NSG 332 PEDIATRIC REVIEW| CONSIDERATIONS FOR PEDIATRICS

CONSIDERATIONS FOR PEDIATRICS MRM SP 17 1 RECORDING THE HISTORY AND PE  Organizational structure for recording the history and physical examination of newborns and infants is the same as for adults  Recorded information varies from the adult’s primarily because of the developmental status of the infant  In newborns, the focus is on the transition to extrauterine life and the detection of any congenital anomalies Additional HISTORY for INFANTS  Present problem o Newborns include the details of the mother’s pregnancy and any untoward events occurring since birth  Details of pregnancy o Mother’s health during pregnancy o Prenatal care o Labor and delivery  Infant’s status at birth o Birth weight, respiratory status, color, Apgar scores if known, nutrition, congenital anomalies, meconium staining, bilirubin phototherapy, bleeding, convulsions, prescriptions  Breast-fed infants o Frequency; use of supplemental formula and vitamin D supplementation o Mother’s diet, fluid intake, concern with milk supply; any problems with nipple soreness, cracking, or infections; age weaned  Formula-fed infants o Specific formula and preparation method, concentration, and amount of water added; frequency of feeding; amount per feeding; total ounces per day; and whether juice, water, or vitamins are given  Solid foods o Age at which cereal and other foods were introduced; feeding methods, amount, food preparation; the response of infant to foods Additional to PHYSICAL EXAM for INFANTs General o Age in hours, days, weeks, or months; gender; race o Gestational age o Length, weight, and head circumference with percentiles; for newborns, percentiles for gestational age Mental status o Infant state during examination (irritable, crying, sleeping, alert, quiet) Skin o Color, texture, presence of lanugo or vernix, Mongolian spot, nails o Presence of hemangiomas, nevi, telangiectasia, milia Lymphatics o Visible or palpable lymph nodes Head o Shape, molding, forceps or electrode marks o Fontanel size, dysmorphic facial features, swelling Eyes o Red reflex, corneal light reflex, follows object with eyes o Swelling of lids, discharge Ears o Shape and alignment of auricles, presence of skin tags or pits o Startle to noise or response to voice Nose o Patency of nares, nasal flaring, discharge Mouth o Palate and lip integrity o Presence and number of teeth o Strength of sucking, coordinated sucking and swallowing Neck o Head position, neck control o Presence of masses, webbing, excess skinfolds Chest and lungs o Symmetry of shape, circumference o Breast swelling or discharge o Abdominal or thoracic breathing o Presence of retractions (intercostal, supraclavicular, substernal), presence of grunting or stridor o Quality of cry Heart and blood vessels o Recording as for adults, but with peripheral vascular findings integrated in this section CONSIDERATIONS FOR PEDIATRICS MRM SP 17 2 Abdomen o Number of umbilical arteries and veins, stump dryness, color, odor o Any bulging or separation of abdominal wall o Apparent peristaltic waves Male genitalia o Appearance of penis, scrotum; position of urethra o Location of testes: descended, descendible, not descended, not palpable o Urinary stream o Presence of hernia or hydrocele Female genitalia o Appearance of labia, presence of discharge Anus, rectum o Perforate, sphincter control o Character of meconium or stool, if observed o Presence of sacral dimple, skin pigmentation, or hair tuft Musculoskeletal system o Alignment of limbs and spine o Presence of joint deformity, fixed or flexible; integrity of clavicles o Symmetry of movement in all extremities, hip abduction o Number of fingers and toes, webbing or extra digits, palmar creases Neurologic system o Presence and symmetry of primitive reflexes o Consolability, presence of tremors or jitteriness o Gross and fine motor development CHILDREN AND ADOLESCENT As during infancy, some adaptations in recorded history reflect the developmental progress of the child  Past medical history o Birth weight and major neonatal problems are generally included in the history of an initial examination until the child reaches school age o If a health problem can be related to birth events, more detail is recorded, often summarized from previous records, because the mother’s recall may not be as accurate as time elapses  Personal and social history o Relationship with parents and other adult caregivers, siblings and other children o Behavior in group situations o Parents’ relationship (e.g., married, divorced, separated, single parent, foster parent) o Education attainment of parents o Involvement with social service agencies o Injury prevention strategies used by family  Older children o School performance, grade level, progress, adjustment to school, and parents’ attitude toward education o Habits of the child, such as nail biting or thumb sucking; note hobbies, sports participation, clubs, and temperament  Adolescents o Peer group activities, conflicts, relationships o Sexual activity o Alcohol or illicit drug use o Concerns with gender identity and independence o Self-esteem o Favorite activities and potential hazards  Growth and development o For toddlers and young children, list motor skills and language milestones attained, age toilet trained, and age weaned from bottle Children and Adolescent  Mental status o Record mental status and cognitive development status  Breasts o For females, record the Tanner stage of breast development  Genitalia o Record the Tanner stage of pubic hair and genital development as appropriate o Record the sexual maturity rating  Neurologic system o Findings should indicate developmental expectations of cerebellar function, cranial nerves, and deep tendon reflexes