(18) Peds Flashcards
Four Principles of Child Development
- Child development proceeds along a predictable pathway.
- Child development proceeds along a predictable pathway governed
by the maturing brain. You can measure age-specific milestones and use
them to characterize development as normal or abnormal. Because your
health care visit and physical examination take place at one point in time,
you need to determine where the child fits along a developmental trajectory.
Milestones are achieved in an order than can be anticipated. Loss of milestones
is always concerning - The range of normal development is wide.
- The range of normal development is wide. Children mature at different
rates. Each child’s physical, cognitive, and social development should
fall within a broad developmental range - Various physical, social, and environmental factors, as well as diseases, can
affect child development and health.
- Various physical, social, and environmental factors, as well as diseases,
can affect child development and health. For example, chronic illnesses, child abuse,
and poverty can all cause detectable physical abnormalities and alter the rate and
course of development. Additionally, children with physical or cognitive disabilities
may not follow the expected age-specific developmental trajectory - The child’s developmental level affects how you conduct the history and
physical examination
- The child’s developmental level affects how you conduct the clinical
history and physical examination. For example, interviewing a 5-year-old is fundamentally different than interviewing an adolescent. Both order and
style differ from the adult examination. Before performing a physical examination,
attempt to ascertain the child’s approximate developmental level and
adapt your physical examination to that level. An understanding of normal
child development helps you achieve these tasks
Key Components of Pediatric
Health Promotion
- Age-appropriate developmental achievement of the child
● Physical (maturation, growth, puberty)
● Motor (gross and fine motor skills)
● Cognitive (developmental milestones, language, school performance)
● Emotional (self-regulation, mood, temperament, self-efficacy, self-esteem,
independence)
● Social (social competence, self-responsibility, integration with family and
community, peer interactions) - Health supervision visits
● Periodic assessment of clinical and oral health
● More frequent health supervision visits for children with special health
care needs - Integration of physical examination findings with health promotion
- Immunizations
- Screening procedures
- Anticipatory guidance4,8
● Healthy habits
● Nutrition and healthy eating
● Safety and prevention of injury
● Physical activity
● Sexual development and sexuality
● Self-responsibility, efficacy, and healthy self-esteem
● Family relationships (interactions, strengths, supports)
● Positive parenting strategies
● Emotional and mental health
● Oral health
● Recognition of illness
● Sleep
● Screen time
● Prevention of risky behaviors (e.g., tobacco, alcohol and drug use, unprotected
sex)
● School and vocation
● Peer relationships
● Community interactions - Partnership among health care provider, child/adolescent, and family
Tips for Examining Newborns
● Examine the newborn in the presence of the parents.
● Swaddle and then undress the newborn as the examination proceeds.
● Dim the lights and rock the newborn to encourage the eyes to open.
● Observe feeding, if possible, particularly breast-feeding.
● Demonstrate calming maneuvers to parents (e.g., swaddling).
● Observe and teach parents about transitions as the newborn arouses.
● A typical sequence for the examination of the newborn:
● Careful observation before (and during) the examination
● Heart
● Lungs
● Head, neck, and clavicles
● Ears and mouth
● Hips
● Abdomen and genitourinary system
● Lower extremities, back
● Eyes, whenever they are spontaneously open or at end of examination
● Skin, as you go along
● Neurologic system
Apgar Score.
an assessment of the newborn
immediately after birth. Its five components classify the newborn’s neurologic
recovery from the stress of birth and immediate adaptation to extrauterine life.
Score each newborn at 1 and 5 minutes after birth according to the following
table. Scoring is based on a 3-point scale (0, 1, or 2) for each component. Total
scores range from 0 to 10. Scoring may continue at 5-minute intervals until
the score is >7. If the 5-minute Apgar score is 8 or more, proceed to a more
complete examination.
Apgar Scoring System
HR: absent, <100, >100
Resp. effort: absent, slow/irregular, good/strong
Muscle tone: flaccid, some flexion, active
Reflex irritability: none, grimace, vigorous cry
Color: blue/pale, pink body/blue extremities, pink all over
Apgar 1-min score
8-10 normal
5-7 some nervous system depression
0-4 severe depression, require immediate resuscitation
Apgar 5-min score
8-10: normal
0-7: high risk for subsequent central nervous system and other organ system dysfunction
Ballard Scoring System
estimates
gestational age to within 2 weeks, even in extremely premature infants.
chart on pg 806
Gestational Age classification at birth
preterm: <34 weeks
late preterm: 34-36 weeks
term: 37-42 weeks
postterm: >42 weeks
Birth weight classification
extremely low: <1000g
very low: <1500g
low: <2500g
normal:>2500g
newborn classifications
small for gestation age: <10%
appropriate for gestation age: 10-90th %
large for gestation age: >90%
Most normal, full-term newborns
lie in a symmetric
position, with the limbs semiflexed and the legs partially abducted at the hip.
