pharm midterm1

• sex-  preponderance of males; difference mainly the result of behavioral characteristics, especially aggression
• temperament - children with difficult temperament profile, especially persistence , high activity level, and negative reactions to new situations
• stress- predisposes children to increased risk taking behaviors; general lack of self protection
• alcohol and drugs use- associated with higher incidence of motor vehicle injuries, drownings, homicides, and suicides
• history of previous injury - associated with increased likelihood of another injury, especially if initial injury required hospitalization
• developmental characteristics - mismatch between childs developmental level and skill required for activity
• natural curiosity to explore environment
• desire to assert self and challenge rules
• in older child, desire for peer approal and acceptance
• cognitive characteristics -infant-sensorimotor:explore environment through taste and touch
• young child-objective permanece actively searches for attractive objects;cause and effect lacks awareness of consequential dangers; tranductive reasoning: may fail to learn from exsperience is unable to comprehend danger to self or thers
• anatomical characteristics- (especially in young children) 
• large head predispose to cranial injury
• large spleen and liver  with wide costal arch- predispose to direct trauma to those organs 
• small and light body- maybe thrown easily, especially, inside a moving vehicle
• other factors- poverty, family stress, substandard alternative child care, young maternal age, low maternal age, low maternal education, multiple siblings

• Authoritarian- control through unquestionable mandates
• punishment is stern withdrawal of love and approval
• children tend to be sensitive shy self-conscious retiring and submissive

• exert little or no control over childrens actions 
• they avoid imposing thier standards and allow their children to regulate thier own activity
• parents consult child with decsision making
• they  have inconsitant  discipline 
• do not set limits
• do not prevent children from upsetting home routine
• parents rarely punish children

• combine practices from authoritarian and permissive styles
• direct children's behaviors by emphasizing the reason for rules and negative reinforment deviations
• respect individual child and allow voice objections
• parental control is firm and consistant

• set realistic goals for acceptance behavior expected achievements
• structure opportunities for small success to lesson feeling of inadequacy
• praise children for desirable behavior with attention and verbal apprasisal
• set clear and reasonable rules:expect the same behavior regardless of the situation if exceptions made explain is for one time only
• teach desirable behavior thru own example
• phrase request for appropriate behavior 
• give advance notice or friendly reminders
• be attentive to situations that increase the likelihood of misbehavior
• keep promises
• offer sympathetic explanations for not granting a request such as "i am sorry i can't read, but i have to finish dinner"
• avoid outright conflicts temper discussions
• provide children with opportunities for power and control
• use i message rather that you

• consistency-implementing action exactly as agreed
• timing-initiate discipline as soon as child misbehaves
• commitment-follow through with the details of the discipline
• unity-make sure all caregivers agree on plan
• flexibility- chose disciplnary actions that are appropiate for age and temperment
• planning- plan disciplinary strageties in advance and prepare child if feasible
• behavior orientation-disapprove of behavior not child
• privacy- discipline in private
• termination- after discipline consider child slate as clean

• contributes to poor mental health
• children recall parental separation with the same emotion felt by victims of a natural disaster; loss grief+vulnerable
• family characteristics are more crucial t the child's well being than specific child characteristics
• high levels of family conflict are related to problems of social development, emotional stability+ cognitive skills for the child

• vietnamese practice that may produce welt like lesions on the child's back
•  the edge of a coin is repeatedly rubbed lengthwise on the child's oiled skin to rid the body od diease

• practiced by vietnames
• placing a container containing steam against the skin to draw out the poison or evil element when heated air in the container cools a vacuum is created that produces a bruise like blemish of the skin directly beneath the mouth of the container

• practiced by southeast asian groups 
• small areas of skin are burned to treat enuresis and temper tantrums

• removal or injury to any part of the female genitalia 
• practiced in africa, the middle east , latin america, india asia, north america  australia and western europe

• a child discipline measure of some caribbean groups
• in which a child is forced to kneel for a long time

