Medical Examinations at Child Welfare Clinics

Aims

• Ensuring that the baby exceeds his/her birth weight
• Diagnosis of developmental dysplasia of the hip by this age at the latest
• Detection of congenital cataract
• Detection of any cholestasis by this age at the latest Jaundice in the Newborn
• Detection of severe visual or hearing impairment, developmental disability or cerebral palsy or serious heart disease
• Noting any problems in the interaction between the child and parent, as well as any depression in the mother
• Organization of extra support, as necessary (such as more frequent visits by a public health nurse, home visits by a family support worker, baby family work, child guidance and family counselling centre, other support by social and/or child welfare services, referring a parent for treatment, interaction therapy)

Course of medical examination

• Read any notes made by the public health nurse (family situation, general observations, depression screening result for the mother), as well as the obstetrician's notes from the maternity hospital, showing the duration of the pregnancy, any abnormalities observed after birth and any risk factors.
• Before examining the child, check the progression of his/her length, weight and head circumference on growth charts Normal and Abnormal Growth in Childhood.
• Ask the parents how caring for the child is going, about nursing/feeding, sleeping, how the parents and other family members are and whether they have any particular concerns. Postnatal depression is common and intervention is warranted, for the benefit of the mother and the infant since interaction problems may have far reaching implications. Make a new appointment to discuss this, as necessary Monitoring a Child's Psychological Development at Child Health Clinics Postpartum Psychosis and other Postpartum Mental Disorders A Crying Infant.
• If the examination leaves you uncertain of whether there might be an abnormality in the child's development, the examination should be repeated after a short time interval (at this age, within one week).
• Interaction and wellbeing should be observed while the parent is undressing the baby, already. Course of the examination - on the examination table or with the infant held by the parent (cf. also the article Physical examination of the newborn] Physical Examination of the Newborn):

1. General impression, muscle tone, alertness. A referral for further investigation is warranted if the child's general health shows abnormal features (emergency referral). Signs suggestive of cardiac problems in an infant include exhaustion whilst feeding, atypical pallor and sweating as well as increased respiratory rate (over 40 bpm).
2. Interaction and contact with the parent. The parent's responses to the infant should be empathetic and warm Monitoring a Child's Psychological Development at Child Health Clinics. The child should look comfortable on the parent's lap.
3. Observe and ask about oral motor functions and any vocalising: the child should be able to suck without problems and make short series of vowel sounds.
4. Observe fixation of the eyes towards light. The child should be able to make brief eye contact and follow with his/her eyes for at least 90 degrees from one side to another and across the midline. Absent fixation or nystagmus may indicate visual impairment.
5. Check pupil size and reaction to light and confirm the presence of the red reflex with an ophthalmoscope Examination of Vision at Child Welfare Clinics. The examiner should be able to establish at least momentary eye contact with the baby.
   • Examine the sclerae. If they are yellowish, test plasma bilirubin; see Jaundice in the Newborn.
6. Auscultate the heart and palpate the femoral pulses. Absence of the femoral pulses is an indication for blood pressure measurement in the lower limbs; see Heart Auscultation and Blood Pressure Recording in Children Cardiac Murmur in a Child.
7. Palpate the head and cranial sutures Head Growth in Children, inspect the skin, palpate the abdomen, liver, spleen, possible masses.
8. Examine the testes or the vulval region. If the testes are undescended, inform the parents and examine the testes again at the next checkup Undescended Testicle.
9. Observe the posture of the child (remember the asymmetric tonic neck reflex which is a normal phenomenon) and spontaneous movements in the prone and supine positions; the movements should be symmetric, alternate and varying. Examine the muscle tone of the trunk and neck-shoulder region by handling and observing the child in various positions. At the same time, observe the muscle tone of the limbs. Examine the tone of the limbs also by flexing the joints. Make sure that the ankles can be flexed with gentle pressure with the hips and knees extended, and that the hips can be easily passively fully flexed. At the same time, inspect the feet for possible structural posture anomalies Structural Anomalies in Children.
10. Holding the child under the arms, check the support and stepping reflexes. Ability to support the whole body weight is not necessarily a sign of hypertonia.
11. Observe whether the child is able to lift the head from the prone position so as to free his/her nose.
12. Observe opening the hand from a fist. This should occur from time to time.
13. Carry out the Ortolani test and the provocation test. In this connection, observe any leg length discrepancy and asymmetry of skin folds. If either one is suspected but the Ortolani test is negative, perform the heel-buttock test. Even a suspicion of congenital dislocation of the hip is an indication for further investigations Congenital Dislocation of the Hip.
14. Check that auditory screening (otoacoustic emission test or automated brainstem auditory evoked potential screening) has been performed at the maternity hospital. If not, this should be arranged. At this age, examination of hearing is unreliable: the infant may stop sucking on the pacifier or blink his/her eyes when hearing a sudden noise (human voice, rustling of paper) but he/she may equally well react to an air current, for instance. Even a person with severe hearing impairment may react to a low-frequency horn.

