Examination screening specific to children

Childhood health record books provide an excellent opportunity for communication between different health care givers; parents should be provided with the record books and encouraged to bring them to every visit. Various recommendations for screening are made under the following headings. Height/weight/head circumference. Record height from age 3 and weight at regular intervals to age 5 years. Record head circumference at birth and then up to 6 months. The adequacy of a child's growth cannot be assessed on one measurement and serial recordings on growth charts are recommended. Head circumference recordings may provide further data about a child's growth. Hips. Screen for congenital dislocation at birth, 6-8 weeks, 6-9 months and 12-24 months.

The flexed hips are abducted, checking for movement and a 'clunk' of the femoral head forwards (the test is most likely to be positive at 3-6 weeks and usually negative after 8 weeks). Shortening or limited abduction is also abnormal. Ultrasound examination is more sensitive than the clinical examination especially up to 3 to 4 months. Observe gait when starting to walk.

Strabismus. Strabismus should be sought in all infants and toddlers by occlusion testing (not very sensitive), examining light reflexes and questioning parents, which must be taken very seriously. Amblyopia can be prevented by early recognition and treatment of strabismus by occlusion and surgery. Early referral is essential.

Visual acuity. At birth and 2 months, eyes should be inspected and examined with an ophthalmoscope with a 3+ lens at a distance of 20-30 cm to detect cataracts and red reflexes. At 9 months gross vision should be determined by assessing ability to see common objects. Visual acuity should be formally assessed at school entry using Sheridan Gardiner charts.

Hearing. Hearing should be tested by distraction at 9 months; also by pure tone audiometry at 1000 and 4000 hertz when child is 4 years (preschool entry) and 12 years.

Note: Formal audiological evaluation should be carried out at any time if there is clinical suspicion or parental concern. No simple screening test is very reliable for sensorineural or conductive deafness. Testes. Screen at birth, and 6-8 weeks, 6-9 months and 3 years for absence or maldescent. Those who have been treated for maldescent have a higher risk of neoplastic development in adolescence. Dental assessment/fluoride. Advise daily fluoride drops or tablets, if water supply is not fluoridated. Children's teeth should be checked regularly, particularly if a school dental service is not available. Advice should be given on sugar consumption, especially night-time bottles, and tooth cleaning with fluoride toothpaste to prevent plaque.

Scoliosis. Screening of females by the forward flexion test, which is carried out around 12 years of age, is of questionable value because of poor sensitivity and specificity.

Congenital heart disease. The heart should be auscultated at birth, in the first few days, at 6-8 weeks and on school entry.

Femoral pulses. Testing for absence of femoral pulses or delay between brachial/femoral pulses at birth and 8 weeks will exclude coarctation of the aorta. Refer the child immediately if concerned. Speech and language. A child's speech should be intelligible to strangers by 3 years. It is related to hearing.

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