• a practice of yemenite jews
• crush cloves of garlic and petroleum jelly  is applied to wrist  to treat infectious disease
• can results in blisters and garlic burns

greta and azarcon mexico  used for digestive problems 

south east asia used for rash or fever 

surma india used a comestic to improve eyesight

numeric alterations affecting the autosomes include trisomy 21(down syndrome) Trisomy 18 (edwards syndrome) and trisomy 13 (patau syndrome

• down syndrome
• effects 1 in 800 to 1 in 1000 live births 
• is the most common aneuploidy compatible with life expectancy into adulthood
• IQ range is mild to moderate impairment
• more likely to develop alzheimer's more than 75% OVER 60  are affected

• trisomy
• translocation
• mosaic

• nomenclature is 47,xx+21 and 47, XY+21
• 92% of all cases of down syndrome
• the extra chromosome 21 is unattached and segregates freely during meiosis
• down syndrome increases with increasing maternal age 
• about 75% of babies with trisomy 21 are born to younger mothers

• male 47, XY,t (14;21)
• accounts for 4% of all down syndromes
• majority of cases are sporadic
• 25% have one balanced translocation parent 
• translocation can be with 2 chromosome 21 and would havE a 100% of producing child with down syndrome

• female with down syndrome 46,XX+21
• can occur in males and females 
• rarer type
• results from mitotic nondisjunction during early embryonic development  of a normal zygote
• children with this type have mixed cell populations some with normal karyotypes and some with extra chromosomes

• edwards syndrome
• fairly common in fetuses
• those who live have severe cognitive impairment  and physical abnormalities that contribute to limited life span

• patau syndrome
• carries more severe malformations
• increased size of extra chromosome and greater gene imbalance 
• life span is shortened

• alterations in number of sex chromosomes
• intelligence may be normal or low normal or child may have learning disabilities  
• most common are klinefelter syndrome and turner syndrome

• 47, XXY
• most common of all sex chromosome aneuploidies
• physical abnormalities include masculinization, gynecomastia, hypogonadism, sterility increase in pubis to sole length, elongated limbs 
• normal mental development
• cognitive difficulties include in expressive language ,auditory processing and memory

• 45, XO
• ovarian dysgenesis
• verbal IQ exceeds performance IQ
• no prepubertal growth spurt
• girls are generally infertile
• common to administer female hormones at the time puberty is to start
• growth is normal until 3 years of age and than slows gradually 
• mosaicism occurs and results in milder phenotype
• may exhibit behavioral problems  and socially isolated behaviors but mostly go on to live independent productive lives

• the mutated gene is dominnat gene located on one of the none sex chromosomes
• males and females are equally likely to be affected
• children of affected parent have a 50% CHANCE of inheriting the mutant allele and being affected 
• a single copy of the mutant allele is typically enough to cause the phenotype to express
•  a carrier state does not exist 
• some people with the same mutant allele do not express and are referred to as carrier of a reduced penetrate allele
• homozygous for the mutant allele is usually more severe than the heterozygote
• if mutant allele is 100% penetrate the family will be free of mutant allele

• children who display are always homozygous for that trait 
• children inherit two mutated genes from each parents 
• both mothers and fathers can be carriers
• rarely appears in x-gene affected children are usually asymptomatic carriers
• carrier parents have 25% chance of producing an affected child and 50% chance of producing a carrier child in each pregnacy

• the transmission of genes located on one of the sex chromosomes X or Y
• few genes are found on the y chromosme
• y linked genes follow a father to son or male to male transmission
• men give their x chromosome to their daughter and their y to their sons