Note the baby’s spontaneous motor activity with flexion and extension alternating
between the arms and legs. The fingers are usually flexed in a tight fist, but
may extend in slow athetoid posturing movements. You will observe brief tremors
of the body and extremities during vigorous crying, and even at rest.
What a Newborn Can Do
Core Elements
● Newborns use all five senses. For example, they will look at human faces and
turn to a parent’s voice.
● Newborns are unique individuals. Marked differences exist in temperaments,
personality, behavior, and learning.
● Newborns interact dynamically with caregivers—a two-way street!
Examples of Complex Newborn Behavior
Habituation Ability to selectively and progressively shut out negative
stimuli (e.g., a repetitive sound)
Attachment A reciprocal, dynamic process of interacting and bonding
with the caregiver
State regulation Ability to modulate the level of arousal in response to different
degrees of stimulation (e.g., self-consoling)
Perception Ability to regard faces, turn to voices, quiet in presence of
singing, track colorful objects, respond to touch, and
recognize familiar scents
newborn to 1 year height/weight
weight - triple
height - increase by 50%
newborn physical development
Physical growth during infancy is faster than at
any other age.12 By 1 year, the infant’s birth weight should have tripled and
height increased by 50% from weight and height at birth.
Newborns have surprising abilities, such as fixing upon and following human
faces. Neurologic development progresses centrally to peripherally. Thus, newborns
learn head control before trunk control and use of arms and legs before
use of hands and fingers (Fig. 18-9).
Activity, exploration, and environmental manipulation contribute to learning. By
3 months, normal infants lift the head and clasp the hands. By 6 months, they roll
over, reach for objects, turn to voices, and possibly sit with support. With increasing
peripheral coordination, infants reach for objects, transfer them from hand to
hand, crawl, stand by holding on, and play with objects by banging and grabbing.
At 1 year a child may be standing and putting objects in the mouth
Newborn: cognitive and language development
Exploration fosters increased
understanding of self and environment. Infants learn cause and effect (e.g., shaking
a rattle produces sound), object permanence, and use of tools. By 9 months, they
may recognize the examiner as a stranger deserving wary cooperation, seek comfort
from parents during examinations, and actively manipulate reachable objects (e.g.,
your stethoscope). Language development proceeds from cooing at 2 months, to
babbling at 6 months, to saying one to three words by 1 year
newborn: social and emotional development
Understanding of self and
family also matures. Social tasks include bonding, attachment to caregivers, and
trust that caregivers will meet their needs (Fig. 18-11). Temperaments vary.
Some infants are predictable, adaptable, and respond positively to new stimuli;
others are less so and respond intensely or negatively. Because environment
affects social development, observe the infant’s interactions with caregivers
Developmental Milestones during infancy
p. 810, figure 18-11
Tips for Examining Infants
DISTRACTION!
● Approach the infant gradually, using a toy or object for distraction.
● Perform as much of the examination as possible with the infant in the parent’s lap.
● Speak softly to the infant or mimic the infant’s sounds to attract attention.
● If the infant is cranky, make sure he or she is well fed before proceeding.
● Ask a parent about the infant’s strengths to elicit useful developmental and
parenting information.
● Don’t expect to do a head-to-toe examination in a specific order. Work with
what the infant gives you and save the mouth and ear examination for last.
The AAP recommends that health care providers use a standardized developmental
screening instrument for infants as young as several months of age.
Several developmental screening instruments have been tested widely and validated
in many nations. In general, these instruments assess five critical domains
of infant/child development:
gross motor, fine motor, cognitive (or problem-solving),
communication, and personal/social domains of development
For babies born
prematurely, adjust expected developmental milestones for the gestational age up to
24 months
The AAP and the group Bright Futures4 recommend health supervision visits for
infants at the following ages:
at birth, at 3 to 5 days, by 1 month, and at 2, 4, 6,
9, and 12 months
? is one of the most important
indicators of infant health
Measurement of growth
The most important tools for assessing somatic growth are
the growth charts
which are published by the National Center for Health Statistics (www.cdc.
gov/nchsv)16 and also the World Health Organization (www.who.int).
Although obtaining accurate blood pressure readings in infants is challenging (Fig. 18-17), this measurement is nevertheless important for
some high-risk infants and should
be routinely performed after age 3 years.
HRs:
birth-1 month
1-6 months
6-12 months
140 (90-190)
130 (80-180)
115 (75-155)
RR newborn
30-60
The respiratory rate may vary considerably from moment to moment in the
newborn, with alternating periods of rapid and slow breathing (called “periodic
breathing”)
tachypnea from birth-1 year
Commonly accepted cutoffs for defining tachypnea are >60/min from birth to
2 months, and >50/min from 2 to 12 months
infants and temperature
Because
fever is so common in infants
and children, obtain an accurate
body temperature when
you suspect infection. Axillary
and thermal-tape skin
temperature recordings in
infants and children are inaccurate.
Auditory canal temperatures
are accurate.
