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PEDIATRIC EXAMINATION
Although some of the principles of examining children are similar to adult examination, there are important differences in both outline and detail. Children are not just small adults, and the pattern of disease, the approach to the examination and content of the examination are quite different in children.
The examination also changes as children develop and get older. Eventually it is similar to examination in adults. The following outline aims to highlight the important differences, give some general principles and provide an outline of the examination in different age groups.
Aims and purposes of paediatric examination
- It is important to distinguish between:
- The routine examination of well babies (to screen largely for abnormalities of growth and development).
- The examination of ill babies (to establish the nature and cause and extent of any illness or injury)[1].
- The examination of children for other specific purposes such as:
- To establish fitness for education or certain activities.
- To examine for signs of sexual abuse in child protection cases.
- However, this is not an absolute distinction. Whether ill or well, the examining doctor should have a good working knowledge of routine examination and normal findings in children at different ages.
- Problems with development, behaviour and growth may thus be identified opportunistically whilst examining an ill child.
- Doctors working with children should have a good knowledge of normal developmental milestones, as well as routine physical development and findings at different ages.
General points
- It is important to have established rapport with parents and child when taking the history.
- The approach to the examination will be determined by the age, level of development and level of understanding of the child.
- Inspection and observation are the most important parts of the examination. Observations can be made whilst taking the history and establishing rapport. For example:
- Observe the child’s behaviour and level of awareness and take these into account with the parent’s or parents’ own reports.
- Consider if the child’s appearance is unusual at all and in what way.
- Note the shape of the head, mould of ears, position of eyes, body proportions, posture.
- Note whether the child looks like the parent/s.
- Establish whether there are any recognisable major or minor anomalies.
- Record the nature and distribution of skin lesions and rashes.
- Note the colouring, shape and positions of bruises. If they have suspicious appearance, consider the possibility of non-accidental injury.
- Avoid waking sleeping children.
- Approach the child at their level; if necessary, kneel on the floor. It may be impossible to examine pyrexial, irritable children without provoking crying and they should be carefully observed before attempting closer examination.
- Start examining peripherally (hands and feet), as this is less threatening.
- Make the examination fun to help with their anxiety. Sometimes a toy may help, either one that the child has brought with them or something in your consulting room. Even a pen torch or an ear speculum rattling in a urine container can be a useful distraction.
- Make sure the child is comfortable, and that your hands, stethoscope and other instruments are warm.
- Ask parents to assist with dressing or undressing children and be aware of sensitivities about this.
- Wherever possible avoid unpleasant procedures (for example, rectal examination). These are seldom necessary and can put children off being examined for a lifetime.
Growth and pubertal development
There are some general points to consider:
- Myelination of the nervous system at birth is incomplete.
- Pubertal development has important implications for growth. Assessment of puberty is important when assessing growth.
- Examination of children should incorporate accurate assessment of growth and pubertal development.
- There are three phases of growth:
- Infant phase:
- Rapid first year and slowing in the second year of life.
- Good nutrition is important for normal growth.
- Metabolic hormones control growth.
- Childhood phase:
- From the second to the tenth year.
- Pituitary hormones and growth hormone are important factors.
- Pubertal or adolescent phase:
- From onset of puberty until adult stature is reached.
- Sex hormones are the important factors.
- Infant phase:
Measurement
A variety of measurements can be recorded and plotted to allow accurate assessment of growth and pubertal development.
- Head circumference routinely in those aged under 2 years.
- Length (under one year) or height.
- Weight.
- Plotting of serial measurements to establish pattern and range of growth.
- Use of appropriate growth charts – see Further Reading, below.
- Skin fold thickness where indicated.
- Assess and plot pubertal development where indicated.
Developmental assessment
- An awareness of normal developmental milestones should be acquired by all doctors working with children.
- Detailed assessment of development is complicated but useful assessments in the course of routine examinations and consultations can be achieved with experience and practice.
- There are large variations in normal development.
- Schemes to assess development centre on:
Examination by system
The emphasis of the examination will vary depending on various factors (indications, age of the child, etc). Some important components of paediatric examination in the main systems are listed.
Cardiovascular system
It may be a good idea to start the examination here, if the child is quiet and settled. Letting the child remain seated/held on a parent’s or carer’s lap, will reassure them:
- Begin by recording pulse rate, rhythm, strength and character.