• in females the alleles of an x-linked recessive gene behave as alleles of any autosomal recessive gene
• the effect of the abnormal allele is hidden by the normal dominant allele therefore females who have a disease-associated mutations in both members of the gene pair will express phenotype
• it is rare for females to express the phenotype
• if only one of the gene pair carries disease-associated mutation it is possible due to x-inactivation
• x-chromosome can be inactivated through a process called methylation
• all daughters of an infected male are heterozygous carriers
• sons of female carriers have a 50% chance of inheriting and being affected
• males can not affect sons because they give y-chromosome
• X-Y\XX
• Father : X-Y (affected)Mother: XX (normal)Outcomes per pregnancy: All daughters X-X (carriers) All sons: XY (normal)
• B= Mating of normal male + carrier female.
• Father: XY (normal)mother : X-Y (carrier)Outcomes per pregnancy: Daughters: 50 % X-X(carrier) 50% XX (normal)Sons: 50% X-Y (affected) 50% XY (normal)

• is rare
• both males and females can be affected but females because of random nature of x-inactivation are usually less affected than males
• affected men do not transmit the defective allele to their sons
• all daughters of affected males are affected to have 50% chance of passing on the defective allele to their sons and
• Father: X- Y affected     Mother: XX normal Outcomes per pregnancy:All daughters: X-X (affected) All sons: XY (normal)B= mating of normal male + affected female

Father: XY (normal)Mother: X-Y(affected) Outcomes per pregnancy: Daughters: 50% X-X (affected) 50% XX (normal)Sons: 50% X-Y(affected) 50% XY(normal)

• genetic diease inherited as an autosomal recessive trait, caused by absence of the enzyme phenylalanine hydroxylase needed to metabolize the essential amino acid phenylalanine
• wide range of variation in ethnic groups
• most prevalent among northern european, american indian, and alaskan natives  where as african americans ,hispanic, jews and asias account for lowest frequencies

• pku is the hepatic enzyme phenylalanine hydroxylase, which control the conversion of PKU to tyrosine, is absent
• this results in the accumulation of PKU in the bloodstream and urinary excretion of abnormal amount of its metabolites the phenyl acids
• amino acids produced by the metabolism produced by the phenylalanine are absent in PKU
• tyrosine is needed to form pigment melanin and hormone epinephrine and thyroxine
• decreased melanin are associated with phenotype of blond hair blue eyes and fair skin
• severe hyperphenylalline causes progressive damage to developing brain include defective myelination cystic degeneration of the gray and white matter and disturbances is cortical lamination
• cognitive impairment occur before the metabolites are detected in the urine  and will progress if phenylalanine is ingested and not lowered

• growth failure 
• frequent vomiting
• irritability
• hyperactivity
• erratic behavior
• older children display bizarre  schizoid behavior patterns such as screaming episodes head banging,arm biting 
• failure to respond to strong stimuli
• many cognitively impaired children have seizures 
• 80%untreated have abnormal electroencephalographs

• is to prevent cognitive impairment
• test for screening newborns is guthrie bacterial inhibition assay for phenylalanine in the blood 
• bacillus subtilis present in culture medium, grows in blood  contains excessive amounts of phenyllaine
• normal range in newborns is 0.5-1 mg/dl test detects amounts greater than 4mg/dl
• only fresh heel blood not cord blood  can be used for test
• newborn screening is mandatory in all states
• newborn screening include 1)collecting initial specimen as close to discharge as possible no later than 7 days after birth  2)obtaining another sample after 2 wks of age3) designating primary care provider to all newborns before discharge  for follow up screening 
• when collecting the specimen avoid layering the blood

• involves restriction of dietary protein
• phenylalanine can not be totally eliminated because it is an essential amino acid in tissue growth
• dietary management must meet 2 criteria 1)meet child's nutritional need for optimum growth 2) maintain phenylalnine levels within safe range
• infants with PKU have a level higher than 10mg/dl
• treatment should be started as soon as possible to establish metabolic control ideally 7-10 days of age 
• a restricted phenylanine  diet including medical food and low protein products will be medically required for a lifetime to reduce cognitive deficits
• frequent monitoring of phenylalanine and tyrosine blood levels
• diet include 20-30 mg of phenylalanine per kg of body weight per day 
• phenylalanine level of 2-8mg
• significant brain damage occurs when levels are over 11 mg
• level 2-6 is recommended in children under 12 
• 2-10 for adults
• diet begins no later than 2 wks old 
• total or partial breastfeeding may be possible
• phenylalanine levels greater than 20 affect fetal development
• women who do adhere to diet before and during pregnancy have 93% RISK OF COGNITIVE IMPAIRMENT AND 72% risk for microcephaly