Rectal temperatures are the
most accurate for infants
Body temperature in infants and children is less constant than in adults. The
average rectal temperature is higher in infancy and early childhood, usually
above 99°F (37.2°C) until after age 3 years. Body temperature may fluctuate as
much as 3°F during a single day, approaching 101°F (38.3°C) in normal children,
particularly in late afternoon and after vigorous activity
Newborns and Infants: Skin Inspection
Examine the skin of the newborn or infant carefully to identify
both normal markings and potentially abnormal ones. The photos on pp. 818–820
demonstrate normal markings. The newborn’s skin has a unique characteristic
texture and appearance. The texture is soft and smooth because it is thinner than
the skin of older children. Within the first 10 minutes after birth a normal newborn
progresses from generalized cyanosis to pinkness. In lighter-skinned
infants, an erythematous flush, giving the skin the appearance of a “boiled lobster,”
is common during the first 8 to 24 hours after which the normal pale pink
coloring predominates.
Vasomotor changes in the dermis and subcutaneous tissue—a response to cooling
or chronic exposure to radiant heat—can produce a lattice-like, bluish mottled
appearance (cutis marmorata), particularly on the trunk, arms, and legs. This
response to cold may last for months in normal infants. Acrocyanosis, a blue cast
to the hands and feet when exposed to cold (see p. 818), is very common in
newborns for the first few days and may recur throughout early infancy. Occasionally
in newborns, a remarkable color change (harlequin dyschromia) appears
with transient cyanosis of one half of the body or one extremity, presumably from
temporary vascular instability.
The amount of melanin in the skin of newborns varies, affecting pigmentation.
Black newborns may have a lighter skin color initially, except in the nail beds,
genitalia, and ear folds which are dark at birth. A dark or bluish pigmentation
over the buttocks and lower lumbar regions is common in newborns of African,
Asian, and Mediterranean descent. These areas, called slate blue patches, result
from pigmented cells in the deep layers of the skin; they become less noticeable
with age and usually disappear during childhood. Document these pigmented areas
to avoid later concern about bruising.
At birth, there is a fine, downy growth of hair called lanugo over the entire body,
especially the shoulders and back. This hair is shed within the first few weeks.
Lanugo is prominent in premature infants. Hair thickness on the head varies
considerably among newborns and is not predictive of later hair growth. All of the original hair is shed within months and is replaced with a new crop, sometimes
of a different color.
Inspect the newborn closely for a series of common skin conditions. At birth, a
cheesy white material called vernix caseosa, composed of sebum and desquamated
epithelial cells, covers the body. Some newborns have edema over their hands,
feet, lower legs, pubis, and sacrum; this disappears within a few days. Superficial
desquamation of the skin is often noticeable 24 to 36 hours after birth, particularly
in postterm babies (>40 weeks gestation), and it can last for 7 to 10 days.
You should be able to identify four common dermatologic conditions in newborns—
miliaria rubra, erythema toxicum, pustular melanosis, and milia—which
are shown on p. 819. None of these is clinically significant.
Note any signs of trauma from the birth process and the use of forceps or suction;
these signs disappear but should prompt a careful neurologic examination.
Newborns/Infants: Jaundice inspection
Carefully examine and touch the newborn’s skin to assess
the level of jaundice. Normal “physiologic” jaundice, which occurs in half
of all newborns, appears on the second or third day, peaks at about the fifth
day, and usually disappears within a week (although it may persist longer
in breast-fed infants). Jaundice is best seen in natural daylight rather than
artificial light. Newborn jaundice appears to progress from head to toe, with
more intense jaundice on the upper body and less intense yellow color in
the lower extremities.
To detect jaundice, apply pressure to the skin (Fig. 18-19) to press out the normal
pink or brown color. A yellowish “blanching” indicates jaundice
newborns/infants: vascular markings
A common vascular marking is the “salmon patch”
(also known as nevus simplex, “flame nevi,” telangiectatic nevus, or capillary
hemangioma). These flat, irregular, light pink patches (see p. 819) are most often
seen on the nape of the neck (“stork bite”), upper eyelids, forehead, or upper
lip (“angel kisses”). They are not true nevi, but result from distended capillaries.
They often disappear by 1 year of age and are covered by the hairline
newborns/infants: palpation
Palpate the newborn or infant’s skin to assess the degree of hydration,
or turgor. Roll a fold of loosely adherent skin on the abdominal wall
between your thumb and forefinger to determine its consistency. The skin in
well-hydrated infants returns to its normal position immediately upon release.
Delay in return is a phenomenon called “tenting” and usually occurs in children
with significant dehydration
Acrocyanosis
This bluish discoloration usually appears in the palms and
soles. Cyanotic congenital heart disease can present with severe
acrocyanosis
Jaundice
Physiologic jaundice occurs during days 2 to 5 of life and progresses
from head to toe as it peaks. Extreme jaundice may
signify a hemolytic process or biliary or liver disease.