Aims

• Detection of hypertonia, abnormal body posture or movements, or asymmetry in order to commence early neurological rehabilitation
• Identification of any serial jerky movements (often there is a change in alertness, such as upon waking) suggesting infantile spasms. If these are suspected, refer the child for further investigation.
• Problems with early interaction, the mother's exhaustion or other need for extra support should be detected and psychosocial support arranged (e.g. more frequent visits by the public health nurse, home visits by a family worker, cooperation with child welfare, referring a parent for treatment, interaction therapy). The 4-month checkup is an extensive health check.
• If the examination leaves you uncertain of whether there is an abnormality in the child's development, repeat the examination in 2-4 weeks' time.

Course of medical examination

• Ask how everyday life is going, how the parents are coping and whether there are any particular concerns. How is the baby, how does he/she eat and sleep?
• Check the progression of the child's length, weight and head circumference Normal and Abnormal Growth in Childhood and read any notes entered in the documents by the public health nurse (vaccinations, general observations).
• Course of the examination on the examination table:

1. General impression and alertness
2. Interaction and contact with the parent. The child should smile in response to a smile and being talked to. He/she should be able to babble, squeal and laugh out loud, and make various sounds in response to talk Monitoring a Child's Psychological Development at Child Health Clinics.
3. The child should lie supine and undressed. Check the child's ability to fixate by moving a red object, a clear picture or your own face above his/her head from one side to the other. If the child fails to follow with his/her eyes ask the mother about her observations regarding eye contact, and if any abnormality is suspected, refer the baby to a specialist. The child's inability to follow an object during the examination and according to parental observation is an indication of an abnormality warranting further investigation Examination of Vision at Child Welfare Clinics.
4. Check the light reflex (Hirschberg test) and the red reflex. Strabismus and absence of red reflex warrant a referral to a specialist.
5. Ask the parent about the baby's reaction to auditory stimuli. Pay special attention to hearing if the child does not vocalize much, the parents suspect a hearing impairment, or the family or pregnancy history (prematurity, asphyxia, infections) suggests the risk of a hearing defect. Ring a small bell at about 20 cm from the ear (each in turn), as necessary. Does the baby stop to listen (stopping moving and vocalizing) or does he/she turn his/her head towards the sound (directional auditory reaction)? Lack of directional auditory response at this age is not a significant finding yet. A directional hearing response can often be obtained on one side, at least, if the sound is sufficiently interesting (human voice, rustling of paper or the like). If the parents suspect hearing loss or hearing appears impaired, the child should be referred for an objective hearing test. A directional auditory response should develop by the age of 6 months. If not, further hearing investigations will be needed.
6. Auscultate the heart and palpate the femoral pulses; cf. Heart Auscultation and Blood Pressure Recording in Children Cardiac Murmur in a Child.
7. Check the use of the upper limbs by handing the child an object that is easy to grasp. Normally, the child will bring his/her hands to the midline and can open his/her hands and grasp the object symmetrically.
8. Inspect the skin. Food allergy (milk) must be excluded as the causative agent of any persistent, extensive or worsening atopic eczema. As far as other skin and intestinal complaints are concerned, evaluate first whether the symptom is abnormal and requires further investigation or whether it is a manifestation of normal infancy. See Atopic Dermatitis in Children: Clinical Picture, Diagnosis and Treatment Cow's Milk Allergy.
9. Palpate the abdomen: liver, spleen, and possible masses. Examine the testes. If one testicle is not felt in the scrotum, palpate along the inguinal canal and try to pull the testicle down. If it is possible to pull the testicle down into the scrotum even for a short moment, observation of the situation is sufficient. An undescended testis should be checked again at the age of 6-8 months. However, if neither testicle can be found, refer the child to a paediatric surgeon Undescended Testicle.
10. Observe the baby's movements in supine and prone positions, assessing ranges of motion, amount and quality as well as symmetry of movements. Note the baby's alertness (less movements when tired) and needs (abundant movements, waving arms and legs around, when hungry). Observe movements when the baby is awake and alert and by him-/herself, not when he/she is crying or his/her attention is aroused. The room temperature will also affect movement. The baby should not have an acute somatic disease or be on anti-inflammatory medication. Movements normally alternate and vary in activation. Ranges of motion should be natural and smooth. Assess muscle tone and development of the ability to assume or maintain a vertical position in various positions (supine, prone, holding him/her in the standing and sitting positions), and assess muscle resistance by examining passive ranges of motion of joints.
11. Check head control by pulling the child up gently by his/her hands to about 45 degrees from the horizontal. The head should follow the body or lag no more than 10-15 degrees behind. The child should be able to hold his/her head and upper body steady when fully supported in a sitting position.
12. Place the child in the prone position and observe how he/she supports his/her upper body. Normally the child can support him-/herself with his/her lower arms so that his/her upper chest will rise from the table. Any disparity in holding the head up suggests problems with muscle tone. Lack of training (the baby has not been kept in the prone position) must be noted and the parents guided (by a physiotherapist, as necessary).
13. Check the abduction of the hips and carry out the Ortolani test Congenital Dislocation of the Hip. If stiffness is noted in the hips (the knees cannot be abducted close to the examination table) or the abduction is clearly asymmetric, leg length discrepancy is apparent or a "click" is heard in the Ortolani test, the child should be referred to a paediatric surgeon.