• many suffer no cognitive or behavioral deficits many have lower IQ
• bone density is lower in children on diet  even though calcium and mag ae increased
• BH4 is used to decrease circulating phenylalanine levels given in a weight base dosage used in children 8 and older may be tolerated in children as young as 4

• nursing care management
• teaching family dietary restrictions foods include some vegetables fruit juices some cereals breads and starches 
• meat and dairy are mostly eliminated or restricted to small amounts
• registered dietician is essential
• support groups

• rare autosomal recessive disorder that results from various gene mutation leading to 3 distinct enzymatic deficiencies
• galactosemia -classic (GALT)-deficiency of hepatic enzyme galactose 1-phosphate uridyltransferse
• effects approx-1-47,000 births
• galatokinase (GALK)-deficiency in the enzyme galactokinase rare disorder
• galactose 4 epimerase (GALE)deficiency of of glactose 4 epimerase rare disorder
• are all involved in the  conversion of galactose to glucose
• accumulation of activated 1-phosphate metabolites of galactose is toxic to various tissues especially kidneys, liver and nervous system
• an accumulation of galactose in the blood causes series of abnormalities to develop
• hepatic dysfunction leads to cirrhosis, resulting in jaundice in infants in the 2nd week of life
• the spleen becomes enlarged due to portal hypertension
• cataracts are recognized by 1 to 2 months of age
• cerebral dam
• age manifested by lethargy and hypotonia 
• infants are normal at birth but on ingestion of milk the begin to show progressive symptoms including diarrhea vomiting and weight loss
• escherichia coli sepsis is another common initial clinical sign
• death during the first month of life is frequent in untreated infants

• made on infants history,physical examination,
• , increased levels of galactose in the blood 
• decreased levels of uridine diphosphate-galactose transferase activity in erythrocytes
• signs of malnutrition and dehydration, decreased muscle mass and body fat may be evident
• heterozygous can be identified by lower levels of essential enzyme
• asymptamatic individuals have been noted to dislike and limit ingestion of galactose containing foods

• treatment consist of eliminating all milk and lactose containing formula including breast milk
• lactose fee and soy formulas are used
• galactose free may be more beneficial tan soy
• nurses should give food list to families
• treatment include monitoring of hypoglycemia, liver failure, bleeding disorders and E. coli sepsis
• long term complications such as ovarian dysfunction,cataracts, abnormal speech, cognitive impairment growth restrictions and motor delay
• eliminating sources of galactose does not significantly improve the outcome
• new therapeutic strategies  include enhancing residual transferase activity, replacing depleted metabolites, or using gene replacement therapy, are needed to improve prognosis on children

• began in 1960 with guthrie PKU testing
• screening based on following criteria:
• disease occurs with significant criteria
• an inexpensive and reliable method of testing exist
• their is effective treatment and intervention
• if untreated the baby will die or be severely developmentally impaired
• an affected newborn may appear normal at birth
• first newborn screening blood sample must be obtained in the first 24 hours after the first protein feeding or 72 hours of life

• potential benefits of carrier screening  include facilitating genetic counseling and reproductive planning and providing useful information to at-risk family members
• newborn screening provides for early detection and treatment initiation,maximizing quality of life
• parents choice in newborn screening may be limited due to state regulations

• general risk factors-maternal age of at least 35 at time of delivery 31 years if twin delivery
• elevated or low trisomy profile screen results
• specific risk factors
• previous child with structural defect or chromosome abnormality
• previous stillbirth or neonatal death
• structural abnormality in mother or father
• balanced translocation in mother or father
• inherited disorders
• medical dieease in mother
• exsposure to a teratogen
• infection
• abnormal ultrasound finding
• ethnic risk factors
• disorder
• tay sachs diease
• sickle cell anemia
• alpha-beta thalasemia

