Week 13 - Newborn and Infant
Terms in this set (109)
When Assessing the Child
Vary the sequence according to child's age and comfort level.
-Perform nondisturbing maneuvers early. (such as heart and lungs)
-Perform potentially distressing maneuvers near end of examination. (such as ears and mouth)
-If child reports pain in one area, examine that part last.
Format of the pediatric medical record is the same as the adult. (although order may vary, convert clinical findings back into traditional format)
Four Principles of Child Development
Child development proceeds along a predictable pathway. (You can measureage-specific milestones and characterize development as normal orabnormal according to the child's achievement of them. Once thechild reaches a milestone, he or she proceeds to the next. Loss of mile-stones is concerning)
The range of normal development is wide. (children develop at different rates however there is a broad developmental range they should fall into)
Various physical, social, and environmental factors, as well as diseases, can affect child development and health. ( Tailor the physicalexamination to the child's developmental level)
The child's developmental level affects how you conduct the history and physical examination. And how you will talk to them (interviewing a 5-year-old is fundamentally different from interviewing an adolescent)
Health Promotion and Counseling Key Components
"An ounce of prevention is worth a pound of cure."
-Don't pick nose
Every interaction is an opportunity for health promotion.
Integrate explanations of your physical findings.
Physical development: Faster during infancy that at any time, by 1 year, the infant's birth weight should have tripled and height increased by 50%. Neurologic development progresses centrally to peripherally)
3months: lift head, clasp hands
6months: roll over and reach for objects, turn to voices, sit with support
6months++: increased peripheral coordination- transfer from hand to hand, crawl, stand by holding on, play with objects by banging and grabbing
1 year: standing and putting everything in mouth
Cognitive and language development
Exploration fosters increased understanding
Learn cause and effect
-9 months: examiner as a stranger, seek comfort from parents, and actively manipulate reachable objects
-Cooing at 2 months, to babbling at 6 months, to saying 1 to 3 words by 1 year.
Social and emotional development
Understanding of self and family
Attachment to individuals
Response to new stimuli varies
Observe interactions with caregivers
Problems during pregnancy?
Delivery on or near due date?
Problems during labor or birth?
Vaginal or C-section birth?
Medications, supplements, vitamins?
Hereditary disease patterns?
Age and health of first- and second-line relatives?
Family structure at home?
Immunizations (reaction to shots?)
Safety measures (car seats, position during sleep)
Tobacco (do parents smoke)
Alcohol (are parents alcoholics)
Environmental hazards (lead paint)
Review of systems (ask parent about any concerns)
Nutrition (intake, how many oz at one time)
Elimination (typical urination and bowel pattern)
Sleep (time of day and amount)
Activity/play (what amuses infant, how do you play)
Approaching the infant
Developmentally appropriate methods
Distraction and play:
Game of peek-a-boo
If you cannot distract the infant or make the awake infant attend to an object, your face, or a sound,consider a possible visualor hearing deficit.
Tips for examining infants
Approach infant gradually, using toy or object for distraction.
Perform much of exam in parent's lap.
Speak softly or mimic infant's sounds to attract attention.
If infant is cranky, make sure infant is well fed before proceeding.
Ask about infant's strengths to elicit useful
developmental and parenting information.
Start with infant sitting or lying in parent's lap.
Hungry infants may need to be fed first.
Observe parent-infant interactions.
Note parent's manner of interaction.
Leave diaper in place until ready to examine genitals, rectum, lower spine, and hips.
Observation of the infant's communication with the parent canreveal abnormalities such asdevelopmental delay, languagedelay, hearing deficits, or inade-quate parental attachment. Like-wise, such observations mayidentify maladaptive nurturingpatterns that may stem frommaternal depressionor inadequatesocial support.
Testing for developmental milestones
Check after interview, before exam.
"Fun and games"
Many disorders cause delays in more than one milestone. For mostchildren with developmental delay,the causes are unknown.
Some known causes include:
- abnormality in embryonic development(e.g., prena-tal insult, chromosomal problem)
- hereditary and genetic disorders(e.g.,inborn errors, genetic abnormalities)
- environmental and social prob-lems(e.g., insufficient stimulation)
-pregnancy or perinatal problems(e.g., placental insufficiency, prematurity),
-childhood diseases (e.g.,infection, trauma, chronic illness).
DENVER II Screening Test
Measure of developmental attainment only
Not a measure of intelligence
Not very sensitive
Use as adjunct to comprehensive developmental examination.
Form is shown on the following two pages and includes instructions for recording specificobservations. Each test item isrepresented on the form underthe age by a bar, which indi-cates when 25%, 50%, 75%,and 90% of children attain themilestones depicted.
If a cooperative infant fails items onthe DENVER II, developmental delay is possible, necessitating more precise testing and evaluation
An infant should start to sit up at around what age?
A. 3 months
B. 5 months
C. 7 months
D. 9 months
B. 5 months
An infant should start to sit up at around 5 months old
Measure growth parameters carefully
Birth to 36 months
2 to 18 years
Height, weight, head circumference for age, BMI
Length: Younger than 2 years, supine
Weight: Infant scale, dry diaper or naked
>2 SD or >95% or <5% common n cause is measurement error, Confirm abnormalities by repeat measurement. A sudden or significant change in growth may indicate systemic disease or malnutrition.
Reduced Growth Velocity
Shown by a drop in height percentile on a growth curve, may signify a chronic condition.
Comparison with normal standards is essential, because growth velocity normally is less during the second year than during the first year
Chronic conditions causing reduced length or height include neurologic, renal, cardiac, and endocrine disorders
Failure to thrive
Inadequate weight gain for age.