Miliaria Rubra
Scattered vesicles on an erythematous base, usually on the face
and trunk, result from obstruction of the sweat gland ducts; this
condition disappears spontaneously within weeks
Erythema Toxicum
Usually appearing on days 2 to 3 of life, this rash consists of
erythematous macules with central pinpoint vesicles scattered
diffusely over the entire body. They appear similar to
flea bites. These lesions are of unknown etiology but disappear
within 1 week of birth
Pustular Melanosis
Seen more commonly in black infants, the rash presents at
birth as small vesiculopustules over a brown macular base;
these can last for several months
Milia
Pinhead-sized smooth white raised areas without surrounding
erythema on the nose (seen here), chin, and forehead result from
retention of sebum in the openings of the sebaceous glands.
Although occasionally present at birth, milia usually appear
within the first few weeks and disappears over several weeks
Eyelid Patch
This birthmark fades, usually within the first year of life
Salmon Patch
Also called the “stork bite,” or “angel kiss,” this splotchy pink
mark fades with age
Café-au-lait Spots
These light-brown pigmented lesions usually have borders and
are uniform. They are noted in more than 10% of black infants. If
more than five café-au-lait spots exist, consider the diagnosis of neurofibromatosis
Slate Blue Patches
These are more common among dark-skinned babies. It is
important to note them so that they are not mistaken for
bruises
newborns/infants: sutures and fontanelles
Membranous tissue spaces called sutures separate
the bones of the skull from one another. The areas where the major sutures intersect
in the anterior and posterior portions of the skull are known as fontanelles.
Examine the sutures and fontanelles carefully
On palpation, the sutures feel like ridges and the fontanelles like soft concavities.
The anterior fontanelle at birth measures 4 to 6 cm in diameter and usually
closes between 2 and 26 months of age (90% between 7 and 19 months). The
posterior fontanelle measures 1 to 2 cm at birth and usually closes by 2 months
Carefully examine the fontanelle, because its fullness reflects intracranial pressure.
Palpate the fontanelle while the baby is sitting quietly or being held upright.
Clinicians often palpate the fontanelles at the beginning of the examination. In
normal infants, the anterior fontanelle is soft and flat. A full anterior fontanelle
with increased intracranial pressure is seen when a baby cries or vomits. Pulsations
of the fontanelle reflect the peripheral pulse and are normal (and parents
often inquire about them). Learn to palpate the fontanelle because a bulging
fontanelle is concerning for increased intracranial pressure and a depressed
fontanelle may suggest dehydration.
Inspect the scalp veins carefully to assess for dilatation
infants/newborns: skull symmetry and head circumference
Carefully assess skull
symmetry (Fig. 18-21). Various conditions
can cause asymmetry; some are benign,
while others reflect underlying pathology.
Look for asymmetric head swelling. A
newborn’s scalp may be swollen over the
occipitoparietal region. This is called
caput succedaneum and results from capillary
distention and extravasation of
blood and fluid resulting from the vacuum
effect of rupture of the amniotic
sac. This swelling typically crosses suture
lines and resolves in 1 to 2 days.
The premature infant’s head at birth is relatively long in the occipitofrontal diameter
and narrow in the bitemporal diameter (dolichocephaly). Usually, the skull
shape normalizes within 1 to 2 years
Pick up the infant and examine the skull shape from behind. Asymmetry of the
cranial vault (positional plagiocephaly) occurs when an infant lies mostly on one
side, resulting in a flattening of the parieto-occipital region on the dependent
side and a prominence of the frontal region on the ipsilateral side. It disappears
as the baby becomes more active and spends less time in one position, and symmetry
is almost always restored. Interestingly, the current trend to have newborns
sleep on their backs to reduce the risk for sudden infant death syndrome (SIDS)
has resulted in more cases of positional plagiocephaly (Fig. 18-22). This condition
can be prevented by frequent repositioning (providing “tummy time” when the
infant is awake).
Measure the head circumference (p. 814) to detect abnormally large head size
(macrocephaly) or small head size (microcephaly), both of which may signify an
underlying disorder affecting the brain.
Palpate along the suture lines. A raised, bony ridge at a suture line suggests craniosynostosis.
Palpate the infant’s skull with care. The cranial bones generally appear “soft” or
pliable; they will normally become firmer with increasing gestational age
newborns/infants: facial symmetry
Check the face of infants for symmetry. In utero positioning
may result in transient facial asymmetries. If the head is flexed on the sternum,
a shortened chin (micrognathia) may result. Pressure of the shoulder on the
jaw may create a temporary lateral displacement of the mandible.