- Check for central perfusion; capillary refill time should be less than two seconds.
- Palpate and percuss the anterior chest wall for heart size and the site and nature of the apex beat.
- Also determine the presence of any thrill.
- Listen to the first heart sound, then the second heart sound, then the sounds between these and then any murmurs between heart sounds.
- Note the timing, character, loudness, site and distribution of any murmur.
- Check if this is transmitted to the neck.
- If disease of the heart or kidney is suspected, record blood pressure.
Respiratory system
Note respiratory rate and movement of the diaphragm and chest wall with quiet breathing and with stronger respiratory effort (requested from an older child, or with crying in a baby). Assess the work of breathing – is there intercostal or subcostal recession, or use of accessory muscles?
Percuss the upper edge of the liver to determine if the lung is over-inflated.
Breath sounds and additional noises can be difficult to interpret in the very young. Noises vary from fine high-pitched to low and coarse depending on the site and nature of the obstruction and the narrowness of the aperture.
- Crepitations (fine crackling noises on inspiration) can occur in apparently normal babies on careful auscultation. Persistent and bilateral crepitations in a distressed toddler usually suggest bronchiolitis or, rarely, left heart failure.
- Rales (intermittent noises during inspiration and expiration) normally indicate liquid debris in larger airways and may be transmitted from the back of the throat.
- Rhonchi (more persistent harsh noises added on to breath sounds) are less common in children and suggest a more persistent obstruction.
- Bronchial breathing (continuous noises that harden and extend the breath sounds) heard over the baby’s upper back are usually transmitted from the main airway.
- Stridor is a harsh noise which originates in the upper airways – for example, in cases of croup. It usually occurs during inspiration.
- Wheezing occurs when the mid-airways are narrowed, and may be bilateral in asthma or viral wheeze, or unilateral in airway obstruction – for example, by a foreign body. It is usually expiratory.
Ear, nose and throat examination
This is probably the most commonly examined system.
- To examine the ears of a young child, it is best to sit the child sideways on the parent’s lap, with one of the parent’s hands holding both the child’s hands and the other holding the child’s head with one ear against the parent’s shoulder while you examine the other one.
- To view the throat of a defiant toddler, insert a tongue depressor into the gap between clamped teeth and cheek and the teeth may briefly open allowing you to deftly insert the tongue depressor.
Gastrointestinal system
First observe the abdomen, looking for swellings and movements.
- Enquire if there is any tenderness and if possible watch the child’s face while you palpate the abdomen. If tenderness is present, and the child is systemically unwell, before palpating, ask the child to puff up their stomach (‘like a balloon’). This may elicit rebound, without touching and unintentionally hurting the child.
- Palpate the four quadrants to determine systematically the position and size of the liver, spleen, kidneys and bladder.
- Note the position, size, surface and texture of any enlarged organ, the character of the edge if it has one and whether or not it is tender.
- Consider whether digital rectal examination is appropriate and explain to the parent/s.
- Assess the child’s hydration, particularly if there is a history of diarrhoea or vomiting. If dehydration is developing, the eyes may look dry and sunken, the lips dry and cracked, in young babies the fontanelle may be depressed and there may be reduced skin turgor.
Musculoskeletal system
- Observe any abnormal curvature or deformities of the spine, particularly at the lower end.
- In small babies, pay particular attention to the sacrum and observe any sinus or hairy naevi.
- Be aware of normal variations of gait (‘in-toeing’, femoral anteversion, genu valgus, genu varus, etc).
- Specific checks of hips and feet (see below).
Central nervous system
During the consultation consider whether the child has normal development in motor functions, speech and language and social interaction. Note whether there are any specific concerns stated by the parent/s.
Always examine the anterior fontanelle by palpation in babies and infants. Note any pulsation and if it is normal.
- The fontanelle should close by the middle of the second year. It should be full or flat.
- Note if the child can hear, see, move the eyes and head well in all directions, move all limbs and whether this movement is normal and full.
- Note whether contour and position of each limb are normal with good power. Handle the child and note the tone of movement of the limb and whether there is any limitation to this.
- Note if the joints are unduly lax and hyperextendable. Watch the child’s face while you move the limbs.
- Although rarely useful, you may be able to elicit reflexes with the percussing finger instead of a hammer.