-Growth <5th percentile for age
-Growth drop >2 quartiles in 6 months
-Weight for height <5th percentile
Causes include environmental or psychosocial factors and a variety of gastrointestinal, neurologic, cardiac, endocrine, renal, and other diseases.
A small head size may be from premature closure of the sutures or microcephaly.
Microcephaly may be familial or the result of various chromosomal abnormalities, congenital infections, maternal metabolic disorders,and neurologic insults.
An abnormally large head size(>97th percentile or 2 standard deviations above the mean) is macrocephaly, which may be from hydrocephalus, subdural hematoma,or rare causes like brain tumor or inherited syndromes.
Familial megaloencephaly (large head) is a benign familial condition with normal brain growth.
-Pulse, More sensitive to illness, exercise, emotion, Auscultate heart, palpate femoral or brachial artery
A pulse rate that is too rapid to count (usually <180 to 200/min) usually indicates paroxysmal supra-ventricular tachycardia.
Bradycardia may be from drugingestion, hypoxia, intracranial orneurologic conditions, or, rarely,cardiac arrhythmia such as heartblock.
Respiratory Rate (infant)
Ranges between 30 and 60 per minute
More responsive to illness, exercise, and emotion
Sleeping respiratory rate most reliable
birth to 2 months: >60/min
2 to 12 months, >50/min
Extremely rapid and shallow respiratory rates are seen in newbornswith cyanotic cardiac diseaseandright-to-left shunting, and meta-bolic acidosis
Fever can raise respiratory rates in infants by up to 10 respirations per minute for each degree centigradeof fever.
Tachypnea and increased respiratory effort in an infant are signs ofpossible pneumonia.
Blood Pressure (infant)
easiest for systolic blood pressure= Doppler method,which detects arterial blood flow vibrations, converts themto systolic blood pressure levels, and transmits them to a digital read out device.
The systolic blood pressure gradually increases throughout childhood.
For example, normal systolic pressure in males is about -70 mm Hg at birth
-85 mm Hg at 1 month
-90 mm Hg at 6 months
Causes of sustained hypertension include renal artery disease (stenosis, thrombosis), congenital renal malformations, and coarctation of theaorta.
Fever common, Rectal temperature
Higher in infancy and early childhood, >99.0°F (37.2°C)
May fluctuate during day (highest in afternoon/evening)
Fever (>38.0°C or >100.0°F) in infants <2 to 3 months may be asign of serious infectionor disease.These infants should be evaluated promptly.
Anxiety may elevate the body temperature of children. Excessive bundling of infants may elevate the skin temperature but not the core temperature.
Temperature instability in a new-born may result from sepsis, metabolic abnormality, or other serious conditions. Older infants rarely manifest temperature instability.
Inspection of the Skin
Color: To detect jaundice, apply pressure toblanch the skin of the normal pink or brown color. A yellowish color indicates jaundice.
Dark or bluish pigmentation: Central cyanosis in a baby or child of any age should raise suspicion of congenital heart disease.The best area to look for central cyanosis is the tongue and oral mucosa, not the nail beds or the extremities.
Birthmarks/Skin markings: Pigmented light brown lesions (<1 to 2 cm at birth) are café-au-lait spots. Isolated lesionshave no significance, but multiplelesions with smooth borders may suggest neurofibromatosis.
Midline hair tufts over the lumbosacral spine region suggest a spinal cord defect. Jaundice that persists beyond 2 to 3 weeks should raise suspicions of biliary obstruction or liver disease.
Vascular markings: "salmon patch"
This birthmark fades, usually within therst yyear of life.
Also called the "stork bite," this splotchy pink mark fades with age
These light brown pigmented lesionsusually have borders and are uniform.They are noted in more than 10% ofblack infants.If more than five café-au-lait spopts exist, consider the diagngosis offneurofibromatosis.
Congenital Dermal Melanocytosis
More common among dark-skinned babies, it is important to note them so that they are not mistaken for abuse or bruising
common white postures surrounded by a red base
red pustules and papules are most prominent over the cheeks and nose of some normal newborns
salmon red, scaly eruption often involves the face, neck, axilla, diaper area, and behind the ears
Erythema, scaling, dry skin, and intense itching characterize this condition.
Characteristic features include more than 5 café-au-lait spots and axillary freckling, both shown above. Later findings include neurofibromas and Lishnodules (not shown).
Candidal Diaper Dermatitis
bright red rash involves the intertriginous folds with small "satellite lesions" along the edges
Contact Diaper Dermatitis
secondary to diarrhea or irritation and is noted along contact areas (here the area touching the diaper)
infection due to bacteria and can appear as bullous or crusty and yellowed with some pus
This baby has total anomalous pulmonary venous return andan oxygen saturation level of 80%.
Perioral Cyanosis (around the lips)
This baby has mild cyanosis above the lips, but the mucousmembranes remain pink.
Bluish Lips, Giving Appearance of Cyanosis
Normal pigment deposition in the vermilion border of the lips gives them a bluish hue, but the mucous membranes are pink.
This commonly appears on the feet and hands of babies shortlyafter birth. This infant is a 32-week newborn.
Palpation of the skin
"Tenting": Sign of dehydration
Dehydration is a common problemin infants. Usual causes are insufficient intake or excess loss of fluidsfrom diarrhea.
Physical Examination: The Head
1/4 of body length
1/3 of body weight
Sutures and fontanelles
An enlarged posterior fontanellemay be present in congenital hypothyroidism.
