale nail beds may indicate anemia or response to cold stimuli
• Bluish nail beds indicate cyanosis from low oxygenation of blood
• Slow capillary refill indicates decreased peripheral circulation (due to pathology or cold)

• Base of nail plate forms angle of 130° to 160° at attachment to finger, when viewed from the side
• Increase of nail plate angle occurs in clubbing and may indicate chronic respiratory or cardiac problems

• Clean and free of nits and parasites
• Small particles that seem stuck to hair may indicate pediculosis (lice); lice may attach on neck at base of hairline

• Symmetrical distribution of hair with no bald patches on head
• Asymmetry of hair distribution or bald areas may indicate hereditary characteristic, abuse, hair pulling, tinea capitis (“ringworm”—not a worm but a fungal infection) that usually manifests as a circular patch of hair loss

• Hair color is appropriate for race
• Unusually pale hair color may indicate albinism
• Protein malnutrition may cause brown hair to turn a reddish color

• Hair is soft in texture
• Coarse or dry hair may indicate hypothyroidism

• Head symmetrical
• During first few days of life, head may be slightly asymmetrical due to molding in infants delivered via vaginal birth
• Infants who are placed on their backs to sleep (as recommended) may appear to have flattening of the occiput (back of head)
• Marked asymmetry of head

• HC measured at largest circumference; size between 5th and 95th percentile on standardized Centers for Disease Control and Prevention (CDC) growth chart for age and gender
• In newborn, HC exceeds chest circumference by 2–3 cm
• At 1–2 yr, HC equals chest circumference
• In older child, chest circumference exceeds HC by 5–7 cm
• HC below 5th may indicate lack of expected brain growth
• HC above 95th percentile may indicate hydrocephaly or increased intracranial pressure

• Anterior fontanel: 3–4 cm in length, 2–3 cm in width until 9–12 mo of age; closes at 9–18 mo
• Posterior fontanel: 0.5–1 cm across; may seem to be closed at birth or by 3 mo of age
• Fontanels normally soft and flat; may normally bulge during crying
• Abnormally large fontanels or delayed closure may indicate hydrocephaly
• Bulging or taunt fontanels in a quiet child may be associated with increased intracranial pressure that occurs with hydrocephaly or meningitis
• Premature closure of anterior fontanel may restrict head/brain growth but is sometimes seen in normal children; children with early fontanel closure are monitored closely for abnormal neurological signs

• Inner canthus of eyes in alignment with tops of ear pinna; note that outer canthus of eyes may appear higher than top of ears as a result of genetic or racial variation in the slant of the eyes
• Upper tip of ear pinna located below inner canthus of eye may be associated with intellectual disability or abnormal genetic syndrome

• Newborn infant startles to unexpected sound (Moro reflex or startle reflex)
• Older infant turns head in attempt to localize (find) sound
• Older child demonstrates intact hearing by repeating or responding appropriately to spoken words or may be assessed using whisper test
• Failure to respond to sound
• Conductive hearing loss
• Example is hearing loss caused by cerumen impaction or swollen ear canal
• Sensorineural hearing loss
• Example is hearing loss caused by nerve damage or structural abnormalities

• No drainage or foreign body in ear canal
• Purulent drainage in ear canal may indicate otitis externa or ruptured tympanic membrane (TM) caused by acute otitis media (AOM)
• Swollen or reddened canal may indicate otitis externa
• Impacted cerumen may obstruct hearing and view of TM. Note: Do NOT irrigate ear canals unless the TM is visible and intact
• TMs and expected bony landmarks visible without redness, retraction, or bulging of TM; redness of TMs is normal in a crying child
• Retracted TM and/or air bubbles or air-fluid line behind TM may indicate serous otitis media; also known as otitis media with effusion
• Red or bulging TM in quiet child may indicate AOM; viral or bacterial

• Red reflex observed bilaterally
• Lack of red reflex indicates abnormality in the globe of the eye such as cataract or retinoblastoma

• Corneal light reflex is symmetrical; transient asymmetry of corneal light reflex or crossing of eyes may be normal in newborns
• Asymmetry of corneal light reflex may indicate strabismus due to nerve injury or poor eye muscle control