Examination at different ages
Examination will be outlined in different age groups. These are not intended to be exhaustive checklists but aim to highlight important aspects of the examination in these selected age groups, particularly where there are notable differences to adult examination. The emphasis and detail of any examination will be determined by the particular aims and purposes of the examination outlined above.
Only the newborn and six-week check are performed on all children – see the separate Healthy Child Programme article.
- Newborn babies (see Newborn Screening).
- 6-week-old babies (see Six-week Baby Check).
- 7- to 9-month-old babies.
- Toddlers or children aged under 2 years.
- Pre-school children.
- School-age children.
- Adolescents (see Normal and Abnormal Puberty).
Normal values
A distinctive feature of paediatric examination is that normal parameters change with growth and development[2]. This is illustrated in the table below by the example of pulse, blood pressure and respiratory rate in different age groups.
VISION ASSESSMENT
The functional vision assessment is a pivotal assessment for children who have low vision. It is an assessment of how a child uses the vision he or she has in everyday life, so it is usually not done with children who are totally blind or have light perception only. Since a child’s visual condition and abilities can change over time, the functional vision assessment needs to be repeated periodically.
A functional vision assessment will investigate how your child uses his vision for
- near tasks, closer than 16 inches;
- intermediate tasks, 16 inches to 3 feet; and
- distance tasks, more than 3 feet away.
This assessment is conducted by the teacher of students with visual impairments or sometimes an orientation and mobility specialist, who uses a combination of formal tests and informal measures, which may differ depending on your child’s age. He or she will review your child’s records, spend time observing your child as he goes through his day, and may interview you, your child, and the regular classroom teacher. Formal tests will include tests to assess:
- Visual acuity, or how clear and sharp your child’s vision is. It is likely that both your child’s near and distance visual acuity will be measured.
- Visual field, or the area your child sees to the sides, above, and below (known as the peripheral area of vision).
- Contrast sensitivity, or the ability of your child to detect differences in grayness and between objects and their background—that is, how clearly your child can see the elements of an image.
- Color vision, or the ability to detect different colors and also hues within a color.
- Light sensitivity, or response to light (sunlight or artificial light), which can be extreme for some children with eye conditions such as aniridia and albinism.
Informal measures might include observing your child to see what eye he prefers to use when looking at materials or if he can locate an object in a picture that has a lot of detail.
Based on the information gathered through these various activities, the teacher of students with visual impairments can make recommendations about ways to help your child learn to use his vision more effectively. The recommendations may include:
- Modifications, or changes to the environment, such as providing additional lighting for certain tasks or seating your child with the glare from the window behind him.
- Areas of specialized instruction for your child, such as learning to use a magnifier to read print.
- Adaptations or materials that may assist your child, such as the use of a black marker to increase the contrast between the letters and the paper being used when he writes, or additional time for completing a test.
- Instructional strategies, such as teaching your child to use his vision to scan all the paint choices at art time, instead of always picking the paint in the container on the right side of the easel because he sees best out of his right eye.
- Referrals to other professionals, such as an assistive technology specialist or an orientation and mobility instructor, for example, if your child often doesn’t see branches or other objects on his right side that could hurt him.
GROWTH ASSESSMENT
Measurement of children’s height and weight at regular intervals is important for identifying growth problems as well as for planning health promotion interventions for those at risk from under or over nutrition. Opportunistic measurement is recommended when children are seen by healthcare professionals for other reasons. Identification of variations in practice around the measurement of height and weight in a children’s unit led to the development of guidelines, purchase of new equipment, implementation of educational strategies, and introduction of a growth link nurse role. A repeat audit revealed that these approaches did not bring about the desired changes in practice. Growth assessment is a quick, non-invasive procedure that can provide valuable information about the general health and well-being of the child but is perceived as a low priority by some healthcare professionals. Different approaches are needed to improve this important aspect of health care for children.
NUTRITIONAL COUNSELLING
What is Nutritional Counseling?
Nutritional counseling is a type of assessment made which analyzes various health needs in regard to diet and exercise. A nutritional counselor helps people to set achievable health goals and teaches various ways of maintaining these goals throughout their lifetime.
Nutrition is an important part of a healthy lifestyle. Without proper nutrition, one does not have enough energy to make it through the day. Also, health declines without proper nutrition, making one more susceptible to illness and disease. Nutritional counseling is sometimes offered at eating disorder treatment clinics for patients in need of anorexia treatment, bulimia help or binge eating assistance.