Expanded Details RE: INTERVIEWING Infants and Children: Avoid patronizing actions. Anticipate anxieties and give reassurance. Include children in data collection. CONSIDERATIONS FOR PEDIATRICS MRM SP 17 3 Adolescents: Recognize special needs of the adolescent. Give clear evidence of your respect for their need for confidentiality and for their impending adulthood. Children  Pay attention to them (place equal emphasis on the child and on the accompanying adult)  Play with them  Be sensitive to their needs  Glean clues about family dynamics Additional history Infant and Children  Mother’s gestational history, pregnancy, and birth  Child’s neonatal period, feeding, and developmental milestones—especially important in preschool  Child’s school adjustment, habits, and home conditions  Review systems for child-specific conditions Adolescents  Respect need for confidentiality  Respect impending adult status  Do not force conversation  Establish an alliance  Be flexible in approach  Factors impacting history taking o Self-esteem, acceptance by peers, tension with parents Cover issues of special concern o (Hint: Use mnemonic HEEADSSS or PACES to zero in on issues)  HEEADSSS o Home environment o Education o Eating o Activities, affect, ambitions, anger o Drugs o Sexuality o Suicide/depression o Safety  PACES o Parents, peers o Accidents, alcohol/drugs o Cigarettes o Emotional issues  School, sexuality Physical Exam  Seidel’s Physical Examination Handbook o Chapter 21: Age-Specific Examination: Infants, Children, and Adolescents, pp. 254-273 REVIEW BY SYSTEM GROWTH and DEVELOPMENT ANATOMY AND PHYSIO  Brain: peak fetus, early infancy  Skeleton: peak fetus, infancy, adolescence  Muscle: peak fetus, adolescence  Adipose: peak infancy, adolescence  Lymphoid: peak age 10 to 12 years  Neural: peak age 4 to 14 years  Genital: peak adolescence Fetus  Head growth predominates Infant  Trunk growth predominates  Weight gain at rapid but decelerating rate  Child  Legs are fastest growing  Weight gained at steady rate Adolescent  Trunk and legs elongate.  50% of ideal weight is gained. o Of adults who are obese  30% become obese during childhood CONSIDERATIONS FOR PEDIATRICS MRM SP 17 4  70% become obese during adolescence  Skeletal mass and organ systems double in size. FACT CHECK: What is area of body is predominating in growth for each age group? HISTORY Infant  Estimated gestational age, birth weight, length, head circumference  Following an established percentile growth curve  Development: achieving milestones at appropriate ages  Congenital anomaly or chronic illness Children and Adolescent  Sexual maturation of girls: early (before 7 years) or delayed (beyond 13 years); signs of breast development and pubic hair, age at menarche  Sexual maturation of boys: early (before 9 years) or delayed (beyond 14 years); signs of genital development and pubic hair  Short or tall stature  Medications: steroids, growth hormones FACT CHECK What is precocious puberty? What are the first indications of sexual development for girls (breast/hair)? At what ages is this considered delayed? What are the first indications of sexual development for boys (genital/hair)? At what ages is this considered delayed? Most girls start puberty between 9 and 12 years of age with breast enlargement. A girl’s breasts often develop at different rates and appear asymmetric. Most boys start puberty between 10 and 13 years of age with testicular enlargement. Pubic hair development, enlargement of the penis, and the growth spurt follow. EXAMINATION—some special equipment  Infant scale  Recumbent measuring device (for infants)  Stature-measuring device (for children) MEASUREMENT—Plot on growth curve charts For eye--Detect strabismus in routine eye testing in children Guidelines  Have child focus on accommodative target  Turn on scope and place over child’s eye  Watch for subtle eye movements  Repeat with other eye Infant lengths can be measured by using an infant measuring device that comes with a rigid headboard and movable footboard  Measuring mat  Pin or pen technique  The infant platform scale is used for measuring weights of infants and small children  Can measure in ounces or grams  Recumbent length  Weight  Head circumference  Chest circumference  Gestational age FACT CHECK For infants, what is considered: …………and this is at what weight percentage? CONSIDERATIONS FOR PEDIATRICS MRM SP 17 5  Appropriate for gestational age (AGA)  Small for gestational age (SGA)  Large for gestational age (LGA) What is the correct positioning of the tape measure for head circumference of infants? Place the measuring tape around the largest circumference of the infant’s head, across the occiput and the forehead. ( GIFT) When does the anterior fontanel close? When does the posterior fontanel close? What is the expectation for growth? When would you expect a baby’s birth weight to double? What is the expectation for a baby’s length by one year? Children Stature and weight  BMI is now standardized for use in children and adolescents, and it is calculated the same way as for adults  Underweight―BMI for age under the 5th percentile  At risk of overweight―BMI for age greater than the 85th percentile  Overweight―BMI for age greater than the 95th percentile  Consider: Upper/lower segment ratio  A higher upper-lower body segment ratio than expected may be associated with dwarfism or bone disorders Arm span  Arm span that exceeds height is associated with Marfan syndrome FACT CHECK The majority of adult obesity begins:  In adolescence  In childhood  After the skeletal growth is completed  Once sexual maturation is complete  During menopause NUTRITION-History Infants/Children  Breast-feeding frequency and duration; type and amount of infant formula; method of formula preparation  