• Conjunctiva pink without excess tearing
• Conjunctival injection (redness) may indicate allergy or infection
• Infant: Excess tearing in infant may indicate congenital blocked tear dacryocystitis (passage) irritation, or infection

• Infant: Eyes of newborn track bright objects held near face; older infant reaches for toy or has a “social smile” in response to caregiver’s smile
• Young child: Child plays appropriately with toys, observes television without moving close to screen, or names objects on special eye chart with simple recognizable shapes (such as a house or heart)
• Preschooler: Child identifies direction on a blackbird or Snellen E chart
• School age and older: Child identifies letters on Snellen chart
• Failure to respond appropriately to vision testing should be reported

• External structure of nose approximately symmetrical
• Marked asymmetry of external nose may indicate history of trauma or congenital anomaly
• No nasal flaring
• Flaring (widening) of nostrils during breathing may indicate respiratory distress

• Mucous membranes pink
• Redness of mucous membranes may indicate infection
• Paleness may indicate allergy or anemia
• Bluish tint may indicate allergy or cyanosis

• No visible deviated or enlarged structures or polyps
• Deviated septum may indicate congenital malformation or history of fracture
• Enlarged structures may indicate irritation or infection
• Nasal polyps may be associated with allergies, chronic sinusitis, or cystic fibrosis and may result in obstructed nares, mouth breathing, and post-nasal drip

• Child breathes through both nares
• Inability to breathe through one naris may indicate congestion or choanal atresia; inability to breathe through both nares usually indicates congestion
• Note: Infants are considered to be obligate nose breathers; nasal congestion may compromise oxygenation

• Lips moist and free of cracking and fissures
• Cracking of lips may indicate dehydration or mouth breathing due to nasal congestion or air hunger
• Fissures in corners of mouth may indicate vitamin deficiency, fungal infection, or irritation

• Oral mucosa moist, pink, and free of lesions and white plaques
• Dry mucosa may indicate dehydration
• Red mucosa may indicate irritation or infection (viral or bacterial)
• Pale mucosa may indicate anemia or allergy
• Mucosal ulcers may indicate autoimmune disorder, stress, viral or bacterial infection
• White plaques on mucosa may indicate Candida (thrush) infection

• Hard and soft palates intact without lesions
• Cleft (fissure) may congenitally occur in upper lip, hard palate, and/or soft palate of mouth
• In infants: Epstein pearls or cysts are benign white or yellow epithelial nodules that occur on the gums or hard palate

• Dentition appropriate for age (see figure Dentition)
• Failure of tooth or teeth to erupt
• Eruption of permanent tooth before loss of primary tooth
• No dental caries
• Dental caries

• Uvula midline
• Slightly deviated uvula may be normal
• Deviated uvula may indicate vagus nerve (CN X) lesion or infection including peritonsillar abscess, or may accompany scoliosis

Grading of Tonsils

• In toddler, tonsils may normally be enlarged but not red or infected
• In older child, tonsils may be atrophic and appear absent
• Red, infected, or enlarged tonsils may impair ability to swallow, which may result in dehydration
• Peritonsillar abscess may result in generalized edema and pus collection around one or both tonsils and may impair breathing
• Cryptic or scarred tonsils appear to have pits or pockets that may trap food particles or bacteria and may cause chronic sore throat

• Tongue extends over lower gum line
• Tongue that does not extend over lower gum line appears “heart” shaped and may indicate ankyloglossia (tongue-tie due to short lingual frenulum)

• No webbing
• Webbing of neck may indicate Turner’s syndrome

• No palpable lymph nodes
• Shotty nodes (shotty refers to buckshot or BB-sized nodes) are expected in children; they may signify past infection
• Nodes 1 cm or larger; if tender and mobile, often signify infection
• Nontender and immobile nodes may signify underlying tumor (attachment to tumor limits mobility)
• Unilateral nontender cervical lymph node may signify Kawasaki disease

• No thyromegaly; thyroid may be nonpalpable or detected as a small soft mass on both sides of the trachea
• Thyroid mass or enlargement palpable

• Full ROM
• Nuchal rigidity demonstrated by limited flexion (chin toward chest) may indicate meningitis
• Torticollis or wryneck (head tilts forward or to the side) may be caused by infection or trauma, including birth injury or malpositioning in utero