Such an assessment is beneficial to a wide variety of people and can help those with numerous disorders. During this assessment, the counselor provides information based on a person’s current status, helping to improve overall health.
Many nutritional counselors recommend fitness programs and nutritional supplements. By seeing a nutritional counselor instead of looking and testing out various products, time is saved. Through nutritional counseling, basic health needs are met and specialized information is given to fit each person’s everyday lifestyle.
Who Can Benefit From Nutritional Counseling?
A variety of people benefit from nutritional counseling. This type of counseling assists all ages, ranging from pregnant women, to vegetarians, to the elderly and people with different medical complications. Those who may benefit include those with:
- Diabetes
- Osteoporosis
- Poor nutrition and eating patterns
- Eating disorders (some of which may require eating disorder treatment)
- Digestive complications
- HIV
- Cancer
- Hypertension
- Nausea
- Nutritional questions
- Allergies
- Organ problems
- Obesity
- Hypoglycemia
- Menopause
- Fitness goals
- Heart diseases
For many people with eating disorders, this type of advice is very beneficial. In fact, many California eating disorder centers as well as other eating disorder residential programs across the country offer nutritional counseling.
Benefits of Nutritional Counseling
Various benefits of nutritional counseling include:
- Increase in energy
- Healthier lifestyle and food choices
- Better quality sleep
- Reduced symptoms of disease
- Less drastic range of emotions
- Happiness
- Possible increase in longevity
- Strengthened immune system
- Lesser chance of disorders and diseases appearing
- Better ability to concentrate
VACCINATION SERVICES
Protecting your children from the very first day is essential in providing them with a healthy and fulfilling life. The road to good health begins with boosting your child’s immunity and by vaccinating them to protect them from a variety of ailments. As parents, we are always worried about our children’s health. The onset of the pandemic has heightened these fears all the more. Why should we leave anything to chance? After all, the greatest cure for a disease is prevention.
with Motherhood, your child can receive all of the vaccines essential for their well-being and safety.
BENEFITS:
- Vaccinations save your child’s life against diseases
- Vaccinations are better than cures
- Vaccines keep kids healthy
- Vaccines are one of the safest ways to protect your and the health of your loved ones
The benefits of vaccines are endless, and with us, safer than ever.
Vaccinations for Adults:
Vaccines save lives. This applies not only to children but also to their parents and grandparents. Throughout your life, you are likely to encounter myriad diseases that can be easily prevented by taking the right precautions. Vaccines are a sure-fire way to strengthen your body and thoroughly immunize it to ensure your longevity. At no age is one too old for vaccines. They are always crucial to your survival whether you are middle-aged in your 30s, or are ageing at 70. They can be recommended to you based on a variety of parameters, including your age, medical conditions, occupation, lifestyle, travel, and prior vaccinations. With these factors playing together, the best possible vaccines to immunize you are then recommended with your best interests at heart.
Leave nothing to chance and get vaccinated today.
DENTAL EVALUATION & REFERRAL
What is a dental exam?
A dental exam is a checkup of your teeth and gums. Most children and adults should get a dental exam every six months. These exams are important for protecting oral health. Oral health problems can become serious and painful if not treated promptly.
Dental exams are usually performed by both a dentist and a dental hygienist. A dentist is a doctor specially trained to care for teeth and gums. A dental hygienist is a health care professional trained to clean teeth and help patients maintain good oral health habits. Although dentists can treat people of all ages, children often go to pediatric dentists. Pediatric dentists are dentists who have received additional training to focus on dental care for children.
Other names: dental checkup, oral exam
What is it used for?
Dental exams are used to help find tooth decay, gum disease, and other oral health problems early, when they’re easier to treat. The exams are also used to help educate people on the best ways to care for their teeth and gums.
Why do I need a dental exam?
Most adults and children should get a dental exam every six months. If you have swollen, bleeding gums (known as gingivitis) or other gum disease, your dentist may want to see you more often. Some adults with gum disease may see a dentist three or four times a year. More frequent exams may help prevent a serious gum disease known as periodontitis. Periodontitis can lead to infection and tooth loss.
Babies should have their first dental appointment within six months of getting their first tooth, or by 12 months of age. After that, they should get an exam every six months, or according to the recommendation of your child’s dentist. Also, your child may need to have more frequent visits if the dentist finds a problem with tooth development or another oral health issue.