Aims

• Detection of undescended testes and referral to a paediatric surgeon.
• Detection of motor abnormalities in order to introduce early physiotherapy. Asymmetry should already have been diagnosed!
• Detection of strabismus, impaired vision or hearing.
• Detection of preverbal problems: the child should be able to eat food that is of a fairly coarse consistency, imitate sounds and vocalize in a polysyllabic fashion. If necessary, referral to a speech therapist, provided that the child's hearing is normal and there are deficiencies in more than one area Speech and Language Development.
  • Find out about locally available tools (e.g. questionnaires) that can be used for support in assessing and supporting linguistic practices in parenthood.
• Detection of delayed mental development.
• Detection of evident interaction disorders. If the child does not seek contact with the parent (to be held, to have eye contact), this may indicate abnormal parent-child interaction or psychosocial deprivation. Detect any maternal exhaustion.
• Discuss how the child sleeps at night. Teething, rapid motor development, constant feeding at night, etc. may often disturb the child's sleep. Feeding at night may also disturb development of a meal rhythm and weight. Sleep school may be necessary.
• Identify the family's possible need for extra support and organize help as necessary.

Course of medical examination

• Talk to the parents first about the situation at home and ask whether the parents have any particular concerns Monitoring a Child's Psychological Development at Child Health Clinics.
• Check the progression of the child's length, weight and head circumference Normal and Abnormal Growth in Childhood and read any notes entered in the documents by the public health nurse (vaccinations, general observations).
• If the examination suggests an abnormality in the child's development, appropriate professionals should be consulted (e.g. a physiotherapist). They are often able to give the parents advice regarding the child's development. The examination should be repeated within 2-4 weeks. An isolated finding is rarely of great significance.