• indications relevant for newborns through adolescence:
• family hx of hereditary disease,birth defects, or developmental problems
• family hx of sudden cardiac death or early onset cancer
• family hx of mental illness
• abnormal newborn screen
• abnormal genetic test result ordered by a nongenetic professionals who lacks the knowledge and experience to discuss implications of result 
• progressive neurological condition
• major congential anomoly
• congential or early onset hearing loss or vision loss
• cognitive impairment or autism
• abnormal sexual maturation or delayed puberty
• abnormally tall or short stature
• excessive bleeding or clotting
• parental request

• major or minor birth defects and dysmorphic features
• growth abnormalities
• skeletal abnormalities 
• visual or hearing problems
• metabolic disorders
• sexual development abnormalities
• skin disorders
• recurrent infection or immunodeficiences
• development and speech delays or loss of developmenatl milstones
• cognitive delays
• behavioral disorders

• information sharing
• flexibility in practice,policy and procedure
• formal and informal support
• collaboration
• strength identificationand empowerment

• stage of protest
• stage of despair
• stage of detachment

• cries
• screams
• searches for parents with eyes clings to parent
• avoids and rejects contact with strangers

• additional behaviors during toddlerhood
• physically or verbally  attacks stranger
• attempts to escape to find parent
• behavior may last for days or hours

• inactive
• withdraws from others
• depressed or sad
• lack of interest in enviroment
• uncommunicative
• regress to earlier behavior
• physical condition may deteriorate from refusal to eat drink or move

• show increased interest in surroundings
• interacts with strangers or caregiver
• forms new but superficial relationships 
• appears happy
• usually occurs after prolonged separation 
• superficial adjustment to loss

• socializing
• giving unrestricted unasked advice
• offering premature or inappropriate reassurance
• giving over ready encouragement
• defending a situation or opinion
• using stereo-typed comments or cliches
• limiting expression of emotion by asking directed ,close-ended questions
• interrupting and finishing the person's sentence
• talking more than the interviewee
• forming prejudged conclusions
• deliberately changing the focus

• long periods of silence
• wide eyed and fixed facial expressions
• constant fidgeting or attemptinkg to move away
• nervous habits
• sudden interuptions
• looking around
• yawning eye drooping
• frequently looking at watch
• attempting to change topic of discussion

• allowing children time to feel comfortable
• avoid sudden or rapid advances,broad smiles,extended eye contact
• talk to parent if child is initially shy
• communicate through transition objects such as dolls 
• give older children the opportunity to talk w/o parents present
• assume a position that is eye level
• speak in a quiet unhurried confident voice 
• speak clearly be specific use simple words 
• state directions and suggestions positively
• offer a choice when one exist
• be honest with children
• allow them to express their concerns
• use a variety of communication techniques

• processes progress from sensorimotor to perceptual to concrete and finally to abstract,formal operations.
• Infancy- receive comfort from the sound of voices cry when provoked or over stimulated respond to nonverbal cues
• become quiet when they are cuddles patted or receive gently physical contact
• they receive comfort from the sound of voice 
• loud harsh sounds or sudden movement is frieghtening

• Early childhood children younger than 5 are egocentric, they see things only in relation to themselves and from their point of view
• focus communication on them, tell them what they can do of how they feel
• experience of others are of no interest to them 
• allow them to touch and examine articles they will come in contact with
• toddler can effectively use their hands to communicate ideas without words
• everything is direct of concrete to small children
• they are unable to work with abstraction and interpret words literally

• school aged years 
• rely less on what they see and more on what they know when faced with a problem
• they want explanations and reasons for everything
• they are interested in the functional aspect of all procedures
• they want to know why an object works 
• they need to know what is going to take place 
• have a heightened concern about body integrity