Intake of protein, calories, vitamins, and minerals adequate for growth  Cow’s milk protein and other food allergies  Supplements  Fast food meals  Hours of screen time and physical activity PMH of: Chronic illness:  Cystic fibrosis  PKU (phenylketonuria)  Celiac disease  Inborn errors of carbohydrate metabolism  Amino acid and fatty acid oxidative disorders Congenital anomalies:  Prematurity  Cleft palate, malformed palate  Tongue thrust, feeding and swallowing disorders  Prolonged enteral tube feeding  Neurologic disorders CONSIDERATIONS FOR PEDIATRICS MRM SP 17 6  Gastroesophageal reflux  Congenital heart disease Adolescent  Intake of protein, calories, vitamins, and minerals adequate for growth  Vegetarianism  Number of fast food meals  Food allergies  Supplements  Appetite suppressants  Laxative and alcohol use  Preoccupation with weight  Overly concerned with developing muscle mass, losing body fat  Excessive exercise  Weighs self daily, boasts about weight loss, weight goals  Omits perceived fattening foods and food groups from diet PAIN o Assessing Pain Behaviors, p. 56 o Newborns and Infants, p. 57 o Children, p. 58 Infants More susceptible to hypothermia o Large body surface area for weight ratio o Thinner skin o Limited ability to cope with cold stress o Higher pulse and respiratory rate than adults o Lower blood pressure than adults o Less able to modify pain impulses HISTORY Children  Word(s) the child uses for pain, such as “owie,” “ouch,” “ache,” or “hurt”  What do you tell your mother or father when you hurt? What do you want him or her to do for the hurt?  What kinds of things caused the hurt in the past? What made the hurt feel better?  Pain behaviors (facial expressions, grimacing, protective posture) that the parent identifies in the infant or child VITALS Newborn/Infants  The pulses of the newborn are easily palpable.  Rates close to 200 beats per minute may occur in neonates.  The decrease in pulse rate is relatively rapid, and the rate may be closer to 120 at a few hours of age.  The newborn’s pulse rate is more variable than that of older infants with activities such as feeding, sleeping, and waking.  Count the respiratory rate for 1 minute.  The expected rate for neonates varies from 40 to 60 breaths per minute, but a rate of up to 80 may be noted.  Babies delivered by cesarean section may have a more rapid respiratory rate than babies delivered vaginally.  The blood pressure of infants is often performed using an electronic sphygmomanometer with a Doppler or other oscillometric technique.  The expected newborn blood pressure ranges from 60 to 96 mm Hg systolic and 30 to 62 mm Hg diastolic.  A sustained increase in blood pressure is almost always significant. Pain Assessment The Premature Infant Pain Profile (PIPP) is best validated for premature infants, but observations are appropriate for full-term neonates and infants o Gestational age o Behavioral state o Heart rate o Oxygen saturation o Brow bulge o Eye squeeze CONSIDERATIONS FOR PEDIATRICS MRM SP 17 7 o Nasolabial furrow to assess procedural pain in preterm and full-term neonates between 28 and 40 weeks’ gestation The Neonatal Infant Pain Scale assesses preterm and full-term infant procedural pain o Facial expression o Cry o Breathing pattern o Arms o Legs o State of arousal The Neonatal Infant Pain Scale assesses preterm and full-term infant procedural pain o Facial expression o Cry o Breathing pattern o Arms o Legs o State of arousal Children/Vital Signs  The heart rates of children are more variable than those of adults and react with wider swings related to exercise, fever, or stress.  The usual respiratory rates for children vary with age.  Rates decrease with age, with a greater variation in the first 2 years of life and without significant gender difference.  Select the correct cuff size to obtain an accurate blood pressure reading.  Children become more cooperative for the blood pressure measurement at 2 to 3 years of age.  Blood pressure standards for children are provided by gender, age, and height percentiles. Pain  History and physical examination will provide much information about child’s pain.  Children do best with practice using your preferred scale and examples of past painful experiences.  Wong/Baker Faces Rating Scale and the Oucher Scale are examples of faces rating scales reliable for children. o The child must choose the face that best represents amount of pain. For nonverbal children, the FLACC Behavioral Pain Assessment Scale can be used: o Face o Legs o Activity o Cry o Consolability o Used most commonly to assess acute pain associated with surgery in children between 2 months and 7 years Mental/Neuro Status The total expression of a person’s emotional responses, mood, cognitive functioning, and personality Anatomy and Physio---Infants and Children  Major brain growth and myelination in first year of life  At birth, the neurologic impulses are primarily handled by the brainstem and spinal cord o Sucking, rooting, yawning, sneezing, hiccupping, blinking at bright light, and withdrawing from painful stimuli  All brain cells are present at birth, but it takes the first years of life for cells to fully develop and myelinate.  Primitive reflexes present in newborn o Moro (startle reflex), stepping, palmar and plantar grasp Motor maturation in cephalocaudal direction o Head and neck o Trunk o Extremities  Brain growth continues until 12 to 15 years of age  Brain insults, such as infection, trauma, or metabolic imbalance, can damage brain cells, leading to potentially serious dysfunction in mental status. Adolescents  Intellectual maturation continues with greater capacity for information and vocabulary development.  