1. General impression and alertness
2. Observe the child's ability to interact: desire to be held, making eye contact, responsive vocalisation, differentiation between familiar and unfamiliar people Monitoring a Child's Psychological Development at Child Health Clinics.
3. Observe and ask about oral motor functions and vocalising: the child should be able to eat from a spoon, chew and swallow. There should be responsive polysyllabic vocalisation Speech and Language Development.
4. Check the ability to follow with the eyes by moving an object up, down and to the sides. The child should notice a ball of 8 mm in diameter from a distance of 30 cm. Children will often reach out to a breakfast cereal or sugar sprinkles with an emerging pincer grasp (with the forefinger leading). Hirschberg test and the red reflex Examination of Vision at Child Welfare Clinics. Recurrent dacryocystitis or blepharitis warrant referral to an outpatient ophthalmology clinic; mild tearing and purulent discharge can be followed until the age of 12 months Lacrimal Duct Stenosis.
5. Observe and ask about firmly grasping objects with both hands. Ability to transfer objects from hand to hand. Putting things in the mouth. Asymmetry in use of hands is so rare at this age that, if observed, the child should be referred for further investigations.
6. Auscultate the heart Heart Auscultation and Blood Pressure Recording in Children and palpate the femoral pulses.
7. Inspect the skin and palpate the abdomen, testes. If a high scrotal testis or cryptorchidism is detected, refer the child immediately for further investigations Undescended Testicle. Movable testes can be followed.
8. Observe whether the ankles are symmetrically dorsiflexed spontaneously while the hips and knees are extended (often only passive dorsiflexion is elicited during the examination while spontaneous dorsiflexion must be asked about). Absent or asymmetric dorsiflexion is an indication for referral Developmental Coordination Disorder (DCD).
9. Observe whether the child can support the upper body with straightened upper extremities when lying prone, and whether he/she can move the weight onto one hand when reaching for an object with the other (able to grasp the toy without losing balance). If this is unsuccessful, further investigations are indicated. If the child crawls on all fours, reaching for an object need not be tested. An ability to move with determination and favouring new objects indicate normal mental development.
10. Examine the protective reflexes of the head forwards and the sideways protective reflex on both sides. If the protective reflex of the head is totally absent the test should be repeated after one month and the child referred for further investigations, as necessary. If the child sits solidly on the floor unsupported with straight back and head up, this is sufficient and no further investigations are needed. The protective reflex backwards may still be defective at this age.
11. Weight bearing on straight legs. Observe for symmetry and whether the child supports his/her body weight on the soles of the feet or just on the toes and whether the legs cross each other ("scissor position"). Standing on the toes occurs in about 10% even of normal children at this age, but crossing of the legs and adduction spasm are always abnormal. If the child does not support his/her weight normally the examination should be repeated, and if there is no improvement a referral for further investigations is warranted.
12. Check sound localization response with a miniature audiometer (45 dB, frequency 3-4 kHz). The child should localize the sound correctly on both sides. A calibrated small bell (45 dB, 3 kHz) can also be used to test localization response. The auditory stimulus should be presented laterally to the ear, at a distance of 50 cm (not obliquely from above or below) ensuring that the examiner's hand remains behind the child's visual field. If there is no localization response, the ears should be examined. If an infection is diagnosed, the hearing screen should be repeated 2-3 weeks later. If the problem persists, and no fluid is seen behind the tympanic membrane, the child should be referred for an ear specialist. Not all children react to a miniature audiometer because they do not find the voice meaningful but they do react to human voice (such as speaking the child's name).

Aims

• Detection of strabismus.
• Detection of major abnormalities in mental development.
• Detection of problems with early interaction and the mother's exhaustion.
• Disturbances of mental development may appear as eating and/or sleep disorders.
• Problems with contact and language development should be detected and measures should be taken, without hesitation, to treat these.
• Re-evaluation of any food restrictions imposed on a child with allergies. Many restrictions may be lifted from this age onwards.
• Identify the family's possible need for extra support and organize help as necessary.

Course of medical examination

• Talk to the parents first about the situation at home and ask whether they have any particular concerns Monitoring a Child's Psychological Development at Child Health Clinics.
• Check the progression of the child's length, weight and head circumference Normal and Abnormal Growth in Childhood Head Growth in Children and read any notes entered in the documents by the public health nurse (vaccinations, general observations).