• No bruit (pronounced “broo-ee”)
• Bruit—a blowing sound—indicates arterial obstruction

• Point of maximum cardiac impulse (PMI) at the 3rd or 4th intercostal space (depending on age) at the left midclavicular line
• Displaced PMI may indicate left ventricular hypertrophy
• No lift or heave
• Lift or heave may indicate heart failure

• Lips and nail beds pink with brisk capillary refill (1–2 seconds) of nails
• Newborns may normally have temporary cyanosis of extremities; called acrocyanosis
• Central cyanosis (lips) may indicate cardiac or respiratory problem

• No edema in extremities or face
• Edema may indicate heart failure or fluid overload; facial edema may indicate renal disorder

• No thrill (palpable vibratory sensation caused by a heart murmur)
• A thrill indicates that a heart murmur is at least a grade IV–VI (see murmur grading criteria)

• Pulses strong and equal (see illustration of peripheral pulse locations on Heart Auscultation Areas and Peripheral Pulses)
• Decreased amplitude of femoral pulses may indicate coarctation of the aorta

• Heart rate within normal limits for age; see Heart and Respiratory Rate by Age Category
• Regular rhythm
• Heart rate may vary markedly as respiratory rate changes (known as sinus arrhythmia)
• Audible splitting of S₁ and S₂ is common in young children and those with thin chest walls
• No murmurs
• Febrile or anemic children may have transient murmurs
• Note whether murmurs are systolic or diastolic
• Murmurs are graded on a I–VI scale according to intensity (volume) (see murmur grading criteria)
• Note for murmurs:
• Location: Aortic, pulmonic, tricuspid, or mitral area
• Radiation: Location of sound
• Timing: Early, mid, or late systole or diastole
• Character: Crescendo—gradual increase in volume; decrescendo—gradual decrease in volume
• Quality: Harsh, blowing, or rumbling
• Pitch: High, medium, or low
• Variance: With position change or respirations

• Blood pressure between 5th and 95th percentile for height, age, and gender; see table at website: https://www.nhlbi.nih.gov/files/docs/guidelines/child_tbl.pdf
• Elevated blood pressure in children is most often due to obesity or a renal disorder
• To be accurately diagnosed with hypertension, a child should have systolic or diastolic blood pressure equal to or greater than the American Academy of Pediatrics guide for age and gender on three separate occasions

• Anterior-posterior (AP)–lateral view of a young child’s chest appears rounded; as child grows, the AP–lateral view is about 2:3
• Chest may remain rounded (barrel shaped) in child with chronic respiratory disease such as chronic obstructive pulmonary disease (COPD)

• Respiratory rate regular and unlabored; rate varies by age: see Heart and Respiratory Rate by Age Category
• Periodic breathing (apnea up to 20 seconds is normal in newborns)
• Infants and young children are abdominal breathers
• No respiratory retractions (sinking in of chest soft tissue with inspiration)
• Retractions indicate air hunger
• No expiratory grunt
• An expiratory grunt indicates an attempt to keep the lungs expanded, as in the child with bronchiolitis

• Bronchial sounds are loud and high-pitched hollow sounds that are heard over the upper anterior chest
• Bronchovesicular sounds are softer tubular sounds heard in the anterior central chest and between the scapula in the posterior chest
• Vesicular sounds are soft blowing sounds heard throughout peripheral lung fields
• Adventitious sounds heard with auscultation may indicate foreign body or mucus in airway, bronchiolitis, asthma, pneumonia, or other pathology
• Rales have a crackling sound and are common in pneumonia
• Rhonchi are coarse sounds that often clear with coughing and are often heard when there are obstruction or secretions in an airway
• Wheezing, musical, or sibilant rales are whistling sounds that are common with asthma and bronchiolitis

• Abdomen is slightly rounded
• Young children are abdominal breathers; abdomen is expected to move with respiratory effort
• No visible peristalsis
• Visible peristalsis may indicate pyloric or bowel obstruction