Examine the face for an overall impression of the facies; it is helpful to compare
with the face of the parents. A systematic assessment of a child with abnormalappearing
facies can identify specific syndromes.18 The box on the next page
describes steps for evaluating fa
Evaluating a Newborn or Child with
Possible Abnormal Facies
Carefully review the history, especially:
● Family history
● Pregnancy
● Perinatal history
Note abnormalities on other parts of the physical examination, especially:
● Growth
● Development
● Other dysmorphic somatic features
Perform measurements (and plot percentiles), especially:
● Head circumference
● Height
● Weight
Consider the three mechanisms of facial dysmorphogenesis:
● Deformations from intrauterine constraint
● Disruptions from amniotic bands or fetal tissue
● Malformations from intrinsic abnormality in face/head or brain
Examine the parents and siblings:
● Similarity to a parent may be reassuring (e.g., large head) but may also be an
indication of a familial disorder
Try to determine whether the facial features fit a recognizable syndrome,
comparing with:
● References (including measurements) and pictures of syndromes
● Tables/databases of combinations of features
Chvostek Sign
Percuss the cheek to check for Chvostek sign, which is present
in some metabolic disturbances and occasionally in normal infants. Percuss at
the top of the cheek just below the zygomatic bone in front of the ear, using the
tip of your index or middle finger
newborn/infants: eyes
Newborns keep their eyes closed except during brief awake periods.
If you attempt to separate their eyelids, they will tighten them even more.
Bright light causes infants to blink, so use subdued lighting. Awaken the baby
gently and support the baby in a sitting position; often the eyes open.
To examine the eyes of infants and young children, use some tricks to encourage
cooperation. Small colorful toys are useful as fixation devices in examining the
eyes.
Newborns may look at your
face and follow a bright light if
you catch them during an alert
period. Some newborns can
follow your face and turn their
heads 90° to each side. Examine
infants for eye movements.
Hold the baby upright, supporting
the head. Rotate yourself
with the baby slowly in one
direction. This usually causes
the baby’s eyes to open, allowing
you to examine the sclerae,
pupils, irises, and extraocular
movements (Fig. 18-23). The
baby’s eyes gaze in the direction
you are turning. When the rotation stops, the eyes look in the opposite direction,
after a few nystagmoid movements.
During the first 10 days of life, the eyes may stare in one direction if just the head
is turned without moving the body (doll’s eye reflex).
During the first few months of life, some infants have intermittent crossed eyes
(intermittent alternating convergent strabismus, or esotropia) or laterally deviated
eyes (intermittent alternating divergent strabismus, or exotropia).
Look for abnormalities or congenital problems in the sclera and pupils. Subconjunctival
hemorrhages are common in newborns and resolve within a
couple of weeks. The eyes of many newborns are edematous from the birth
process.
Observe pupillary reactions by response to light or by covering each eye with
your hand and then uncovering it. Although there may be initial asymmetry in
the size of the pupils, over time they should be equal in size and reaction to
light.
Inspect the irises carefully for abnormalities Examine the conjunctiva for swelling or redness. Most newborn nurseries use an
antibiotic eye ointment to help prevent gonococcal eye infection.
You will not be able to measure the visual acuity of newborns or infants. You can
use visual reflexes to indirectly assess vision: direct and consensual pupillaryconstriction in response to light, blinking in response to bright light (optic
blink reflex), and blinking in response to quick movement of an object toward
the eyes.
Visual Milestones of Infancy
Birth - Blinks, may regard face 1 month - Fixes on objects 1½–2 months - Coordinated eye movements 3 months - Eyes converge, baby reaches toward a visual stimulus 12 months - Acuity around 20/60–20/80
newborns/infants: Ophthalmoscopic Examination.
For the ophthalmoscopic examination,
with the newborn awake and eyes open, examine the red retinal (fundus) reflex
by setting the ophthalmoscope at 0 diopters and viewing the pupil from about
10 inches. Normally, a red or orange color is reflected from the fundus through
the pupil.
A thorough ophthalmoscopic examination is difficult in young infants but may
be needed if ocular or neurologic abnormalities are noted. The cornea can ordinarily
be seen at +20 diopters, the lens at +15 diopters, and the fundus at 0
diopters.
Examine the optic disc area as you would for an adult. In infants, the optic disc
is difficult to visualize but is lighter in color, with less macular pigmentation. The
foveal light reflection may not be visible. Papilledema is rare in infants because
the fontanelles and open sutures accommodate any increased intracranial pressure,
sparing the optic discs.
newborns/infants: ears
The physical examination of the ears of infants is important because many
abnormalities can be detected, including structural problems, otitis media, and
hearing loss.
The goals are to determine the position, shape, and features of the ear and to detect
abnormalities. Note ear position in relation to the eyes. An imaginary line drawn
across the inner and outer canthi of the eyes should cross the pinna or auricle;
if the pinna is below this line the infant has low-set ears. Draw this imaginary
line across the face of the baby on p. 821; note that it crosses the pinna.
Otoscopic examination of the newborn’s ear can detect only patency of the ear
canal because accumulated vernix caseosa obscures the tympanic membrane for
the first few days of life A small skin tab, cleft, or pit found just forward of the tragus represents a remnant
of the first branchial cleft and usually has no significance. However, occasionally
it may also be associated with renal disease and acquired hearing loss if
there is a family history of hearing loss.
The infant’s ear canal is directed downward from the outside; therefore, pull
the auricle gently downward, not upward, for the best view of the eardrum.
Once the tympanic membrane is visible, note that the light reflex is diffuse; it
does not become cone-shaped for several months.