What happens during a dental exam?
A typical dental exam will include a cleaning by a hygienist, x-rays on certain visits, and a checkup of your mouth by the dentist.
During a cleaning:
- You or your child will sit in a large chair. A bright overhead light will shine above you. The hygienist will clean your teeth using small, metal dental tools. He or she will scrape your teeth to remove plaque and tartar. Plaque is a sticky film that contains bacteria and coats teeth. If plaque builds up on teeth, it turns into tartar, a hard mineral deposit that can get trapped at the bottom of teeth.
- The hygienist will floss your teeth.
- He or she will brush your teeth, using a special electric toothbrush.
- He or she may then apply a fluoride gel or foam to your teeth. Fluoride is a mineral that prevents tooth decay. Tooth decay can lead to cavities. Fluoride treatments are given to children more often than to adults.
- The hygienist or dentist may give you tips on how to care for your teeth, including proper brushing and flossing techniques.
Dental x-rays are images that can show cavities, gum disease, bone loss, and other problems that can’t be seen by just looking at the mouth.
During an x-ray, the dentist or hygienist will:
- Place a thick covering, called a lead apron, over your chest. You may get an additional covering for your neck to protect your thyroid gland. These coverings protect the rest of your body from radiation.
- Have you bite down on a small piece of plastic.
- Place a scanner outside your mouth. He or she will take a picture, while standing behind a protective shield or other area.
- For certain types of x-rays, you will repeat this process, biting down in different areas of your mouth, as instructed by the dentist or hygienist.
There are different types of dental x-rays. A type called a full-mouth series may be taken once every few years to check your overall oral health. Another type, called bitewing x-rays, may be used more often to check for cavities or other tooth problems.
During the dentist’s checkup, the dentist will:
- Check your x-rays, if you’ve had them, for cavities or other problems.
- Look at your teeth and gums to see if they are healthy.
- Check the bite (the way the top and bottom teeth fit together). If there is a bite problem, you may be referred to an orthodontist.
- Check for oral cancer. This includes feeling under your jaw, checking the insides of your lips, the sides of your tongue, and on the roof and floor of your mouth.
In addition to the above checks, a pediatric dentist may check to see if your child’s teeth are developing normally.
Will I need to do anything to prepare for a dental exam?
If you have certain health conditions, you may need to take antibiotics before your exam. These conditions include:
- Heart problems
- Immune system disorders
- Recent surgery
If you’re not sure whether you need to take antibiotics, talk to your dentist and/or other health care provider.
Also, some people feel anxious about going to the dentist. If you or your child feels this way, you may want to talk to the dentist beforehand. He or she may be able to help you or your child feel more relaxed and comfortable during the exam.
Are there any risks to a dental exam?
There is very little risk to having a dental exam. The cleaning may be uncomfortable, but it is not usually painful.
Dental x-rays are safe for most people. The dose of radiation in an x-ray is very low. But x-rays are not usually recommended for pregnant women, unless it’s an emergency. Be sure to tell your dentist if you are pregnant or think you may be pregnant.
What do the results mean?
Results may include one or more of the following conditions:
- A cavity
- Gingivitis or other gum problems
- Bone loss or tooth development problems
If results show that you or your child has a cavity, you probably will need to make another appointment with the dentist to treat it. If you have questions about how cavities are treated, talk to the dentist.
If results show that you have gingivitis or other gum problems, your dentist may recommend:
- Improving your brushing and flossing habits.
- More frequent dental cleanings and/or dental exams.
- Using a medicated mouth rinse.
- That you see a periodontist, a specialist in diagnosing and treating gum disease.
If bone loss or tooth development problems are found, you may need more tests and/or dental treatments.
Is there anything else I need to know about a dental exam?
To keep your mouth healthy, you’ll need to take good care of your teeth and gums, both by having regular dental exams and practicing good dental habits at home. Good home oral care includes the following steps:
- Brush your teeth twice a day using a soft-bristled brush. Brush for about two minutes.
- Use a toothpaste that has fluoride. Fluoride helps prevent tooth decay and cavities.
- Floss at least once a day. Flossing removes plaque, which can damage teeth and gums.
- Replace your toothbrush every three or four months.