Abstract thinking develops: o Ability to develop theories o Ability to use logical reasoning o Ability to make future plans o Ability to use generalizations o Ability to consider risks and possibilities  Judgment begins to develop with education, intelligence, and experience. CONSIDERATIONS FOR PEDIATRICS MRM SP 17 8 PMH and SOCIAL HISTORY Child  Prenatal history  Birth history  Respiratory status at birth  Neonatal health  Congenital anomalies  Hypotonia or hypertonia in infancy  Developmental milestones o Age attained o Pattern of development o Evidence of developmental delay  Speech and language  Behavior- Hyperactive or impulsive behavior  Performance of self-care activities: dressing, toileting, feeding  Personality and behavior patterns  Learning or school difficulties Health problems  Headaches, seizures, clumsiness or unsteady gait, muscle weakness or falling Adolescent  Risk-taking behaviors  School performance and peer interactions  Family interactions, reluctance to communicate and to speak of attitudes and experience PHYSICAL EXAM Infants Levels of activity  Lethargic  Drowsy  Stuporous  Alert  Active  Irritable Responsiveness to environmental stimuli  Smile  Caregiver depression  Crying and other vocal sounds Neuro Exam  Cranial nerves indirectly assessed by observing: o CN II, III, IV, and VI  Optical blink reflex  Gaze and tracking  Doll’s eye o CN V  Rooting  Sucking o CN VII  Facial expressions- Responsiveness to environmental stimuli  Forehead wrinkling  Smile o CN VIII  Acoustic blink reflex  Doll’s eye maneuver o CN IX and X  Swallow and gag reflex o CN XII  Sucking and swallowing ability  Tongue position with pinch test  Observe the infant’s spontaneous activity for symmetry and smoothness of movement  Coordinated sucking and swallowing are also functions of the cerebellum CONSIDERATIONS FOR PEDIATRICS MRM SP 17 9  A withdrawal of all limbs from a painful stimulus provides a measure of sensory integrity  The patellar tendon reflexes are present at birth, and the Achilles and brachioradial tendon reflexes appear at 6 months of age  Posture and movement are routinely evaluated by primitive reflexes o Rooting (birth) o Palmar grasp (birth) o Plantar grasp (birth) o Moro (birth) o Placing (4 days of age) o Stepping (between birth and 8 weeks) o Asymmetric tonic neck (by 2 to 3 months)  Inspect and palpate muscle for strength and tone Children  Types of words and speech patterns  Mood  Activity level  Preferences  Responsiveness to parent and ability to separate  Self-comforting measures  Does the child play and have fun?  Attempt memory testing at about age 4  Concerns about behaviors and mood disorders may be assessed in children 4 to 18 years of age with tools like the Pediatric Symptom Checklist.  Positive responses should prompt questions about school, family, friends, moods, and activities.  Observe neuromuscular development progress and skills displayed during physical exam  Developmental screening tests  Modify CN examination according to age  Observe at play: o Gait and fine motor coordination o Heel-to-toe walking, hopping, jumping  Deep tendon reflexes are not always tested in a child who demonstrates appropriate development  Evaluate light touch sensation by asking the child to close his or her eyes and point to where you touch or tickle o Use the tuning fork to evaluate vibration sensation  Superficial pain sensation is not routinely tested in young children Common Abn Neuro Cerebral palsy o Permanent disorder of movement and posture development Myelomeningocele (spina bifida) o Congenital defect of one or more vertebrae (commonly the lumbar or sacral) that permits a meningeal sac filled with a portion of the spinal cord to protrude Shaken baby syndrome o Severe form of child abuse resulting from the violent shaking of infants under 1 year of age o Stretching and tearing of nerve tissue and blood vessels causes brain damage and a subdural hematoma o Spinal cord may also be damaged Mental retardation  Significant subaverage general cognitive functioning and deficits in adaptive behavior manifested during the child’s development  May be associated with structural brain defects or genetic disorders  Signs and symptoms  Delayed motor development  Delayed speech and language skills Attention-deficit/hyperactivity disorder (ADHD)  A neurobehavioral problem of impaired attention and hyperactive behavior affecting 5% to 10% of school-age children  Theorized that dopamine system disturbances may be associated with ADHD onset Signs and symptoms  Short attention span  Easily distracted  Trouble completing assignments  Fidgets and squirms, moving, running, jumping  Disruptive behavior, poor impulse control Autistic disorder CONSIDERATIONS FOR PEDIATRICS MRM SP 17 10  Pervasive neurodevelopmental disorder of unknown etiology  Refers to a wide spectrum of disorders typically prior to 3 years of age  Believed to have multifactorial causes and a strong genetic influence Signs and symptoms  Does not make eye contact  Resists being held or touched  Odd and repetitive behaviors  Ritualized play, preoccupation with parts of objects  Motor development appropriate for age Concussion, depression, mania, anxiety, ADHD, schizophrenia SKIN Anatomy and Physiology Infants  Skin of infants and children appears smoother than that of adults because:  Of the absence of coarse terminal hair  Skin has not been subjected to years of exposure to the elements  Desquamation of stratum corneum may be present at birth or very shortly afterward  Vernix caseosa, a mixture of sebum and cornified epidermis, covers the infant’s body at birth  Subcutaneous fat is poorly developed in newborns, predisposing them to hypothermia o Lanugo is the fine silky hair that covers the newborn’s body, particularly on the shoulders and back  Shed within 10 to 14 days  Most of the infant’s hair