• adolescence 
• fluctuate between child and adult thinking and behavior
• when tension rise  they may seek security of the more familiar and comfortable expectations of childhood
• confidentiality is of great importance when interviewing

• weight @ 6mths, 1 yr,2yr & 5yr
• length @ 1&4
• dentition, including age of onset, number of teeth & systems during teething
• developmental milestones
• age of holding head steady
• age of sitting alone with support
• age of walking w/o support
• age of saying 1st word with meaning
• present grade in school
• scholastic performance
• if child has bestfriend
• interaction with other children, peers, and adults

• position-supine or prone or sitting on parents lap
• sequence-auscultate heart,lungs, abdomen,
• heart and respiratory rate
• palpate & percuss at same time 
• head to toe direction
• perform traumatic procedures last
• moro reflex last

• preparation- completely undressed
• leave diaper on boy
• pacify of bottle of sugar water
• enlist parents aid

position-sitting or standing on or by parent

• sequence- inspect body through play 
• use minimal physical activity at first
• introduce equipment slowly
• auscultate, percuss,palpate
• perform traumatic procedure last

• preparation- have parent remove outer clothing
• remove underwear when inspecting that part of the body
• allow to inspect equippment
• perform procedure quickly
• restraint when appropiate
• praise for cooperative behvaior

position-standing or sitting  or prone or supine prefer parents closeness

sequence- head to toe direction if uncooperative use toddler technique

• preparation- request self-undressing, allow to wear underpants 
• offer equipment for inspection
• use paper doll technique
• give choice whenever possible 
• expect cooperation
• use positive statment

position-prefer sitting, older child may prefer privacy

• sequence- head to toe direction
• examine genitalia last in older child

• preparation- respect need for privacy
• request self undressing allow to wear underwear
• give gown to wear
• explain purpose and equipment
• teach about body function and care

position-prefer sitting

• sequence head to toe direction
• examine genitalia last

• preparation- allow to undress in private
• give gown
• exspose only area to be undressed 
• respect need for privacy
• explain findings  during exam
• matter of factly comments
• emphasize normalcy
• examine genitalia as any other part of the body

• can be taken radially in children older than 2 y/o
• infants and young children the apical pulse (heard through a stethoscope held to the chest at the apex of the hearts) is more reliable
• count for 1 min in children and infants because of possibility for irregular rhythm
• for greater accuracy count when child is sleep
• grade pulse 
• compare radial and femoral pulses at least once during infancy to detect the presence of circulatory impairment such coarctation of the aorta

• 0 not palpable
• +1 difficult to palpate, thready, weak easily obliterated with pressure
• +2 difficult to palpate,may be obliterated with pressure
• +3 easy to palpate,not easily obliterated with pressure (normal)
• +4 strong, bounding, not obliterated with pressure

• use of an oversized cuff rather than an undersized one
• if cuff is too small reading will be falsely high
• if cuff is too large reading will be low

• cross eye or one eye deviates from the point of fixation
• if the misalignment is constant the weak eye beomes lazy and the brain eventually suppresses the image produced by that eye
• if not corrected by age 4-6 y/o blindness from disuse may results (amblyopia)

when the eye becomes lazy and the brain starts to suppress the image produced by the eye the eye will start to go blind if that persist

shine a light directly into the patient's eye from a distance of about 16 inches if the eyes are normal the light falls symmetrically  within each pupil if the light falls off center in one eye the eyes are misaligned

one eye is covered and the movement of the uncovered eye is observed while the child looks at a near 13 inches away oor distant 20 ft object. if the uncovered eye does not move, it is aligned. if the uncovered eye moves, a misalignment is present because when the stronger eye is temporarily covered, the misalignment eye attempts to fixate on the object

• occlusion shifts back and forth from one eye to the other, and the movement of the eye  that was covered is observed as soon as ocular is removed while the child focuses on a certain point
• if normal alignment is present, shifting the cover from one eye to the other will not cause the eye to move
• if misalignment is present movement will occur when the cover is moved