1. General impression and alertness
2. Observe the child's ability to interact: desire to be held, making eye contact. The child should show distress with strangers at this age at the latest Monitoring a Child's Psychological Development at Child Health Clinics.
3. Language development Speech and Language Development: children usually have several appropriately used words. Delay in the development of a vocabulary is not critical as such. If the child understands speech and commands well, the situation can be followed even if his/her active vocabulary is limited. The entity of social communication and symbolic skills predicts later linguistic ability and problems. Assessment will require recurrent examinations in more than one area of communication. Refer the child to a speech therapist, as necessary.
   • Find out about locally available tools (e.g .questionnaires) to assist in assessing linguistic parenting practices and the child's linguistic development.
4. Uses a spoon to eat and chews (parental observation)
5. Pincer grasp
6. Builds a tower with two bricks (any problems may be associated with muscle tone, impaired hand-eye coordination or inability to imitate)
7. Appropriate handling of objects
8. Interest in a new toy (sign of visual observation and processing ability)
9. Ability to interact (a ball game, or "give and take" game)
10. Ability to follow with eyes and strabismus: move an object up, down and to the sides Assessment of Vision
11. Hirschberg's test Examination of Vision at Child Welfare Clinics
12. Direct cover test at least for children whose close relatives have had amblyopia or strabismus.
13. Ability to walk without support
14. Ability to stand up without support, e.g. when picking up a ball from the floor
15. Spontaneous movements, sitting posture, muscle tone: pay particular attention to any asymmetry and to torticollis due to visual problems.
16. Hearing test if there are problems with speech production: localization response as at 8 months (miniature audiometer or whispering the child's name, tympanometry to detect glue ear)
    • The development of sound localization responses may be delayed in children with delayed overall development.
17. Skin, heart sounds Heart Auscultation and Blood Pressure Recording in Children Cardiac Murmur in a Child, abdomen, inguinal pulses, testes Undescended Testicle
18. Discuss the vaccination against chickenpox, as necessary, according to locally applicable policy.

Aims

• Detection of strabismus
• Detection of minor abnormalities in mental development
• Detection of linguistic problems
• Detection of chronic diseases delaying growth.
• Difficulty associated with psychosocial development may appear as problems in toilet training, defiance, sleeping and/or eating disorders or as problems in acting in a group. More thorough assessment and support of interaction and parenthood may be necessary. Maltreatment and traumatic experiences of the child should be detected. Contact problems originating from the child should be detected (and the child referred to a paediatric neurologist, as necessary). Support by a child welfare clinic psychologist, a child guidance and family counselling centre or a paediatric psychiatrist may be needed.
• Identify the family's possible need for extra support and organize help as necessary.
• No medical examination is needed for 3-year-olds because a public health nurse can detect all the above problems. Nevertheless, a child welfare clinic physician should also see healthy 3-year-olds from time to time to be able to assess what is normal for children of this age and what not.
• If the child will not settle for the examination or cannot cope with the tasks, this may be due to various causes (fatigue, hunger, distress with strangers, developmental problems). It is worth listening to the parents' explanation and also to the day care centre's view of the child's behaviour and interaction. Repeat the assessment. In some cases, a home visit will provide a more reliable picture. Problems of mental development and interaction, in particular, can be influenced or alleviated by interaction, preventing secondary mental problems, which can otherwise easily accumulate. It is important to recognize behavioural problems; guidance of the parents is an effective form of treatment.