A bulging, tense fontanelle isobserved in infants with increasedintracranial pressure,which may becaused by central nervous systeminfections, neoplastic disease or hydrocephalus
A depressed anterior fontanelle may be a sign of dehydration.
Dilated scalp veins are indicative of long-standing increased intracranial pressure.
Skull symmetry and head circumference
Asymmetric head swelling? = Plagiocephaly?
Occurs when an infant liesmostly on one side, resulting in a flattening of the parieto-occipital region onthe dependent side and a prominence of the frontal region on the oppositeside. It disappears as the baby becomes more active and spends less time inone position, and symmetry is almost always restored
Plagiocephalymay also reflect pathology such as torticollis from injury to the sternocleidomastoidmuscle at birth, or lack of stimula-tionof the infant.
Palpate carefully, along the suture lines. A raised, bony ridge at a suture line suggests craniosynostosis.
Premature closure of cranial suturescauses craniosynostosis, with an abnormally shaped skull. Sagittal suturesynostosis causes anarrow head from lack of growth ofthe parietal bones.
In craniotabes,the cranial bonesfeel springy. Craniotabes can resultfrom increased intracranial pressure, as with hydrocephaly,meta-bolic disturbances such as rickets,and infection such as congenitalsyphilis.
In hydrocephaly, the anterior fontanelle is bulging, and the eyes may be deviated downward, revealing the upper scleras and creating the setting sun sign, as shown here.
The setting sun sign is also seen briefly in some normal newborns.
Sutures grow together too early, brain cant grow like its supposed to (which is why head circumference is vital)
premature closure of one or more sutures of the skull. This results in an abnormal growth andshape of the skull because growth will occur across sutures that are not affected but not across sutures that are affected.
The figures demonstrate different skull shapes associated with the various types of craniosynostosis.
The prematurely closed suture line is notedby the absence of a suture line in each figure.
Scaphocephaly and frontal plagiocephaly are most common.
Theblue shadingshowsareas of maximal flattening.
Thered arrowsshow the direction of continued growth across the sutures, which is normal.
Compare facies with face of parents. (shape palpebral fissures)
Abnormal-appearing facies can identify specific syndromes
Upslanting (Down syndrome)
Downslanting (Noonan syndrome)
Short (fetal alcohol effects)
Micrognathia may also be part of asyndrome, such as the Pierre Robin syndrome
Fetal Alcohol Syndrome
Babies born to women with chronic alcoholism are at increased risk for growth deficiency, microcephaly, and mental retardation.
Facial characteristics include short palpebralfissures, a wide and flattened philtrum (the vertical groove inthe midline of the upper lip), and thin lips.
The child with congenital hypothyroidism (cretinism) hascoarse facial features, a low-set hair line, sparse eyebrows, andan enlarged tongue.
Associated features include a hoarse cry,umbilical hernia, dry and cold extremities, myxedema, mottledskin, and mental retardation.
Most infants with congenitalhypothyroidism have no physical stigmata; this has led to screening of all newborns in the United States and most other developed countries for congenital hypothyroidism.
In utero infection by Treponema pallidumusually occurs afterthe 16th week of gestation and affects virtually all fetal organs.
If it is not treated, 25% of infected babies die before birth andanother 30% shortly thereafter. Signs of illness appear insurvivors within the first month of life.
Facial stigmata shownhere include bulging of the frontal bones and nasal bridgedepression (saddle nose), both from periostitis; rhinitis fromweeping nasal mucosal lesions (snuffles); and a circumoral rash.
Mucocutaneous inflammation and fissuring of the mouth andlips (rhagades), not shown here, may also occur as stigmata ofcongenital syphilis, as may craniotabes tibial periostitis (sabershins) and dental dysplasia
Facial Nerve Palsy
Peripheral (lower motor neuron) paralysis of the facial nervemay be from (1) an injury to the nerve from pressure duringlabor and birth, (2) inflammation of the middle ear branch ofthe nerve during episodes of acute or chronic otitis media, or(3) unknown causes (Bell's palsy).
The nasolabial fold on the affected left side is flattened, and the eye does not close. This is accentuated during crying, as shown here. Full recovery occursin>90% of those affected.
The child with Down syndrome (trisomy 21) usually has a small, rounded head, a flattened nasal bridge, oblique palpebralfissures, prominent epicanthal folds, small, low-set, shell-likeears, and a relatively large tongue.
Associated features include generalized hypotonia, transverse palmar creases (simian lines),shortening and incurving of the 5th fingers (clinodactyly),Brushfield's spots and mental retardation
Battered Child Syndrome
The child who has been physically abused (battered) may haveold andfresh bruises on the head and face and may either looksad and forlorn or be actively seeking to please, sometimes evenparticularly involved with and attentive to the abusing parent
Other stigmata include bruises in areas (axilla and groin) notusually subject to injury rather than the bony prominences; x-rayevidence of fractures of the skull, ribs, and long bones in variousstages of healing; and skin lesions that are morphologicallysimilar to implements used to inflict trauma (hand, belt buckle,strap, rope, coat hanger, or lighted cigarette)
Perennial Allergic Rhinitis
The child suffering from perennial allergic rhinitis has an openmouth (cannot breathe through the nose) and edema anddiscoloration of the lower orbitopalpebral grooves ("allergicshiners").
Such a child is often seen to push the nose upwardand backward with a hand ("allergic salute") and to grimace (wrinkle the nose and mouth) to relieve nasal itching and obstruction.