• child stands 10 ft away from the chart
• test right eye first by covering the left
• children with glasses should be tested witht hem on 
• if the child fails to read the line read the line above continue up the chart until the child is able to reard the line the begin moving down the line until the child can not read 
• to pass the child must successfully read 4 of 6 symbols from the line

• test for preschool children are 
• tumbling E child tells what way the e is facing
• HOTV child holds up matching letter that dr is pointing to

• heard over entire surface of lung, with exception of upper interscapular area and are beneath manubrium
• inspiration is louder, longer and higher pitched than expiration
• sound is soft, swishing noise

• heard over manubrium and in upper interscapular regions where trachea and bronchi bifurcate
• inspiration is louder and higher pitched than in vesicular breathing

• heard over trachea near suprasternal notch
• inspiratory phase is short, and expiratory phase is long

• produced by vibrations within the heart chambers or in the major arteries from the back and forth flow  of blood
• classfied as 
• innocent-no anatomic or physiologic abnormality exist
• functional- no anatomic cardiac defect exists, but a physiologic abnormality such as anemia is present
• organic- a cardiac defect with or without a physiologic abnormality exists

• Grade
• i- very faint,often not heard if child sits up
• ii- usually readily heard,slightly louder than grade 1  audible in all positions
• iii-loud but not accompanied by a thrill
• iv-loud and accompanied by a thrill
• v-loud enough to be heard with stethoscope barely touching the chest accompanied by a thrill
• vi-loud enough to be heard by a stethoscope barely touching the chest  often heard

• heart rate increases with inspiration and decreases with expiration
• differentiate this rhythm by having child hold their breath

• marked curvature in posture
• lateral curvature of the spine
• more common in girls
• identified by observing and palpating the spine

• knocked knee
• the opposite of bowleg
• knees are close together but the feet are spread apart
• measure distance between malleoli should be less than 3 inches
• present in children 2-7
• knock knee that is excessive ,asymmetric accompanied by short stature or evident in a child nearing puberty require further evaluation

• bowlegs
• lateral bowing of the tibia
• usually an outward curvature of both femur and tibia
• toddlers are usually bowlegged until their lower back and leg muscles are developed 
• presence beyond 2-3 particularly in african american children may represent pathologic conditions requiring further investigations

• I -olfactory nerve (nasal cavity) smell
• w/eyes closed have child identify odors test each nostril

II- optic nerve (vision) check for perception of light,visual acuity,peripheral vision,color vision and normal optic disc

• III-oculomotor nerve (pupil constriction and accommodation eyelid closing)-troch a child follow and object or light in 5 cardinal positions of gaze
• perform PERRLA

IV-trochlear nerve (moves eyeball down and out )have child look down and in

• V-trigeminal nerve (sensory face,scalp,nasal,& buccal mucosa) have child bit down hard and open jaw test symmetry and strength w/eyes closed see if child can detect light touch of mandibular and maxillary region
• test blink and corneal reflex by touching corneal lightly

VI- abducens nerve (moves eye temporarily) have child look toward temporal side 

VII-facial nerve (muscle for facial expression and tongue sensory)have child smile make face show teeth have child identify sweet or salty solution

VIII-auditory,acoustic or vestibulocochlear nerve(internal ear hearing and balance ) test hearing and any presence of vertiligo or loss of equilibrium

IX glossopharyngeal nerve( pharynx tongue 3rd  of tongue sensory) stimulate tongue posterior pharynx w/tongue blade child should gag test sense of sour or bitter

X vagus nerve (muscle of pharynx,larynx some gastro root tongue heart and lung)gag reflex ability to swallow  check if uvula is midline 

XI accessory nerve (sternocleidomastoid and trapezius muscles of shoulder) have child shrug shoulder while applying pressure  have child turn head against resistance not sym strength

XII-hypoglossal nerve-(muscles of tongue)have child move tongue in all directions