In examining children this orderly sequence of head to toe is frequently altered to accommodate the child's developmental needs, although the examination is recorded following the head to toe model. Usually head-to-toe sequence. Infants and young children the exam is opportunistic. Begin with parent holding child. While quiet, listen to heart, lung and bowel sounds, then proceed to move invasive aspects of the exam, taking advantage of opportunities such as opening a mouth to yawn or cry for inspection. The ear exam is disturbing to young children and is done last. Any painful area examines last. A nurse may use atraumatic care when an infant or toddler is in distress. This can be performed when the nurse is using the otoscope to look into the child's ear. Make examining the ear a game by using imagination. Normally the split of the two sounds in S2 is a distinguishable and widens during inspiration. Physiologic splitting is a significant normal finding. Fixed splitting in which the split in S2 does not change during inspiration is an important diagnostic sign of atrial septal defect. S3 is normally heard in some children. S4 is rarely heard as a normal heart sound. Infant heart: (PMI may be prominent - located at the 4th ICS. HR is rapid; assess brachial or apical pulse - not radial. 50% of infants have innocent murmurs: short, systolic, Gr III or less, non-radiating, LSB 4th ICS, Supine, low pitched, musical or vibratory). Toddlers PE: (Lungs- have child blow a cotton ball to aid auscultation; breath sounds are rarely absent- rather note diminished BS. Vesicular sounds predominate over lung fields. Heart- Sinus arrhythmia is normal (HR increases with respiration and decreases expiration, disappears with exercise or breath holding. Apical impulse and PMI are lateral to LMCL ad 4th ICS in children under age 7).