Thyrotoxicosis (Graves' disease) occurs in approximately 2 per 1,000 children younger than 10 years. Affected children exhibit hypermetabolism and accelerated linear growth. Facial characteristics shown in this 6-year-old girl are "staring" eyes(not true exophthalmos, which is rare in children) and anenlarged thyroid gland (goiter)
Use subdued lighting. (bright lights cause infant blinking)
Use tricks, small colorful toys, or light. (cooperation)
Eye movements (by two months infants can follow object)
Examine infants foreye movements. Hold the baby upright, supporting thehead. 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. 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.
Nystagmus (wandering or shakingeye movements) persisting after afew days after birth or persistingafter the maneuver described onthe left may indicate poor visionorcentral nervous system disease.
(during first few months of life intermittent cross eyes) convergent or divergent strabismus persisting beyond 3 months, or persistent strabismus of any type, may indicate ocular motor weakness or another abnormality in the visual system
Brush field spots are a ring of white specks in the iris. Although some-times present in normal children,these strongly suggest Down syndrome
Abnormalities of Eyes, Ears and Mouth. Persistent ocular discharge and tearing since birth may be from dacryocystitis or nasolacrimal ductobstruction.
For the ophthalmoscopic examination,with the infant awake and eyes open, examine the red retinal reflex by set-ting the ophthalmoscope at 0 diopters and viewing the pupil from about10 inches.
Normally, a red or orange color is reflected from the fundus through the pupil.
Congenital glaucoma may cause cloudiness of the cornea. A darklight reflex can result from cataracts, retinopathy of prematurity,or otherdisorders.
A white retinal reflex(leukokoria) is abnormal, and cataract, retinal detachment, chorioretinitis, orretinoblastoma should be suspected.
If history or examination indicate possible problem, refer to pediatric ophthalmologist
These abnormal speckling spots on the iris suggest Down syndrome.
Strabismus, or misalignment of the eyes, can lead to visualimpairment. Esotropia, shown here, is an inward deviation.
Features of ear (Note ear position in relationto the eyes. An imaginary line drawn across the inner and outer canthi of theeyes should cross the pinna or auricle; if the pinna is below this line, then theinfant has low-set ears)
Ear canal: directed downward from outside
Pull auricle gently downward.
Light reflex is diffuse.
Small, deformed, or low-set auricles may indicate associated congenital defects,especially renal disease.
A small skin tab, cleft, or pit foundjust forward of the tragus repre-sents a remnant of the firstbranchial cleftand usually has nosignificance.
Many children with hearing deficitsare not diagnosed until as old as 2 years. Clues to hearing deficits include parental concern about thearing, delayed speech, and lack of developmental indicators of hearing.
Otitis media is one of the most common conditions in young children. The spectrum of otitis media is shown here.
(A)Typicalacute otitis media with a red, distorted, bulging tympanic membrane in a highly symptomatic child.
(B)Acute otitis media withbullae formation and fluid visible behind the tympanic membrane.
(C)Otitis media with effusion, showing a yellowish fluidbehind a retracted and thickened tympanic membrane.
The Nose and Sinuses
Patency of nasal passage
Gently occlude each nostril alternately while holding mouth closed.
Obligate nasal breathers.
Do not occlude both nares simultaneously!
Indeed, some infants are obligate nasal breathersand have difficulty breath-ing through their mouths.
The nasal passages in newbornsmay be obstructed in choanal atresia.
The Mouth and Pharynx
Inspect pharynx during crying.
Do not expect to visualize tonsils.
Occasionally,pearl-like retention cysts are seen along the alveolar ridges and are easilymistaken for teeth—they 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 hardpalate. They disappear within months.
Rarely, super numerary teeth are noted. These are usually dysmorphic and are shed within days but are removed to prevent aspiration
Cysts may be noted on the tongueor mouth: Thyroglossal duct cysts
The newborn's mouth is edentulous, and the alveolar mucosa is smooth, with finely serrated borders.
Although unusual, a prominent,protruding tongue may signal con-genital hypothyroidismor Down syn-drome.
Oral candidiasis (thrush)is commonin infants. The lesions are difficultto wipe away and have an erythe-matous raw base.
Macroglossia is associated with several systemic conditions. If associated with hypoglycemia and omphalocele, the diagnosis is likely Beckwith-Wiedemann syndrome
Examine while supine.
Palpate lymph nodes.
Inspect position of thyroid cartilage and trachea.
Because the necks of infants are short, it is best to palpatethe neck while infants are lying supine, whereas older children are bestexamined while sitting. Check the position of the thyroid cartilage andtrachea.
Preauricular cysts and sinuses are common, pinhole-size pits, usually located anterior to the helix of the ear. They are often bilateral and may occasionally be associated with hearing deficits.
The Thorax and Lungs
Do not rush to stethoscope. Observe the patient
Lack of breath sounds
Feel for symmetry in transmitted vibrations.
Percussion is not helpful in infants.
Because everything close together
Two types of chest wall abnormali-ties noted in childhood includepectus excavatum,or "funnelchest," and pectus carinatum,or"chicken breast deformity.
Apnea is cessation of breathing for more than 20 seconds. It is often accompanied by bradycardia and may indicate respiratory disease, central nervous system disease, or, rarely, a cardiopulmonary condition.
Apnea may be a high-risk factor for sudden infant death syndrome (SIDS).
Nasal flaring may be the result ofupper respiratory infections,withsubsequent obstruction of theirsmall nares, but it may also becaused by pneumonia or otherserious respiratory infections.
Any of the abnormalities listed above should raise concern about underlying respiratory pathology.