Normal 3-year-old

1. There is nothing particular about the general impression, such as abnormal movements.
2. Psychosocial development: the child should be able to wait for a short time and tolerate a short absence of the parent. He/she should be able to talk about the happenings of the day, for example, relating to himself/herself (narrative self), show interest in other children, tell the difference between reality and fiction and be able to differentiate between the sexes Monitoring a Child's Psychological Development at Child Health Clinics.
3. Gross motor skills: gait, walking on toes, standing on one leg, jumping and throwing a ball. Walking should be directional, rhythmical, bouncy and relaxed. The child should be able to keep the direction even when looking around. If an abnormality is detected in at least three subtasks, when testing gross motor skills, the child should be referred for a physiotherapist or to an outpatient clinic of paediatric neurology for further assessment Developmental Coordination Disorder (DCD). If the child fails two subtasks the examination should be repeated after some time. An overall assessment can also be made in other sub-areas by using the same approach.
4. Speech comprehension: obeys simple commands, able to point to limbs and parts of the face Speech and Language Development
5. Speech production: uses sentences with at least 3 words, uses plural forms Speech and Language Development. Take into account potential linguistic variation in different countries and relevant recommendations.
6. Speech comprehension and perception: able to tell the difference between big and small in a picture, able to place different coloured bricks in their allocated place
7. Hearing comprehension: understands the meaning of similar words that mean different things
8. Hand-eye coordination: able to stack seven bricks, copy a circle and a horizontal and vertical line, able to unscrew a cap
9. Vision: check near and distance vision with an appropriate chart (if the child is not co-operative, the test may be carried out at the next visit) Examination of Vision at Child Welfare Clinics. Checking near vision is most important. Refer the child to an ophthalmologist if the difference in vision between the eyes is 2 lines or more and the combined visual acuity is below 0.5. Notice that country-specific differences may apply, depending e.g. on the charts used. There should be no strabismus.
10. If the child exhibits problems in comprehending or producing speech, check hearing with a miniature audiometer or by whispering the child's name from a distance of approximately 2 m, from both sides of the child.
11. Refer the child to a speech therapist if his/her speech is unclear or scant, if he/she has problems understanding short commands, changes the subject instead of replying to questions or is unable to concentrate on listening.

Aims

• Neurological problems which could lead to learning difficulties at school are evident at this age and appropriate support can be given so as to prevent secondary psychosocial problems, in particular. For learning problems, see Learning Disorders
• Refusing to do tasks may suggest developmental problems. It is necessary to understand the reason for refusal and to perform a holistic assessment.
• Disturbances of psychosocial development may appear as fear symptoms, low mood, clinging to the parents, disobedience, difficulty acting in a group or other interactive or behavioural problems Monitoring a Child's Psychological Development at Child Health Clinics. Assessment and support by a psychologist or child guidance and family counselling centre may be needed. Counselling the parents is an effective form of treating behavioural problems. Find out about local tools for this purpose.
• The Strengths and Difficulties Questionnaire, SDQ (www.sdqinfo.com) http://www.sdqinfo.com/ http://www.sdqinfo.com/py/sdqinfo/b3.py?language=Finnish can be used to collect information on the child's psychosocial wellbeing. Both parents and the person taking care of the child during daytime can fill in their separate questionnaires, and the results can be compared.
• Detect any overweight, discuss the family's eating habits and physical activity, and provide guidance as necessary Overweight and Obesity in Children.
• Identify the family's possible need for extra support and organize help as necessary.

Course of medical examination

• A questionnaire for the parents may be included in the procedure, so that they can consider and write down some key information in advance.
• It is recommended that for the 4-year examination a report be requested from the child's day care facility. They often have a good idea of the child's behaviour, interaction, self-direction, social and other skills and any problems. It is also possible to carry out a part of the 4-year examination in the day care centre.
• Most of the examination will be carried out by the public health nurse but the detailed division of tasks must be agreed locally. The public health nurse uses locally available tool(s) to assess sensory, gross and fine motor functions, interaction, attentiveness, language development, visual perception, play and self-direction. In addition, preparedness for reading and writing can be assessed. The doctor will usually carry out the somatic examination and assess the gross neurological status.
• However, the main task of the doctor is to draw conclusions of any suspected abnormalities, risk factors, resources and the child's overall situation. The doctor should then explain his/her findings to the child and the family and work together with the family to plan any necessary further measures.
• The examination should include the following, at least:

