Information 1

  • A head to toe physical observation is undertaken to identify physical abnormalities, injuries or Skin (child)

Child safety notification 2

  • See Child safety reporting, where general appearance provides a suspicion of abuse, harm or neglect. Consider:
    • bruises on any part of a child’s body, especially over soft tissue areas (normal bruises in children commonly occur over bony areas)
    • human bite marks
    • circular cigarette burns
    • lighter burns (might resemble a smiley face)
    • scalds from immersion in hot water such as feet, hands or buttocks
    • fractures of any type
    • grazes or trauma to genitalia

Health check recommendations

  • Head and face, limbs and joints for all children < 15 years of age
  • Genitalia up to 18 months of age for all children

1. Procedure

  • Undertake a head to toe physical observation as per Table 1.
  • Provide brief intervention if any issues are identified
  • Determine if the child requires a referral and place on a follow-up and recall register

Table 1. General appearance observations

Area for observation

Action

Birth–18 months

Genitalia

  • With parent present and with consent, observe and feel

Birth–15 years of age

Head, neck and face

  • Observe and feel

Limbs and joints

  • Observe and feel
  1. Head, neck and face 1
    • Observe and feel child’s head for general appearance e.g. small (microcephaly), flattened back of head (plagiocephaly), asymmetry, sores, scars or injuries
    • Check head and neck for range of motion and if head tilts to one side while the chin tilts to the other (torticollis)
    • Child’s face for general appearance:
      • thin upper lip
      • flattened groove between the upper lip and nose (philtrum)
      • nose for alignment and structure
      • lips for fullness and colour
      • short eye openings (palpebral fissures)
    • Open, look at and feel the child’s mouth:
      • palate for ridges
      • presence of teeth
      • cleft lip
      • tongue ties
    • Child’s hair for general appearance:
      • healthy and shiny
      • matted and dull
      • nits or lice
      • patchy or missing
    • Child’s ears for size, shape, colour and the level in relation to the eyes
  2. Limbs and joints birth–18 months observe and feel 1
    • Posture
    • Appearance of the limbs, muscle tone and range of movements
    • Any swelling, tenderness, redness, warm or hot skin or pain around the joints. See Rheumatic heart disease
    • Signs of injury e.g. bruising, cuts, burns, parasites (scabies), limping
    • Misalignment or incorrect anatomical position
    • Abnormalities of the hips:
      • lay the infant on their back (supine) without a nappy
      • ensure the pelvis is horizontal
      • keeping the hips symmetrical, extend the legs and check for equal length and knee creases for symmetry
      • place middle fingers of each hand over the outer side of hip joint (greater trochanter) and thumbs on the inner side of the thighs
      • flex the knees and hips upwards parallel to the midline
      • slowly and gently move both legs outward away from the midline (abduct) then back inwards again (adduct)
      • note any limited or unequal movement, dislocation (listen and feel for clicking) or distress caused to the infant
    • Abnormalities of the back (posterior):
      • lay the infant on their stomach (prone) without a nappy
      • observe back and buttock creases for:
      • symmetry
      • birthmarks (e.g. Mongolian blue spots)
      • midline hairy tufts (may indicate spina bifida) and swelling or lumps (may indicate meningomyelocele)
      • deep dimples at the top of the buttocks (pilonidal sinus)
      • evidence of trauma
  3. Limb and joints 18 months–15 years observe and feel 1
    • Appearance of limbs, muscle tone and range of movements e.g. general moving, walking, weight bearing and standing
    • Any swelling, tenderness, redness, warm or hot skin or pain around the joints. See Rheumatic heart disease
    • Signs of injury e.g. bruising, cuts, burns, parasites (scabies), limping
    • Misalignment or incorrect anatomical position
    • Abnormal lateral curvature of spine i.e. scoliosis
    • Abnormal walking, limping, shuffling, widely placed gait, toe walking, foot
      flopping, leg lagging, dragging, staggering, uncoordinated gait
  4. Genitalia general 1,2
    • Lay the infant on their back (supine) without a nappy. Observe or feel for:
      • appearance of the genital area
      • rashes, grazes, bruises, bleeding or other abnormality
      • nappy hygiene related issues e.g. urine burns (nappy rash) or faecal matter
      • abnormalities, incomplete development or sexual ambiguity
      • groin lumps
Always assess genitalia with parent present, with consent and after providing sound reasoning for the assessment. Be mindful that trauma during a parents childhood can trigger confronting emotions.
  1. Genitalia girls 1
    • Using 2 fingers gently separate the outer labia to reveal the inner labia and clitoris
    • Note any discharge, thrush or faecal matter
    • Observe for female genital mutilation (seen from infancy–15 years)
  2. Genitalia boys 1
    • Ensure hands are warm. Cold hands can stimulate cremasteric muscle reflex causing the scrotum skin to shrink and pull the testicles into the pelvic cavity
    • Inspect the penis for size and the placement of the urethral opening
    • Do not retract the foreskin of an uncircumcised penis more than is necessary to view the urethra
    • Check if the testicles have descended by placing a thumb and index finger of one hand at the top and bottom of the scrotum to prevent the testicles receding into the inguinal canals or abdomen
    • Use the other hand to gently feel the scrotum for the presence of testicles