The acoustic blink reflex is a blinking of the infant’s eyes in response to a sudden
sharp sound. You can produce it by snapping your fingers or using a bell, beeper,
or other noisemaking device approximately 1 foot from the infant’s ear. Be sure you
are not producing an airstream that may cause the infant to blink. This reflex may
be difficult to elicit during the first 2 to 3 days of life. After it is elicited several times
within a brief period, the reflex disappears, a phenomenon known as habituation.
This crude test of hearing certainly is not diagnostic. Most newborns in the United
States undergo hearing screenings, which are mandatory in the majority of states
Signs That an Infant Can Hear
0–2 mo: Startle response and blink to a sudden noise
Calming down with soothing voice or music
2–3 mo: Change in body movements in response to sound
Change in facial expression to familiar sounds
Turning eyes and head to sound
3–4 mo: Turning to listen to voices and conversation
6–7 mo: Appropriate language development
infants/newborns: nose and sinuses
The most important component of the examination of the infant nose is to test
for patency of the nasal passages. You can do this by gently occluding each nostril
alternately while holding the infant’s mouth closed. This usually will not cause
stress because most infants are nasal breathers. Some infants are obligate nasal
breathers and have difficulty breathing through their mouths. Do not occlude
both nares simultaneously, as this will cause considerable distress.
Inspect the nose to ensure that the nasal septum is midline.
At birth, the maxillary and the ethmoid sinuses are present. Palpation of the
sinuses of newborns is not helpful.
newborns/infants: mouth and pharynx
Use both inspection with a tongue depressor and flashlight and palpation to inspect
the mouth and pharynx (Fig. 18-24). One method employs the parent to hold theinfant’s head and arms. The newborn’s
mouth is edentulous and the alveolar
mucosa is smooth with finely serrated
borders. Occasionally, pearl-like retention
cysts are seen along the alveolar
ridges and are easily mistaken for teeth;
these disappear within 1 or 2 months.
Petechiae are commonly found on the
soft palate after birth.
Palpate the upper hard palate to make sure it is intact. Epstein pearls, tiny white
or yellow, rounded mucous retention cysts, are located along the posterior midline
of the hard palate. They disappear within months.
Cysts may be noted on the tongue or mouth. Thyroglossal duct cysts may open
under the tongue.
Infants produce little saliva during the first 3 months. Older infants produce a
lot of saliva and drool frequently.
Inspect the tongue. The frenulum varies in tightness; sometimes it extends
almost to the tip and other times it is short, limiting protrusion of the tongue
(ankyloglossia or tongue tie).
You will often see a whitish covering on the tongue. If this coating is from milk,
it can be easily removed by scraping or wiping it away. Use a tongue depressor
or your gloved finger to wipe away the coating.
While there is a predictable pattern of tooth eruption, there is wide variation in the
age at which teeth appear. A rule of thumb is that a child will have 1 tooth for
each month of age between 6 and 26 months, up to a maximum of 20 primary
teeth.
The pharynx of the infant is best seen while the baby is crying. You will likely have
difficulty using a tongue depressor because it produces a strong gag reflex. Infants
do not have prominent lymphoid tissue so you will probably not visualize the
tonsils which increase in size as children grow.
Listen to the quality of the infant’s cry. Normal infants have a lusty, strong cry. The
following box lists some unusual types of infant cries
Abnormal Infant Cries (If Persistent)
Shrill or high pitched:
Increased intracranial pressure. Also in newborns born to
narcotic-addicted mothers.
Hoarse: Hypocalcemic tetany or congenital hypothyroidism
Continuous
inspiratory
and expiratory
stridor:
Upper airway obstruction from various lesions (e.g., a polyp
or hemangioma), a relatively small larynx (infantile laryngeal
stridor), or a delay in the development of the cartilage
in the tracheal rings (tracheomalacia)
Absence of cry: Severe illness, vocal cord paralysis, or profound brain damage
newborns/infants: neck
Palpate the lymph nodes of the neck and assess for any additional masses such as
congenital cysts (Fig. 18-25). Because the necks of infants are short, it is best to
palpate the neck while infants are lying supine, whereas older children are best
examined while sitting. Check the position of the thyroid cartilage and trachea.
In newborns, palpate the clavicles and look for evidence of a fracture. If present,
you may feel a break in the contour of the bone, tenderness, crepitus at the fracture
site, and may notice limited movement of the arm on the affected side.
newborns/infants: thorax and lungs
The infant’s thorax is more rounded than that of adults. The thin chest wall has
little musculature; thus, lung and heart sounds are transmitted quite clearly. The
bony and cartilaginous rib cage is soft and pliant. The tip of the xiphoid process
often protrudes anteriorly, immediately beneath the skin
newborns/infants: thorax and lungs inspection
Carefully assess respirations and breathing patterns. Newborns,
especially those born prematurely, show periods of normal rate (30 to 40 per
minute) alternating respirations that may even cease for 5 to 10 seconds. This
alternating pattern of rapid and slow breathing is called “periodic respiration” or
“periodic breathing.”