1. General impression
2. Progression of height and weight Normal and Abnormal Growth in Childhood
3. Gross motor skills (see also Developmental Coordination Disorder (DCD)): gait, walking along a straight line, standing and skipping on one leg, doing jumping jacks. Should be able to throw and catch a ball from a distance of about 2 m.
4. Interactive skills: capable of reciprocity; refusal to cooperate very often stems from problems in the development of mental, neurological or interactive skills.
5. Attention and motivation: should be able to concentrate continuously (approx. 10 minutes) on the tasks of the examination.
6. Understanding speech and concepts Speech and Language Development: understands 2-part commands, answers questions appropriately, can name colours and count to three, at least
7. Speech production: uses sentences with at least 3-4 words (local linguistic differences may apply), easily understandable speech
8. Hearing comprehension: understands the meaning of similar words that mean different things.
9. Hand-eye coordination: able to copy patterns (a cross and a square), able to cut along a straight line with scissors, able to thread beads of 1 cm in diameter onto a plastic thread.
10. A shape sorter can be used to examine spatial perception. A four-year-old will be able to insert the 3 easiest blocks into the box. He/she will either be able to insert the 2 most difficult ones (triangle and polygon) straight away or will learn this after having been shown once, and the ability will remain.
11. Vision: check near and distance vision with an appropriate chart, for instance, if this has not been checked at the age of 3.
    • Refer the child to an ophthalmologist in the following cases:
      • combined visual acuity is < 0.5 or
      • there is a difference of ≥ 2 lines in both near and distance vision between the eyes or
      • near vision (combined) is > 2 lines worse than the acuity of distance vision.
      • Notice that country-specific variation may apply concerning the criteria, depending e.g. on the charts used.
      • For more detail, see Examination of Vision at Child Welfare Clinics.
12. Check hearing with an audiometer (screening). If the child does not concentrate well on the examination, it should be repeated. The child should be referred for further examinations and for fitting of a hearing aid if his/her hearing is below 20 dB at 0.25-4 kHz.
13. Somatic examination: skin, facial symmetry, heart auscultation Heart Auscultation and Blood Pressure Recording in Children Cardiac Murmur in a Child, abdomen, femoral pulses, testes Undescended Testicle.
14. Draw conclusions regarding any suspected abnormalities, risk factors, resources and the child's overall situation. Plan any necessary further measures together with the family.

Aims

• This is the last chance to detect and to treat any abnormality before school entry.
• If the child underwent an extensive health check at the age of 4, already, and nothing abnormal was detected there, a medical examination can be skipped at this age. In the 5-year checkup, it is most important to review the conclusions and plans made one year ago and to find out whether these were put into practice.
• Any issues detected at the age of 4 should be re-examined considering that the child is one year older now and the expectations for various skills are thus higher.
• Below is a plan for a health check at the age of 5 years if it has to be done in full (if no extensive checkup was performed at the age of 4).
• Nocturnal enuresis Enuresis in a Child must be treated before school entry.
• Disturbances of psychosocial development should be detected Monitoring a Child's Psychological Development at Child Health Clinics.
• Identify the family's possible need for extra support and organize help as necessary.
• The Strengths and Difficulties Questionnaire, SDQ (www.sdqinfo.com) http://www.sdqinfo.com/ http://www.sdqinfo.com/py/sdqinfo/b3.py?language=Finnish can be used to collect information on the child's psychosocial wellbeing. Both parents and the person taking care of the child during daytime can fill in their separate questionnaires, and the results can be compared.

Course of examination if the child did not undergo an extensive health check at the age of 4 years

• Review any reports: a questionnaire for the parents may be included in the procedure. Day care may also provide useful information for the health check, possibly as a standard procedure.
• A public health nurse will conduct most of the examination. The doctor will carry out the somatic examination and assess the gross neurological status. However, the main task of the doctor is to draw conclusions about any suspected abnormalities, risk factors, resources and the child's overall situation. The doctor should then explain his/her findings to the child and the family and work together with the family to plan any further measures.