is shed by about 2 to 3 months of age, to be replaced by more permanent hair with a new texture and often a different color  Eccrine glands function after 1 month  Apocrine glands do not function o Less oily texture o Inoffensive perspiration Adolescent  Apocrine glands enlarge and become active  Increased axillary sweating and sometimes body odor  Increased sebum production in response to increased hormone levels, primarily androgen  Oily appearance and predisposing the individual to acne  Coarse terminal hair appears in the axillae and pubic areas of both female and male adolescents and on the face of males. HISTORY-Infants  Feeding history  Diaper history  Types of clothing and washing practices  Bath practices  Dress habits  Temperature/humidity of home  Rubbing head against external surfaces Children and Adolescent  Eating habits and types of foods  Food allergies  Exposure to infectious diseases  Allergic disorders: eczema, urticaria, pruritus  Pets or animal exposure  Outdoor exposures: camping, hiking, picnics  Skin injury history: cuts, unexplained injuries  Chronic manipulation of hair  Nail biting PHYSICAL EXAM-Infant Inspection and palpation of skin for: Expected color changes  Jaundice or hyperbilirubinemia  Defects signaling systemic conditions CONSIDERATIONS FOR PEDIATRICS MRM SP 17 11  Contour distortions  Skin creases indicating congenital abnormalities  Lesions indicating internal problems  Pinch skin for test of turgor FACT CHECK:  What is considered a ‘normal’ skin turgor finding for an infant?  What skin crease findings would be considered abnormal in a newborn? Adolescent Inspect for:  Increased oiliness and perspiration  Acne  Maturational changes Common Abnormal Seborrheic dermatitis  Little known about etiology  Condition most commonly occurs in infants within the first 3 months of life Miliaria (prickly heat)  Caused by sweat retention from occlusion of sweat ducts during periods of heat and high humidity Impetigo  Common, contagious superficial skin infection Acne vulgaris  Impaction and obstruction of the outflow of sebum Chickenpox (varicella)  Acute, highly communicable disease common in children and young adults Measles (rubeola)  Measles virus infects by invasion of the respiratory epithelium German measles (rubella)  Mild, febrile, highly communicable viral disease Hair pulling (trichotillomania)  Loss of scalp hair can be caused by physical manipulation Patterns of injury in physical abuse Bruises, burns, lacerations, scars, bony deformities, alopecia, retinal hemorrhages, dental trauma, and head and abdominal injuries Skin and hair abnormalities may be the most visible clues in detecting this problem LYMPH Anatomy and Physio--Infant and Children  Antibody production is immature at birth.  Thymus is at its largest relative to the rest of the body shortly after birth.  Tonsils are larger in early childhood.  Lymph node distribution is same as in adults.  Lymphatic system gradually reaches adult competency during childhood. HPI  Recurrent infections  Present or recent infections or trauma distal to nodes  Poor growth, failure to thrive  Loss of interest in play or eating  Immunization history  Maternal HIV infection  Hemophilia  PHYSICAL EXAM CONSIDERATIONS FOR PEDIATRICS MRM SP 17 12  Technique of examination is similar for all ages.  Enlarged lymph nodes common  Enlarged postauricular/occipital not unusual in children younger than age 2  Enlarged cervical/submandibular less frequent in children younger than age 1, much more frequent in children older than age 1  Enlarged tonsils common, not necessarily abnormal HEAD Anatomy and Physio--Infant  Cranial bones are soft and separated by sutures  Sutures and fontanels permit skull expansion to accommodate brain growth o Sutures ossify (age 6 to 18 years) o Fontanels close (age 2 months to 2 years)  Skull molding from birth through vaginal canal o Skull bones shift and overlap o Normal shape and size resumed within days FACT CHECK: o When does Anterior Fontanel close? o When does Posterior Fontanel close? HISTORY  Prenatal history  Birth history  Unusual head shape  Head control  Acute illness  Congenital anomalies  Neonatal screening for hypothyroidism PHYSICIAL EXAM Infants  Head circumference  Head symmetry of shape  Fontanels  Scalp scaling or crusting, dilated scalp veins  Hair and hairline  Caput succedaneum or cephalohematoma  Head control, position, movement  Facial features  Facial symmetry  Neck symmetry, size, and shape Palpation  Suture lines and fontanels  Craniotabes: softening of the outer table of the skull  Neck muscle tone and masses  Trachea  Thyroid goiter Children  Percussion of skull with one finger to detect Macewen sign Stronger resonant sound when either hydrocephalus or a brain abscess is present  Bruits common in children up to 5 years of age or in children with anemia  Thyroid may or may not be palpable Common Abn Torticollis-- Define Encephalocele Neural tube defect with protrusions of brain and membranes that cover it through openings in the skull Hydrocephalus CONSIDERATIONS FOR PEDIATRICS MRM SP 17 13 A problem in the formation, flow, or absorption of cerebrospinal fluid (CSF) that leads to an increase in volume of the CSF Microcephaly Circumference of head is smaller than normal because brain has not developed properly or has stopped growing Craniosynostosis Premature closure of one or more cranial sutures before brain growth is complete Leads to misshapen skull FACT CHECK Closure of the anterior skull fontanels should occur by _____ months.  