Do not rush to the stethoscope. Instead, observe the infant carefully as demonstrated
in Figure 18-26, which demonstrates locations for retractions among
infants. Inspection is easiest when infants are not crying; thus, work with the
parents to settle the child. Observe for 30 to 60 seconds, note general appearance,
respiratory rate, color, nasal component of breathing, audible breath
sounds, and work of breathing, as described below.
Because infants are obligate nasal breathers, observe their nose as they breathe.
Look for nasal flaring. Observe breathing with the infant’s mouth closed or during
nursing or sucking on a bottle to assess for nasal patency. Listen to the sounds of
breathing; note any grunting, audible wheezing, or lack of breath sounds (obstruction).
Nasal flaring, grunting, retractions, and wheezing are all signs of respiratory distress.
Observe two aspects of the infant’s breathing: audible breath sounds and work of
breathing. These are particularly relevant in assessing both upper and lower respiratory
illness. Studies in countries with poor access to chest radiographs have found these signs at least as useful as auscultation. Any of the abnormalities listed
below should raise concern about underlying respiratory pathology.
In healthy infants, the ribs do not move much during quiet breathing. Any outward
movement is produced by descent of the diaphragm which compresses the
abdominal contents and in turn shifts the lower ribs outward.
Pulmonary disease causes increased abdominal breathing and can result in
retractions (chest indrawing), an indicator of pulmonary disease before 2 years
of age.
Chest indrawing is inward movement of the skin between the ribs during inspiration.
Movement of the diaphragm primarily affects breathing with little assistance
from the thoracic muscles. As mentioned in the preceding table, four types
of retractions can be noted in infants: suprasternal, intercostal, substernal, and
subcostal.
Thoracoabdominal paradox, inward movement of the chest and outward movement
of the abdomen during inspiration (abdominal breathing), is a normal finding in
newborns (but not older infants). It persists during active, or rapid eye movement
(REM), sleep even when it is no longer seen during wakefulness or quiet sleep
because of the decreased muscle tone of active sleep. As muscle strength increases
and chest wall compliance decreases with age, abdominal breathing should no
longer be noted. If observed, it may signify respiratory disease
observing respiration before you touch the child: general appearance
Inability to feed or smile
Lack of consolability
observing respiration before you touch the child: respiratory rate
Tachypnea (see p. 815), apnea
observing respiration before you touch the child: color
Pallor or cyanosis
observing respiration before you touch the child: nasal component of breathing
Nasal flaring (enlargement of both nasal openings during inspiration)
observing respiration before you touch the child: audible breath sounds
Grunting (repetitive, short expiratory sound)
Wheezing (musical expiratory sound)
Stridor (high-pitched, inspiratory noise)
Obstruction (lack of breath sounds)
observing respiration before you touch the child: work of breathing
Nasal flaring (excessive movement of nares)
Grunting (expiratory noises)
Retractions (chest indrawing):
Supraclavicular (soft tissue above clavicles)
Intercostal (indrawing of the skin between ribs)
Substernal (at xiphoid process)
Subcostal (just below the costal margin)
newborns/infants: thorax and lungs - palpation
Assess tactile fremitus by palpation. Place your hand on the
chest when the infant cries or makes noise. Place your hand or fingertips over
each side of the chest and feel for symmetry in the transmitted vibrations.
Percussion is not helpful in infants except in extreme instances. The infant’s
chest is hyperresonant throughout, and it is difficult to detect abnormalities
on percussion.
newborns/infants: thorax and lungs - auscultation
After performing these maneuvers, you are ready for auscultation.
Infant breath sounds are louder and harsher than those of adults because
the stethoscope is closer to the origin of the sounds. It is often difficult to distinguish
transmitted upper airway sounds from sounds originating in the chest.
Upper airway sounds tend to be loud, transmitted symmetrically throughout the
chest, and loudest as you move your stethoscope toward the neck. They are usually
coarse inspiratory sounds. Lower airway sounds are loudest over the site of
pathology, are often asymmetric, and often occur during expiration
Expiratory sounds usually arise from an intrathoracic source, whereas inspiratory
sounds can arise from an extrathoracic airway such as the trachea or from
an intrathoracic source. During expiration, the diameter of the intrathoracic airways
decreases because radial forces from the surrounding lung do not “tether”
the airways open as occurs during inspiration. Higher flow rates during inspiration
produce turbulent flow, resulting in appreciable sounds.
Expiratory sounds usually arise from an intrathoracic source, whereas inspiratory
sounds can arise from an extrathoracic airway such as the trachea or from
an intrathoracic source. During expiration, the diameter of the intrathoracic airways
decreases because radial forces from the surrounding lung do not “tether”
the airways open as occurs during inspiration. Higher flow rates during inspiration
produce turbulent flow, resulting in appreciable sounds.
infants/newborns: heart inspection
Before examining the heart itself, observe the infant carefully for any
cyanosis. Acrocyanosis in the newborn is discussed on pages 816 and 918. It is
important to detect central cyanosis because it is always abnormal and because
many congenital cardiac abnormalities, as well as respiratory diseases, present with
cyanosis.20
Recognizing minimal degrees of cyanosis requires care. Look inside the body
(i.e., the inside of the mouth, the tongue, or the conjunctivae) in addition to
assessing skin color. A true strawberry pink is normal, whereas any hint of
raspberry red suggests desaturation and requires urgent evaluation.