Upper vs Lower Airway Sounds
Lower respiratory infections,definedas infections below the vocal cords,are common in infants and include bronchiolitis and pneumonia.
Acute stridor is a potentially seriouscondition; causes include laryngo-tracheobronchitis (croup), epiglot-titis, bacterial tracheitis, foreignbody, or a vascular ring.
In infants, abnormal work ofbreathing plus abnormal findingson auscultation are the best find-ings for ruling inpneumonia.Thebest sign for ruling outpneumoniais the absence of tachypnea.
Asymmetric chest movement mayindicate a space-occupying lesion.Pulmonary disease causes increasedabdominal breathing and can resultin retractions (chest indrawing),anindicator of pulmonary diseasebefore 2 years of age. Chest indraw-ing is inward movement of the skinbetween the ribs during inspiration.
Obstructive respiratory disease ininfants can result in the Hoover sign,or paradoxical (seesaw), breathing.
Because of the excellent transmission of sounds throughout the chest, any abnormalities of tactile fremitus or on percussion suggestsevere pathology, such as a large pneumonic consolidation
Biphasic sounds (wheezing) implysevere obstruction from intratho-racic airway narrowing or severeobstruction from extrathoracic airway narrowing.
Diminished breath sounds in oneside of the chest suggest unilaterallesions (e.g., congenital diaphrag-matic hernia).
Wheezes in infants occur commonly from asthmaor bronchiolitis.
Crackles (rales) can be heard withpneumoniaand bronchiolitis
Central cyanosis without acute respiratory symptoms suggests cardiac disease.
General signs of health: Tachypnea, tachycardia, and hepatomegaly in infants suggest congestive heart failure.
Common noncardiac findings in infants with cardiac disease
A diffuse bulge outward of the leftside of the chest suggests long-standing cardiomegaly.
The absence or diminution offemoral pulses is indicative ofcoarctation of the aorta.If femoralpulses cannot be detected, mea-sure blood pressures of the lowerand upper extremities. If they areequal or lower in the legs, coarcta-tion is likely to be present.
A weak or thready, difficult-to-feel pulse may reflect myocardial dysfunction and congestive heart failure, particularly if associated withan unusual degree of tachycardia.
A "rolling" heave at the left sternal border suggests an increase in right ventricular work, whereas the same kind of motion closer to the apex suggests the same thing for the left ventricle
Thrills have a somewhat rough, vibrating quality. The figure above shows locations of thrills from various cardiac abnormalities that occur in infants and children.
Visible and palpable chest pulsa-tions suggest a hyperdynamic statefrom either increased metabolic rateor inefficient pumping as a result ofan underlying cardiac effect.
The heart rhythm can be evaluatedmore easily in infants bylistening to the heart than by feeling the peripheral pulses; in older childrenit can be done either way
The most common dysrhythmia in infants is paroxysmal supraventricular tachycardia,or paroxysmal atrial tachycardia (PSVT, or PAT).It canoccur at any age, including inutero.
Distant heart tones suggest pericar-dial effusion;mushy, less distinctheart sounds suggest myocardial dysfunction.
A louder-than-normal pulmoniccomponent, particularly whenlouder than the aortic sound, sug-gests pulmonary hypertension.
Persistent splitting of S2may indicate a right ventricular volume load such as atrial septal defect, anomalies of pulmonary venous return, or chronic anemia
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.
The third heart sound (S3) shouldbe differentiated from the higher-intensity third heart sound gallop,which is a sign of underlying pathology.
Fourth heart sounds represent decreased ventricular compliance,suggesting congestive heartfailure.
Note specific location
Benign murmurs in children have no associated abnormal findings.
Most children will have one or more functional, or benign, heart murmur before reaching adulthood.
It is important to identify functional murmursby their specific qualities rather than by their intensity
Any of the non cardiac findings that frequently accompany cardiac disease in children markedly raises the possibility that a murmur that appears benign is really pathologic
A newborn with a heart murmurand central cyanosis likely has congenital heart disease and requires urgent cardiac evaluation.
Paroxysmal supraventricular tachycardia (SVT) is the most common dysrhythmia in children.
Some infants with SVT look well or may be somewhat pale with tachypnea, but have a heart rate of 240 beats per minute or greater.
Others are ill and in cardiovascular collapse. SVT in infants is usually sustained, requiring medical therapy for conversion to a normal rate and rhythm.
In older children, it is more likely to be truly paroxysmal, with episodes of varying duration and frequency
Undeveloped (maternal estrogen can increase size)
Flush with chest wall
Residual enlargement from maternal estrogen may be present for several months after birth.
In premature thelarche, breast development occurs, most often between 6 months and 2 years. Other signs of puberty or hormonal abnormalities are not present.
Protuberant due to poorly developed abdominal musculature
Blood vessels and peristalsis easily noted
Inspect for redness or swelling
Umbilical herniasin infants arecaused by a defect in the abdomi-nal wall and can be up to 6 cm indiameter and quite protuberantwith intra-abdominal pressure.
An increase in pitch or frequencyof bowel sounds is heard with gas-troenteritisor, rarely, with intestinal obstruction.
A silent, tympanic, distended and tender abdomen suggests peritonitis
An enlarged, tender liver may bedue to congestive heart failureor tostorage diseases. Among newborns, causes of hepatomegaly include hepatitis, storage diseases, vascular congestion, and biliary obstruction.
Several diseases can causesplenomegaly, includinginfections, hemolytic anemias, infil-trative disorders, inflammatoryorautoimmune diseases,and portal hypertension.