3  6  12  18  24 FACT CHECK What are some of the classical history and physical exam findings for these diagnoses? Define Caput succedaneum and discuss with the new parent what to expect regarding the clinical course. Define cephalohematoma and discuss with the new parent what to expect regarding the clinical course. EYES Anatomy and Physiology  Eye forms during the first 8 weeks of gestation  May become malformed due to maternal drug ingestion or infection  Lacrimal drainage is complete at birth  By 2 to 3 weeks of age, the lacrimal gland begins producing full volume of tears  Vision development depends on nervous system maturation and occurs over time  Term infants hyperopic [20/400]  Peripheral vision fully developed at birth  Central vision develops later  By 3 to 4 months of age, binocular vision development is complete  By 6 months, vision has developed sufficiently so that the infant can differentiate colors  The globe of the eye grows as the child’s head and brain grow, and adult visual acuity is achieved at about 4 years of age HPI Infants  Preterm  Maternal sexually transmitted infections  Congenital abnormalities of the eye  Symptoms of congenital abnormalities including gazing and blinking problems  Excessive tearing or discharge  Strabismus some or all the time Young children  Excessive rubbing of the eyes, frequent hordeola, inability to reach for and pick up small objects, night vision difficulties  School-age children  Necessity of sitting near the front of the classroom to see the board; poor progress in school not explained by intellectual ability PHYSICAL EXAM--Infants  Note symmetry, muscle balance, and presence of red light reflex  Inspect lids for swelling and epicanthal folds  Inspect lid level covering eye  Note eye spacing  Inspect sclera, conjunctiva, pupil, and iris  Test cranial nerves o Vision: Observe object preference/focus/tracking o Optical blink: Note closure and head response to bright light o Corneal reflex: same as adult CONSIDERATIONS FOR PEDIATRICS MRM SP 17 14  Funduscopic examination deferred until infant is 2 to 6 months old (unless visual problems)  Red reflex should be elicited in all newborns Children  External structure inspection same as for infant  Visual acuity tested in younger children by observing activities  Photoscreening is recommended as an alternative to visual acuity screening for ages 3 to 5  Visual acuity tested with vision charts at 5 years of age  Peripheral vision tested in cooperative child  Cranial nerve tests same as for adult  Funduscopy requires patience FACT CHECK: What are some of the classical history and physical exam findings for these diagnoses? Abnormalities  Retinoblastoma o Embryonal malignant tumor arising from retina  Retinopathy of prematurity o Disruption of normal progression of retinal vascular development in preterm infant  Retinal hemorrhages in infancy o Abnormal bleeding of the retinal blood vessels o Occurs in infant victims of shaken-baby syndrome FACT CHECK: What eye examination is performed on the newborn? EARS NOSE THROAT Anatomy and Physio  Inner ear development in first trimester  External auditory canal in infants shorter than in adults  Eustachian tube in infants wider, shorter, more horizontal than in adults  Salivation increased by 3 months  Maxillary and ethmoid sinuses are present at birth but are very small.  Frontal and sphenoid sinuses begin to develop at about 3 years of age and complete development in late adolescence.  Twenty deciduous teeth usually erupt between 6 and 24 months of age.  Permanent teeth begin forming in the jaw by 6 months of age.  Eruption of the permanent teeth begins about 6 years of age and is completed around 14 or 15 years of age in most races.  Tooth eruption timing may be delayed in cases of poor nutritional status and chronic conditions. HISTORY  Prenatal history  Prematurity  Serum bilirubin greater than 20 mg/100 mL serum  Infections  Secondary tobacco smoke exposure, out-of-home childcare, siblings in the home  Congenital defect  Playing with small objects  Behaviors indicating hearing loss  Failure on language domain of developmental screening tool; failure on hearing screen  Dental care  PHYSICAL EXAM--Infants  Ears o Inspect auricle for full formation and flexibility o Auditory canals should be examined in first few weeks of life o Tympanic membrane becomes conical after first few months of life o Evaluate infant hearing using sound stimuli  Nose and sinuses o Inspect for symmetry and positioning o Determine nasal patency o Paranasal sinuses are poorly developed during infancy, and examination is generally unnecessary  Mouth CONSIDERATIONS FOR PEDIATRICS MRM SP 17 15 o Inspect lip shape and irregularities o Inspect buccal mucosa color and moisture o Observe for drooling o Inspect gums, teeth, and tongue o Inspect palatal arch and soft palate o Evaluate suck reflex o Avoid depressing the tongue because this stimulates a strong reflex and protrusion of the tongue, making visualization of the mouth difficult Children Because the young child often resists otoscopic and oral examinations, it may be wise to postpone these procedures until the end Be prepared to immobilize if encouraging the child to cooperate fails o Another person, usually the parent, may be needed to effectively hold the child  Ears o Otoscopic examination  Pull auricle down to view tympanic membrane  Pneumatic otoscope is especially important for differentiating a red tympanic membrane caused by crying (the membrane is mobile) from that resulting from disease (no mobility)  Evaluate toddler’s hearing by observing response to whispering, noisemakers, and speech  Audiometric evaluation should be performed in all young children at regular intervals  Nose and sinuses o To inspect the internal nose, shine a light while tilting the nose tip upward with your thumb o Palpate the paranasal sinuses after they have developed (maxillary sinuses by 4 years of age and frontal sinuses by 7 to 8 years of age) o Note any periorbital edema or tenderness