- Eat a healthy diet, avoiding or limiting sweets and sugary drinks. If you do eat or drink sweets, brush your teeth soon after.
- Don’t smoke. Smokers have more oral health problems than nonsmokers.
ADOLESCENT COUNSELLING
- Adolescent counseling is aimed at young people to help them make sense of their feelings, behaviors and thoughts and entails the use of unique techniques. Thus, our team at Focus Eye Hosptial diagnoses the problematic behavior of the concerned individuals and they have to go through certain counseling sessions accordingly.
- Any parent can attest to the fact that the adolescence stage of any child can be extremely difficult and confusing. Hence, it is very important for parents to handle their adolescent children in the best ways. Thus, these counseling sessions are organized and they turn out to be effective, most of the time.
- Focus Eye Hospital is certainly a reliable service for anxiety treatment & stress management in Andhra Pradesh. Anxiety is yet another problem faced by adolescents which become very tough to handle. Hence, these counseling sessions are needed.
- Interactive counseling workshops are often performed with the main intention of counseling groups of young adults all at once. During such workshops, adolescents participate in different one on one and interactive activities like talks, games and other practical sessions. Our team at Focus Eye Hospital mainly focuses on these activity based counseling sessions that have been very fruitful.
- One-on-One adolescent counseling involves having the adolescent attend counseling sessions. And this is also needed at times to diagnose the basic problems.
Adolescence is the most complicated phase of one’s life. These adolescent counseling sessions focus not only on the patient but also on the patient’s family and this is what we do at Focus Eye Hospital. Our counselors prefer involving the family as they play a crucial role in the adolescent’s life and will determine how well the young adult will handle the changes they are experiencing.
SLEEP COACHING
Our SLEEP WELL philosophy
At Focus Eye Care, we believe that every child has the ability to sleep well and that every family can successfully use basic sleep tools to make this happen.
Good sleep can reduce child and caregiver stress, and helps support a healthier and happier family. From our experience, there is no one-size-fits-all solution for every family. Our commitment is to work with you until your child is sleeping well.
Before creating a plan, we first make sure we understand your particular situation, struggles and goals. Together, we then create a strategy that works for your family to ensure your child gets a good night’s sleep.
What is a sleep coach?
A sleep coach, or sleep consultant, is a general term for someone who provides education, advice and support services to help improve a child’s sleep. However, the criteria for who can call themselves a “sleep coach” can be quite variable and the term does not guarantee any specific training or certification. So when choosing a sleep coach, be sure to do your homework about the coach’s background, training and previous experience to determine if he or she is the right fit for you. Learn more about questions to consider about sleep coaching.
We are pleased to offer sleep coaching here at the Sleep Center. Our sleep coaches are certified pediatric nurse practitioners with backgrounds and extensive training in child development, general pediatric medicine and sleep science. While they specialize in treating the sleep problems of young children, they also address sleep difficulties arising in children of all ages, from infants to adolescents.
Sleep coaching is typically covered by your medical insurance plan as it would be for any other medical specialty referral.
What to expect during a sleep coaching clinic visit
Your sleep coach will first perform a comprehensive evaluation of your child including,
assessment of current sleep patterns and habits
full past medical history
family history
brief physical exam
Your coach will then discuss your child’s particular sleep problem or diagnosis with you in detail, providing education about,
how sleep works
how this information relates to your family’s sleep issues
(most importantly) how to fix the problem
By the end of your visit, you will receive a customized, written plan that fits your family’s needs and our common goal of helping your child get a good night’s sleep.
After your visit you can expect:
follow-up in clinic every three to five weeks, as needed, until the sleep problem is resolved (most are resolved in two to four visits)
a detailed visit note included in your child’s medical record and sent to your primary care provider.
Common problems discussed during sleep coaching
Infants and toddlers
My baby wakes every few hours to feed at night.
My baby refuses to sleep in his crib.
I need to rock my baby to sleep then she wakes and I have to rock her again several times each night.
My daughter has trouble napping.
Any age
My daughter will not fall asleep without me.
My son wakes up almost every night.
My son has trouble falling asleep.
My daughter wakes up way too early and won’t go back to sleep.
My son sneaks into my bed every night.
My daughter wakes up and looks scared and confused — I’m not sure if she’s fully awake.
My teenager has trouble falling asleep on school nights until very late and then has trouble waking up on time for school. I think her grades are suffering!