The distribution of the cyanosis should be evaluated. An oximetry reading will
confirm desaturation.
Observe the infant for general signs of health. The infant’s nutritional status,
responsiveness, irritability, and fatigue are all clues that may be useful in evaluating
cardiac disease. Note that noncardiac findings (see box on the next page) are
often present in infants with cardiac disease.
Observe the respiratory rate and pattern to help distinguish the degree of illness
and cardiac versus pulmonary diseases. An increase in respiratory effort is
expected from pulmonary diseases, whereas in cardiac disease there may be
tachypnea without increased work of breathing (called “peaceful tachypnea”)
until heart failure becomes significant.
Cardiac Causes of Central Cyanosis in
Infants and Children
Immediately at birth Transposition of the great arteries
Pulmonary valve atresia
Severe pulmonary valve stenosis
Possibly Ebstein malformation
Within a few days after birth All of the above plus: Total anomalous pulmonary venous return Hypoplastic left heart syndrome Truncus arteriosus (sometimes) Single ventricle variants
Weeks, months, or years of life All of the above plus:
Pulmonary vascular disease with atrial,
ventricular, or great vessel shunting
(right-to-left shunting)
Noncardiac Findings Commonly Present in
Infants with Cardiac Disease
Poor feeding Tachypnea Poor overall appearance Failure to thrive Hepatomegaly Weakness Irritability Clubbing Fatigue
newborn/infant: heart palpation
Palpation of the chest wall will allow you to assess volume changes
within the heart. For example, a hyperdynamic precordium reflects a big volume
change.
The point of maximal cardiac impulse, or PMI, is not always palpable in infants and
is affected by respiratory patterns, a full stomach, and the infant’s positioning. It
is usually an interspace higher than in adults during the first few years of life
because the heart lies more horizontally within the chest.
Thrills are palpable when turbulence within the heart or great vessels is transmitted
to the surface. Knowledge of the structures of the precordium helps pinpoint
the origin of the thrill. Thrills are easiest to feel with your palm or the base of
your fingers rather than your fingertips. Thrills have a somewhat rough, vibrating
quality. Figure 18-27 shows locations of thrills that occur in infants and
children from various cardiac abnormalities
newborn/infant: pulses
The major branches of the aorta can be assessed by evaluation of
the peripheral pulses. All neonates should have an evaluation of all pulses at the
time of their newborn examination. In neonates and infants, the brachial artery
pulse in the antecubital fossa is easier to feel than the radial artery pulse at the wrist.
Both temporal arteries should be felt just in front of the ear.
Palpate the femoral pulses. They lie in the midline just below the inguinal crease,
between the iliac crest and the symphysis pubis. Take your time to search for
femoral pulses; they are difficult to detect in chubby, squirming infants. If you
first flex the infant’s thighs on the abdomen, this may overcome the reflex flexion
that occurs when you then extend the legs.
Palpate the pulses in the lower extremities
using your index or middle finger.
The dorsalis pedis and posterior tibial
pulses (Fig. 18-28) may be difficult to
feel unless there is an abnormality
involving aortic run-off. Normal pulses
should have a sharp rise and should be
firm and well localized.
As discussed on p. 814, carefully measure the blood pressure of infants and children
(using an appropriate-sized infant blood pressure cuff) as part of the cardiac
examination.
newborn/infant: heart auscultation
You can evaluate the heart rhythm more easily in infants by
listening to the heart than by feeling the peripheral pulses; in older children
assess the rhythm either way.
Infants and children commonly have a normal sinus dysrhythmia, with the
heart rate increasing on inspiration and decreasing on expiration, sometimes
quite abruptly. This normal finding can be identified by its repetitive nature and
its correlation with respiration.
Many neonates and some older children have premature atrial or ventricular
beats that are often described as “skipped” beats. You can usually eradicate them
by increasing their intrinsic sinus rate through exercise such as crying in an
infant or jumping in an older child, although they may also be more frequent
in the postexercise period. In a completely healthy child, they are usually benign
and rarely persist.
In addition to trying to detect splitting of the S2, listen for the intensity of A2 and
P2. The aortic, or first component of the second sound at the base, is normally
louder than the pulmonic, or second component (Fig. 18-29).
You may detect third heart sounds which are low-pitched, early diastolic sounds
best heard at the lower left sternal border, or apex; they reflect rapid ventricular
filling. These are frequently heard in children and are normal.
Fourth heart sounds represent decreased ventricular compliance, suggesting heart
failure.
You may also detect an apparent gallop (widely split S2 that varies), in the presence
of a normal heart rate and rhythm. This is frequently found in normal
children and does not represent pathology