in the sinus areas  Mouth o Inspect teeth for grinding, decay, and brown spots o Check gag reflex, enabling brief view of mouth and oropharynx o Inspect buccal mucosa o Inspect tonsils and epiglottis Review Common Abnormalities What are some of the common diagnoses seen in children? FACT CHECK: What are some of the classical history and physical exam findings for these diagnoses? FACT CHECK: What direction do you pull the auricle to examine a child? When should hearing be evaluated? CHEST AND LUNG Anatomy and Physio--Infant  Fetal lungs contain no air; gas exchange is through placenta  At birth, lungs adapt to postnatal function o Relative decrease in pulmonary pressure most often leads to closure of the foramen ovale within minutes after birth o Increased oxygen tension in the arterial blood usually stimulates contraction and closure of the ductus arteriosus o Reminder: The foramen ovale and the ductus arteriosus do not always close so readily  Chest of the newborn is generally round  Chest circumference is same as head circumference until about 2 years of age  With growth, the chest assumes adult proportions, with the lateral diameter exceeding the anteroposterior diameter  Chest wall is thinner and bony structures more prominent and yielding than in adults FACT CHECK: What is the relationship between the AP diameter and the lateral diameter? HISTORY  Low birth weight and prematurity  Coughing and sudden-onset shortness of breath  Possible ingestion of kerosene, antifreeze, or hydrocarbons in household cleaners CONSIDERATIONS FOR PEDIATRICS MRM SP 17 16  Apneic episodes; use of apnea monitor  Swallowing dysfunction o Gastroesophageal reflux  History of pneumococcal and influenza vaccination PHYSICAL EXAM--Infants  Examination approach is similar to that in adults; percussion is less reliable in infants  Inspect the thoracic cage, noting size and shape  Measure the chest circumference o Usually 2 to 3 cm smaller than the head circumference  Respiratory rate varies between 40 and 60 respirations per minute  Periodic breathing, a sequence of relatively vigorous respiratory efforts followed by apnea of as long as 10 to 15 seconds, is common  Coughing is rare; sneezing is frequent  Hiccups are also frequent  At first, breathing is primarily diaphragmatic; use of intercostal muscles is gradual  Paradoxic breathing (the chest wall collapses as the abdomen distends on inspiration) is common, particularly during sleep  Palpate the clavicle, rib cage, and sternum, noting loss of symmetry, unusual masses, or crepitus  Listen to the chest o Breath sounds are easily transmitted from one segment of the auscultatory area to another o Localization of breath sounds can be difficult o Absence of sounds in any given area may be difficult to detect  Stridor o High-pitched, piercing sound most often heard during inspiration o Result of an obstruction high in the respiratory tree  Respiratory grunting o Mechanism by which the infant tries to expel trapped air or fetal lung fluid while trying to retain air and increase oxygen levels o Cause for concern if persistent  Flaring of the alae nasi o Another indicator of respiratory distress Children  Children use the thoracic (intercostal) musculature for respiration by the age of 6 or 7 years  Variable respiratory rate, decreasing with age, reaching adult rates at about 17 years  Roundness of chest persisting past second year is a possible indication of a pulmonary problem  The younger the infant or toddler, the more difficult to evaluate wheezing Abnormalities FACT CHECK: What are some of the classical history and physical exam findings for these diagnoses?  Diaphragmatic hernia o Result of an imperfectly structured diaphragm, occurs once in slightly more than 2000 live births  Cystic fibrosis o Autosomal recessive disorder of exocrine glands involving the lungs, pancreas, and sweat glands  Epiglottitis o Acute, life-threatening infection involving the epiglottis and surrounding tissues  Croup (laryngotracheal bronchitis) o Syndrome that generally results from infection with a variety of viral agents, particularly the parainfluenza viruses occurring most often in children from about 1.5 to 3 years of age  Tracheomalacia o Lack of rigidity or a floppiness of the trachea or airway  Bronchiolitis o Bronchiolar (small airway) inflammation leading to hyperinflation of the lungs occurring most often in infants younger than 6 months HEART/BLOOD VESSEL ANATOMY AND PHYSIO  Heart assumes adult function early in fetal life  Changes at birth: o Ductus arteriosus and interatrial foramen ovale close o Right ventricle assumes pulmonary circulation o Left ventricle assumes systemic circulation CONSIDERATIONS FOR PEDIATRICS MRM SP 17 17 o Cutting of umbilical cord necessitates breathing  Respiration onset expands lungs  Pulmonary vascular resistance drops; systemic resistance increases  Ductus arteriosus closes in first 12 to 14 hours of life  Foramen ovale closes after pressures shift  Ventricle muscle mass increases over first year  Heart lies more horizontally and apex higher o Adult heart position reached by age of 7 years o HISTORY--Infants  Tiring easily during feeding  Breathing changes  Cyanosis  Weight gain as expected  Knee-chest position or other favored position  Mother’s health during pregnancy Children  Tiring during play  Naps  Positions at play and rest  Headaches  Nosebleeds  Unexplained joint pain  Unexplained fever  Expected height and weight gain  Expected physical and cognitive development  Hemophilia  Sickle cell disease  Renal disease  Coarctation of the aorta  Leg pains during exercise PHYSICAL EXAM--Infant  Examine newborn at birth or at 2 to 3 days for circulation transition signs.  Heart function examination includes skin, lungs, and liver.  