Abnormal abdominal masses ininfants can be associated with thekidney (e.g., hydronephrosis),bladder (e.g., urethral obstruction),bowel (e.g., Hirschsprung diseaseor intussusception), and tumors.
In pyloric stenosis,deep palpationin the right upper quadrant ormidline can reveal an "olive," or a 2-cm firm pyloric mass. Whilefeeding, some infants with thiscondition will have visible peri-staltic waves pass across theirabdomen, followed by projectilevomiting.
Shaft of penis
Inspect the scrotum,noting rugae, which should be present by 40 weeks'gestation.
Palpate the testes in the scrotal sacs, proceeding downward fromthe external inguinal ring to the scrotum. If you feel a testis up in theinguinal canal, gently milk it downward into the scrotum.
The newborn's testes should be about 10 mm in width and 15 mm in length and should liein the scrotal sacs most of the time.
most common congenital penileabnormality. The urethral meatus opens abnormally on theventral surface of the penis. One form is shown above; moresevere forms involve openings on the lower shaft or scrotum
present when the urethral orifice appears at somepoint along the ventral surface ofthe glans or shaft of the penis
The foreskin is incompletely formed ventrally.
A fixed, downward bowing of thepenis is a chordee; this may accompany a hypospadias.
(cryptorchidism), the scrotum often appears underdevelopedand tight, and palpation reveals anabsence of scrotal contents
You should distinguish between undescended testes, shownabove (with testes in the inguinal canals), from highlyretractile testes from an active cremasteric reflex.
Examine the testes for swelling within the scrotal sac and over the inguinal ring. If you detect swelling in the scrotal sac, try to differentiate it from the testis. Note whether the size changes when the infant increases abdominal pressure by crying.
Two common scrotal masses in newborns are hydroceles and inguinal hernias;frequently both coexist, and both are more common on the right side.
Hydroceles overlie the testes and the spermatic cord, are not reducible, and can betransilluminated (see photo at left). Most resolve by 18 months.
Hernias are separate from the testes, are usually reducible, and often do not transilluminate. They do not resolve.
Labia majora and minora
Size of clitoris
Ambiguous genitalia,involving masculinization of the female external genitalia, is a rare condition caused by endocrine disorders such as congenital adrenal hyperplasia.
Labial adhesions occur not infrequently, tend to be paper thin, and often disappear without treatment. An imperforate hymen may be noted at birth.
Rectal exam is generally not performed on infants or children.
Focus on detection of congenital abnormalities.
Hands, spine, hips, legs, feet
Learn to combine musculoskeletal examination with neurologic and developmental examination.
Careful inspection can reveal gross deformities such as dwarfism, congenital abnormalities of the extremities or digits, and annular bands that constrictan extremity.
Palpate clavicle. noting any lumps, tenderness, or crepitus; thesemay indicate a fracture.
Inspect and Palpate spine. Spina bifida occulta (a defect of the vertebral bodies) may be associated with defects of the spinal cord, which can cause severe neurologic dysfunction.
place the baby supinewith the legs pointing toward you. Flex the legs to form right angles at thehips and knees, placing your index fingers over the greater trochanter ofeach femur and your thumbs over the lesser trochanters.
Abduct both hips simultaneously until the lateral aspect of each knee touches the examining table.
A soft audible "click" heard withthese maneuvers does not prove a dislocated hip, but should prompt a careful examination.
With a hip dysplasia, you feel a"clunk" as the femoral head, which lies posterior to the acetabulum,enters the acetabulum. A palpablemovement of the femoral headback into place constitutes a posi-tive Ortolani sign.
Congenital hip dysplasia is important to detect: Early appropriate treatment has excellent outcomes.
Legs and Feet
Torsion of legs?
Torsion of tibia?
Pathologic tibial torsion occursonly in association with deformitiesof the feet or hips. (Parents may be concerned about a toeing inor toeing out of the foot and an awkward gait, all of which are usually normal. Tibial torsion corrects itself during the second year of life after monthsof weight bearing)
True deformities of the feetdo notreturn to the neutral position evenwith manipulation.
Common Musculoskeletal Findings in Young Children, the most commonsevere congenital foot deformity istalipes equinovarus (talipes calca-neovalgus), or clubfoot
Finally, most toddlershave some pronation during early stages of weight bearing, with eversion ofthe foot. In all of these normal variants, the abnormal position can be easily over corrected past midline. They all tend to resolve within 1 or 2 years
The Nervous System
Techniques are highly specific.
Abnormalities often present as developmental abnormalities.
Gross and fine motor function
Deep tendon and primitive reflexes
Signs of severe neurologic disease include extreme irritability; persistentasymmetry of posture; persistent exten-sion of extremities; constant turningofthe head to one side; marked exten-sion of the head, neck,and extremities(opisthotonus); severe flaccidity;andlimited response to pain.
Alert when awake
Attend to parent's voices
Display mental activity appropriate for his or her age
Persistent irritability in the newborn may be a sign of neurologic insult or may reflect a variety of metabolic,infectious,or other constitutional abnormalities,or environmental conditions such as drug withdrawal.
Motor function and tone
Watch movements at rest.
Test resistance to passive movement.
Range of motion of major joints
Hold the baby in your hands, as shown inthe figure, to determine whether the tone is normal, increased, ordecreased. Either increased or decreased tone may indicate intracranial dis-ease, although such disease is usually accompanied by a number of other signs.
Infants with hypotonia often lie in a frog-leg position, with arms flexedand hands near the ears. Hypotonia can be caused by a variety of central nervous system abnormalities and disorders of the motor unit.
-Flicking infant's palm or sole
-Observe for withdrawal, arousal, and change in facial expression.