Examination by a public health nurse

1. General impression; height, weight and head circumference
2. Gross motor skills: walking on heels and toes, walking on toes along a straight line for 5 m, standing on one leg (at least 10 seconds without marked swaying) and skipping on one leg (should be able to do at least 10 times rhythmically). Should be able to throw and catch a beanbag from a distance of 2 m with arms clearly off the body.
3. Interaction, attention and motivation: should be able to concentrate continuously on the tasks of the examination (approx. 25-30 minutes). Speech should be adequate, taking both parties into consideration. Inability to move on from task to task may also be indicative of an attention deficit Monitoring a Child's Psychological Development at Child Health Clinics. Refusal to cooperate very often stems from problems in the development of mental, neurological or interactive skills.
4. Speech and language skills should preferably be tested with an appropriate, standardized test. Assess descriptive speech, speech comprehension (interrogative sentences, tenses), speech motor control, serial auditory memory, sentence memory and word images, naming objects and articulation as well as the understanding of basic concepts and various instructions. Speech impediment involving one or two sounds is quite common and a single speech sound error is not a cause for concern if the speech is otherwise fluent and language skills are appropriate for age Speech and Language Development.
5. Visual perception: the child should be able to reproduce a six brick structure.
6. Hand-eye coordination: able to copy patterns (a triangle and a combination of a triangle and a square), able to cut out a circle with scissors, able to thread 5-6 beads (1 cm) onto a plastic thread in a minute.
7. Vision: check near and distance vision with an appropriate chart. Check visually for strabismus.
   • Refer the child to an ophthalmologist in the following cases:
     • combined visual acuity is < 0.63 or
     • there is a difference of ≥ 2 lines in both near and distance vision between the eyes
     • near vision (combined) is > 2 lines worse than the acuity of distance vision.
     • Notice that country-specific variation may apply concerning the criteria, depending e.g. on the charts used.
     • For more details, see Examination of Vision at Child Welfare Clinics
8. Check hearing with an audiometer. The child should be referred for further examinations and for fitting of a hearing aid if his/her hearing is below 20 dB at 0.25-4 kHz.
9. Blood pressure Heart Auscultation and Blood Pressure Recording in Children Hypertension in Children

Course of medical examination

• Familiarize yourself with medical notes and test results, interview the parents and examine the child. Some of the above tests might be included in the medical examination, particularly if the public health nurse has been unsure of the outcome of a particular test.
• If the child has an ongoing problem (e.g. enuresis) it should naturally be addressed as normally. Address critically the reasons for, as well as the necessity of, any avoidance diets.

1. General impression; the progression of height, weight and head circumference Normal and Abnormal Growth in Childhood Head Growth in Children
2. Rapid alternating movements of the hands, i.e. diadochokinesis/DDK (able to repeat five times at the same speed without moving the upper arm) Developmental Coordination Disorder (DCD)
3. Finger-to-nose test (should be able to perform without tremor or compulsive movements)
4. Vision: check results from visual acuity testing, Hirschberg's test Examination of Vision at Child Welfare Clinics, cover test, convergence
5. Skin, facial symmetry, heart auscultation Heart Auscultation and Blood Pressure Recording in Children, abdomen, femoral pulses, testes Undescended Testicle
6. Chat with the child: how does he/she perceive his/her health, who are his/her friends, what are his/her favourite games. It is important to listen to the child's opinions and to evaluate his/her ability to interact and concentrate. The child should be able to follow simple rules, concentrate on one game at a time for 10-15 minutes and enjoy role playing.
7. Draw conclusions regarding any suspected abnormalities, risk factors, resources and the child's overall situation. Plan any further measures together with the family.

Necessary

• Stethoscope
• Spatula
• Spot light (preferably an otoscope without an earpiece)
• Ophthalmoscope
• Headlamp
• Pneumatic otoscope + a series of earpieces
• Instruments for cleaning wax from the ears
• Reflex hammer
• Sphygmomanometer (5 cm and 7.5 cm cuffs)
• Appropriate chart for visual examination
• Equipment for hearing examination: miniature audiometer (45 dB, 3-4 kHz frequency) or, alternatively, a calibrated small bell (45 dB, 3 kHz), audiometer
• Equipment for neurological examination (e.g. books, pictures, red ball of wool, bell, rattle, bricks, ball, beanbag, pencil, scissors, raisins, gym mat for examining an infant of crawling age so that spontaneous movement can be seen)

Recommended

• Doppler stethoscope
• Tympanometer (for easy examination of tympanic membrane movement, see Tympanometry