2. Results

  1. Head and face results 1
    • The child’s head and face should be symmetrical, clean and free of abnormalities and wounds, and hair shiny and free of parasites
  2. Limbs and joints results 1,2
    • Limbs and joints should be symmetrical, aligned and free of abnormalities, wounds and swelling
    • Hips and knees should have full range of well paced and intentional movements
  3. Genitalia general results 1,2
    • Consider Child safety reporting for any rashes, grazes, bruises, bleeding, signs of trauma, neglected hygiene or other abnormality
    • Consider inguinal hernia if lumps noted in the groin
  4. Genitalia girls results
    • Partially or fully fused labia may suggest the presence of a scrotum. Do not attempt to separate
    • A urinary opening not located below the clitoris may indicate the presence of a penis i.e. ambiguous genitalia
  5. Genitalia boys results
    • A non-erect penis at birth is 2–3 cm in length with a straight projection
    • Microphallus (a small penis) may indicate other organ anomalies
    • Testicles in a newborn are approximately 1 cm in diameter
    • A testicle that cannot be palpated is considered undescended, which should descend by 3–6 months
    • Oedema of the scrotum (hydrocele) is common and usually resolves by 1 years old

3. Brief intervention

  • Discuss reducing soap and scented cream use on infant skin to avoid rashes and allergies. Warm water is usually enough when < 6 months
  • As children age, encourage showering routines
  • Discuss penile and vaginal hygiene. Remove faecal matter from genitalia folds
  • Avoid retracting the foreskin of an uncircumcised penis:
    • the foreskin will retract > 4 years of age from erection or childhood exploration
    • once foreskin retracts, educate the child to clean underneath without soap. Soap will cause drying and excoriation
  • Reassure and normalise parental concerns:
    • normal childhood genitalia exploration
    • Mongolian spots
    • nappy rash (and how to prevent)
    • plagiocephaly. Encourage child to move, avoiding prop feeding

4. Referral 1,2

  • Refer to Child safety reporting for suspicion of abuse, harm or neglect
  • Refer to the Primary Clinical Care Manual for:
    • swelling, tenderness, redness or pain around joints which may indicate acute rheumatic fever or Rheumatic heart disease
    • infected sores, scabies or other skin conditions
  • Refer to a MO/NP, child health nurse, physiotherapist or speech pathologist for:
    • thin upper lip, flattened philtrum or short palpebral fissures which may indicate fetal alcohol spectrum disorder. See Developmental delay or disability (child)
    • limited head and neck range of motion or if head tilts to one side while the chin tilts to the other (torticollis)
    • unresolving plagiocephaly once child starts moving
    • any cleft palate or cleft lip which may hinder a baby’s feeding
    • limited abduction of one or both legs or unequal leg length in 0–6 month olds
    • any asymmetrical knee or buttock creases
    • lateral curvature of spine i.e. scoliosis
    • any pilonidal sinuses or deep dimples (spina bifida)
    • any ambiguous genitalia or fused labia
    • testicles which are unable to be milked into scrotum
    • one or both testicles are not palpable
    • testicles felt in groin or lower abdomen
    • any unexplained nodules or lumps
    • any parental or clinician concerns

5. Follow-up

  • Place the child on a recall register if required
  • Ensure all referrals are actioned
  • Provide the parent with details for the next scheduled follow-up appointment

6. References

7. Resources

  1. Raising Children child health resources

Last updated: September 2024

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