Observe for withdrawal, arousal, and change in facial expression. Do not use a pin to test for pain.
If changes in facial expression or cry follow a painful stimulus but no withdrawal occurs, paralysis may be present.
The cranial nerves of the infant can be tested, but requires methods that differ from those used for the older child or adult. The following table provides useful strategies.
Abnormalities in the cranial nervessuggest an intracranial lesion such as hemorrhage or a congenital malformation.
Deep tendon reflexes
Variable due to undeveloped corticospinal pathways
Same technique as adult, except use finger instead of hammer
variable in infants because the corticospinal pathways are not fully developed. Thus, the exaggerated presence or their absence has little diagnostic significance,unless this response is different from results of previous testing or extreme responses are observed.
A progressive increase in deep ten-don reflexes during the first year oflife may indicate central nervoussystem disease such as cerebralpalsy,especially if it is coupled withincreased tone.
As in adults, asymmetric reflexessuggest a lesion of the peripheralnerves or spinal segment
An absent anal reflex suggests lossof innervation of the externalsphincter muscle caused by aspinal cord abnormality such as a congenital anomaly (e.g., spinabifida), tumor,or injury.
When the contractions are continuous (sustained ankle clonus), central nervous system disease should be suspected.
the fanning of the toes with the great toe pointing toward the dorsum of the foot
Indicates CNS disease, the ankle plantar flexes and dorsiflexes repetitively and rhythmically.
Develop during gestation
Demonstrable at birth
Disappear at defined ages
A neurologicordevelopmentalabnormalityis suspected if primitive reflexes are
-Absent at appropriate age
-Present longer than normal
-Associated with posturing or twitching
Palmar Grasp Reflex
Place your fingers into the baby's hands and press against the palmar surfaces.
The baby will flex all fingers to grasp your fingers.
Birth to 3-4 months
Persistence beyond 4 months sug-gests pyramidal tract dysfunction.
Persistence of clenched hand beyond 2 months suggests central nervous system damage, especially if fingers overlap thumb.
Plantar Grasp Reflex
Touch the sole at the base of the toes. The toes curl.
Birth to 6-8 months
Persistence beyond 8 months suggests pyramidal tract dysfunction.
Hold the baby supine,supporting the head,back, and legs. Abruptly lower the entire body about 2 feet.
The arms abduct and extend, hands open, and legs flex. Baby may cry.
Birth to 4 months
Persistence beyond 4 months suggests neurologic disease (e.g., cerebral palsy); beyond 6 months strongly suggests it.
Asymmetric response suggests fracture of clavicle or humerus orbrachial plexus injury.
Asymmetric Tonic Neck Reflex
With baby supine, turn the head to one side holding jaw over shoulder
The arms/legs on side to which head is turned extend while the opposite arm/leg flex.Repeat on other side
Birth to 2 months
Persistence beyond 2 months suggests asymmetric central nervous system development and sometimes predicts the development of cerebral palsy.
Positive Support Reflex
Hold the baby around thetrunk and lower until the feet touch a flat surface.
The hips, knees, and ankles extend; the baby stands up, partially bearing weight, and sags after 20-30 second
Birth or 2 months until 6 months
Lack of reflex suggests hypotoniaor flaccidity.
Fixed extension and adduction oflegs (scissoring) suggests spasticity from neurologic disease, such as cerebral palsy.
Stroke the perioral skin at the corners of the mouth.The mouth will open and baby will turn the head toward the stimulated side and suck.
Birth to 3-4 months
Absence of rooting indicates severe generalized or central nervous system disease.
Trunk Incurvation Reflex
Support the baby prone with one hand, and stroke one side of the back 1 cm from midline, from shoulder to buttocks.The spine will curve toward the stimulated side.
Birth to 2 months
Absence suggests a transversespinal cord lesion or injury.
Persistence may indicate delayed development
Placing and Stepping Reflexes
Hold baby upright from behind as in positive support reflex. Have one sole touch the tabletop.The hip and knee of that foot will flex and the other foot will step forward. Alternate stepping will occur.
Birth (best after 4 days).Variable age to disappear
Absence of placing may indicate paralysis. Babies born by breech delivery may not have placing reflex.
Suspend the baby prone with one hand.The head will lift up,and the spine will straighten.
Birth to 6 months
Persistence may indicate delayed development.
Suspend the babyprone and slowly lower the head toward a surface.
The arms and legs will extend in a protective fashion
4-6 months and does not disappear
Delay in appearance may predict future delays in voluntary motor development.
The average heart rate for an infant around 5 months old is:
The average heart rate is around 130 beats per minute for infants around 5 months old.
Health Promotion and Counseling
Infant periodicity schedule
Recommended health supervision visits at:
-Within first week
-1, 2, 4, 6, 9, 12 months
Assess infant's growth and development.
Perform comprehensive physical examination
Components of visit
Discussions with parents
Congenital Heart Murmurs
Some heart murmurs reflect underlying heart disease. If you understand their physiologic causes, you will more readily be able toidentify and distinguish them from innocent heart murmurs.
Obstructive lesions result when blood flows through valves that are toosmall. Because this problem does not depend on the drop in pulmonary vascular resistance following birth, these murmurs are audible atddbirth. Defects with left-to-right shunts, on the other hand, depend on the drop in pulmonary vascular resistance.
High-pressured shuntssuch as ventricular septal defect, patent ductus arteriosus, and persistent truncus arteriosus are not heard until 1 week or more afterbirth.
Low-pressured left-to-right shunts, such as in atrial septal defects, may not be heard for considerably longer, usually first beingnoted at 1 year or more.