• Abdomen is soft with no masses or bulges
• A distended and rigid abdomen may indicate gas or obstruction
• Rigidity may indicate guarding due to pain
• Young children with a palpable abdominal mass should be assessed for tumor, including Wilms’ tumor, a tumor of the kidney
• Visible peristalsis may indicate bowel obstruction
• A reducible transient umbilical hernia may exist in infants and young children; most resolve without treatment as muscles strengthen
• Nonreducible hernia (report immediately because blood supply may be impaired)
• The lower edge of liver may be palpated and percussed about 1–3 cm below the right costal margin (RCM)
• Liver that is more than 3 cm below the RCM may indicate heart failure
• The tip of the spleen may be palpated and percussed below the left costal margin (LCM)
• Palpation of a large area of the spleen may accompany sickle cell disease or infectious mononucleosis
• Note that the scratch test (placing a stethoscope on the abdomen and lightly using your fingertips to make a scratching movement over the abdomen) may be used to estimate edges of the liver and spleen. Quality of sound heard with the stethoscope changes as fingertip motions move away from solid organs such as the liver and spleen

• All structures are symmetrical in form, movement, and strength; one foot, hand, ear, etc., may normally be slightly larger than the other
• Marked asymmetry of structures, movement, or strength may be due to congenital malformation or injury

• Length (measured supine) or stature (height measured standing) between the 5th and 95th percentile for age and gender (CDC growth charts availability Growth Charts)
• Weight between the 5th and 95th percentile for age and gender
• Weight or length/stature measurements that are below the 5th percentile or above the 95th percentile on CDC growth charts require further assessment

• BMI between 5th and 84th percentiles for age and gender (see charts on BMI Calculation and Interpretation)
• Children whose BMI for age and gender is at or above the 84th percentile but below the 95th percentile are termed “overweight”
• Children whose BMI for age and gender is at or above the 95th percentile are termed “obese”

• Spine midline with mild convex curve of thoracic and mild concave curve of lumbar areas
• Kyphosis: Exaggerated convex curvature of thoracic spine
• Lordosis: Exaggerated concave curvature of lumbar spine
• Scoliosis: Lateral curvature of spine; most frequent in females and during adolescent growth spurt; uneven shoulder height or uneven hip height may indicate scoliosis

• Moves upper extremities symmetrically, through full range of motion
• Marked structural difference or limited or asymmetrical range of motion requires further investigation

• Genu varum (bowleggedness) is normal until age 2 years
• Bowing of one leg or worsening of this variation beyond 2 years of age may indicate rickets or Blount’s disease
• Genu valgum (knock-knees) is common in preschoolers
• Toes point forward and plantar aspect (bottom) of feet touch level surface when standing
• Metatarsus adductus or varus (toeing inward or pigeon toes) is normal in young children
• Talipes equinovarus (clubfoot): Plantar aspect of foot turns inward and downward and is not flexible
• Scissoring of lower extremities may indicate cerebral palsy
• Flatfeet (arches touch floor when standing) are normal in infancy and early childhood; arch develops during childhood

• Moves lower extremities symmetrically, through full range of motion
• Toe-walking is common in young toddlers

• Skin intact without lesions
• Lesions may indicate diaper dermatitis, candidal infection, or sexually transmitted disease (STD) or infection (STI)

• Urinary meatus located at tip of penis
• Hypospadias: Urethral opening is on the ventral or underside of the penis
• Epispadias: Urethral opening is on the dorsal or upper side of the penis

• Testes descended with rugae present
• Cryptorchidism: Undescended testicles

• Rectal area clean and free of lesions and protrusions
• Caking of fecal matter may indicate neglect of an infant or poor hygiene in an older child
• Lesions may indicate sexually transmitted diseases and/or sexual abuse
• Protrusion from the rectum may indicate hemorrhoids or prolapsed rectum (prolapsed rectum more common in child with cystic fibrosis)

• Skin intact without lesions
• Lesions may indicate diaper dermatitis, candidal infection, or sexually transmitted disease
• Labia majora covers labia minora and clitoris
• Labia majora are poorly developed in premature infants
• A prominent clitoris may indicate a chromosomal abnormality
• Urethral and vaginal orifices patent
• Imperforate vaginal hymen should be referred

• Rectal area clean and free of lesions and protrusions
• Caking of fecal matter may indicate neglect of an infant or poor hygiene in an older child
• Lesions may indicate sexually transmitted diseases and/or sexual abuse
• Protrusion from the rectum may indicate hemorrhoids or prolapsed rectum