Many children with congenital cardiac defects have combinations of defects or variations of abnormalities, sottfindings on cardiac examination may not follow these classic patterns. This table shows a limited selection of the more common defects.
Pulmonary Valve Stenosis
Usually a normal valve anulus with fusion ofsome or most of the valve leaflets, restricting flow across the valve
-Location- Upper left sternal border
-Radiation- In mild degrees ofstenosis, the murmur may be heardover the course of the pulmonaryarteries in the lung fields.
-Intensity- Increases in intensity andduration as the degree of obstruction increases
-Quality- Ejection, peaking later insystole as the obstruction increases
Usually a prominent ejection click in early systole.
Pulmonary component of thesecond sounds at the base (P2) becomes delayed and softer,disappearing as obstruction increases.Inspiration may increasemurmur; expiration may increase click.
Growth is usually normal.
Newborns with severe stenosis maybe cyanotic from right-to-left atrial shunting and rapidly develop congestive heart failure
Aortic Valve Stenosis
Usually a bicuspid valve with progressive obstruction, but there may be a dysplastic valve or damage from rheumatic fever or degenerative disease
-Location- Midsternum, upper rightsternal border
-Radiation-To the carotid arteriesand suprasternal notch; may also be a thrill
-Intensity-Varies, louder withincreasingly severe obstruction
-Quality-An ejection, often harsh,systolic murmur
May be an associated ejection click
The aortic closure sound may beincreased in intensity. There may bea diastolic murmur of aortic valveregurgitation. Newborns withsevere stenosis may have weak orabsent pulses and severe congestiveheart failure. May not be audible until adulthood even though the valve is congenitally abnormal
Tetralogy of Fallot
Complex defect with ventricular septaldefect, infundibular and usually valvularright ventricular outflow obstruction,malrotation of the aorta, and right-to-leftshunting at ventricular septal level
-General-Variable cyanosis, increasing with activity
-Location-Mid-to-upper left sternalborder. If pulmonary atresia, there isno systolic murmur but thecontinuous murmur of ductusarteriosus flow at upper left sternalborder or in the back.
-Radiation-Little, to upper left sternal border, occasionally to lung fieldsIntensity.Usually grade III-IV
-Quality- Midpeaking, systolic ejection murmur
The pulmonary closure sound isusually not heard. May have abrupthypercyanotic spells with suddenincrease in cyanosis, air hunger,altered level of awareness
Failure to gain weight with persistentand increasingly severe cyanosis
Long-term persistence of cyanosisaccompanied by clubbing of fingersand toes
Persistent hypoxemia leads topolycythemia, which will accentuatethe cyanosis.
Transposition of the Great Arteries
A severe defect with failure of rotation of thegreat vessels, leaving the aorta to arise fromthe right ventricle and the pulmonary arteryfrom the left ventricle
-General- Intense generalized cyanosis
-Location- No characteristic murmur.If present, it may reflect an associateddefect such as VSD.
-Radiation and Quality.- Depends on associated abnormalities
Single loud second sound of theanterior aortic valve
Frequent rapid development ofcongestive heart failure
Frequent associated defects asdescribed at the left
Ventricular Septal Defect
Blood going from a high-pressured left ventricle through a defect in the septum tothe lower-pressured right ventricle creates turbulence, usually throughout systole.
-Location- Lower left sternal border
-Intensity- Variable, only partiallydetermined by the size of the shunt.Small shunts with a high pressuregradient may have very loudmurmurs. Large defects with elevatedpulmonary vascular resistance mayhave no murmur. Grade II-IV/VIwith a thrill if grade IV/VI or higher.
-Quality- Pansystolic, usually harsh,may obscure S1and S2if loud enough
With large shunts, there may be alow-pitched middiastolic murmur ofrelative mitral stenosis at the apex.
As pulmonary artery pressureincreases, the pulmonic componentof the second sounds at the baseincreases in intensity. Whenpulmonary artery pressure equalsaortic pressure, there may be nomurmur, and P2will be very loud.
In low-volume shunts, growth is normal.
In larger shunts, congestive heartfailure may occur by 6-8 weeks;poor weight gain.Associated defects are frequent.
Patent Ductus Arteriosus
Continuous flow from aorta to pulmonaryartery throughout the cardiac cycle when ductus arteriosus does not close after birth
-Location- Upper left sternal borderand to left
-Radiation- Sometimes to the back
-Intensity- Varies depending on size ofthe shunt, usually grade II-III/VI.
-Quality- A rather hollow, sometimes machinery-like murmur that is continuous throughout the cardiac cycle, although occasionally almostinaudible in late diastole, uninterruptedby the heart sounds, louder in systole
Full to bounding pulses
Noticed at birth in the prematureinfant who may have boundingpulses, a hyperdynamic precordium,and an atypical murmur
Noticed later in the full-term infantas pulmonary vascular resistance falls
May develop congestive heartfailure at 4-6 weeks if large shunt
Poor weight gain related to size ofshuntPulmonary hypertension affectsmurmur as above.
Atrial Septal Defect
Left-to-right shunt through an opening inthe atrial septum, possible at various levels
-Location- Upper left sternal border
-Radiation- To the back
-Intensity- Variable, usually gradeII-III/VI
-Quality- Ejection but without the harsh quality
Widely split second soundsthroughout all phases of respiration,normal intensity
Usually not heard until after age of1 year
Gradual decrease in weight gain asshunt increases
Decreased exercise tolerance, subtle,not dramatic
Congestive heart failure is rare