Inspect color of skin and mucous membranes.  Look for enlargement of heart and position if dyspneic.  Heart sounds are difficult to assess; vigor and quality are indicators of heart function.  Heart rates vary with eating, sleeping, and waking.  Murmurs are common until 48 hours of age.  Brachial, radial, femoral pulses easily palpable  Evaluate capillary refill  Very rapid (less than 1 second)  Prolonged (longer than 2 seconds) Children  Bulging precordium if long-standing heart enlargement  Sinus arrhythmia a physiologic event of childhood  Other arrhythmias usually ectopic in origin (supraventricular and ventricular ectopic beats) and only occasionally require investigation  Heart rates more variable than in adult  Expected heart rates variable with child’s age  Most murmurs in infants and children are the result of congenital heart disease o Kawasaki disease accounts for most acquired murmurs o Some murmurs are innocent, caused by the vigorous expulsion of blood from the left ventricle into the aorta; it increases in intensity with activity and diminishes when the child is quiet (still murmur)  Child with known heart disease o Weight gain or loss o Developmental delays o Cyanosis o Clubbing of fingers or toes FACT CHECK: What are some of the classical history and physical exam findings for these diagnoses? CONSIDERATIONS FOR PEDIATRICS MRM SP 17 18 COMMON ABNORMAL o Tetralogy of Fallot o Coarctation of the aorta  Stenosis seen most commonly in the descending aortic arch near the origin of the left subclavian artery and ligamentum arteriosum o Kawasaki disease  Acute small vessel vasculitic illness of uncertain cause affecting young males more often than females  Critical concern is cardiac involvement in which aneurysms of a coronary artery may develop o Ventricular septal defect o Pulmonic stenosis o Dextroposition of the aorta o Right ventricular hypertrophy  Ventricular septal defect o Opening between the left and right ventricles  Patent ductus arteriosus o Failure of the ductus arteriosus to close after birth  Atrial septal defect o Congenital defect in the septum dividing the left and right atria  Acute rheumatic fever o Systemic connective tissue disease occurring after streptococcal pharyngitis or skin infection BREAST/AXILLA Anatomy and Physio  Breast development o Latent phase in children and preadolescence o Thelarche (breast development) early sign of puberty in adolescent girls o Tanner sexual maturity rating system to stage breast development  Breasts develop at different rates in individuals and may result in asymmetry TANNER STAGES  Tanner 1 (preadolescent) o Only the nipple is raised above the level of the breast, as in the child  Tanner 2 o Budding stage, bud-shaped elevation of the areola  Tanner 3 o Breast and areola enlarged o No contour separation  Tanner 4 o Increasing fat deposits o Areola forms a secondary elevation above that of the breast  Occurs in approximately half of all girls and in some cases persists in adulthood  Tanner 5 (adult stage) o Areola is (usually) part of general breast contour and is strongly pigmented o Nipple projects PHYSICAL EXAM--Infant  Breasts of many well newborns, male and female, are enlarged for a relatively brief time o Result of passively transferred maternal estrogen  Small amount of clear or milky white fluid, commonly called “witch’s milk,” is sometimes expressed  Breast enlargement usually disappears within 2 weeks, and rarely lasts beyond 3 months of age Adolescent The right and left breasts of the adolescent female may not develop at the same rate Reassurance Breast tissue of the adolescent female feels homogeneous, dense, firm, and elastic Transient unilateral or bilateral subareolar masses in males Firm, sometimes tender, and often a source of great concern to the patient and his parents Disappear, usually within a year Gynecomastia in males o Unusual and unexpected enlargement that is readily noticeable o Usually temporary and benign and resolves spontaneously ABNORMAL Premature thelarche CONSIDERATIONS FOR PEDIATRICS MRM SP 17 19  Breast enlargement in girls before onset of puberty  Cause unknown  Breasts continue to enlarge slowly throughout childhood until full development is reached during adolescence ABDOMEN Anatomy and Physio--Infants  Pancreatic buds, liver, and gallbladder all begin to form during week 4 of gestation o Intestine already exists as a single tube  Meconium, an end product of fetal metabolism, is produced at about 17 weeks  By 36 to 38 weeks’ gestation, the gastrointestinal tract is capable of adapting to extrauterine life  Elasticity, musculature, and control mechanisms continue to develop, reaching adult levels of function at 2 to 3 years of age  Liver is very large at birth o Metabolic and glycogen storage organ o Remains the heaviest organ in the body  Pancreatic islet cells are developed by 12 weeks’ gestation and begin producing insulin  Spleen is active in blood formation during fetal development and the first year of life. o Afterward, the spleen aids in the destruction of blood cells and functions as a lymphatic organ for immunological response.  Nephrogenesis begins during the second embryologic month. o By 12 weeks, the kidney is able to produce urine. o Development of new nephrons ceases by 36 weeks of gestation. o After birth, the kidney increases in size because of enlargement of the existing nephrons and adjoining tubules. HISTORY Infants  Gestational age and birth weight  Passage of first meconium stool within 24 hours  Jaundice  Vomiting, frequency, projectile  Diarrhea, colic, failure to gain weight, weight loss, or steatorrhea (malabsorption syndrome)  Apparent enlargement of abdomen (with or without pain), constipation, or diarrhea Children  Constipation o Toilet training methods; diet; soiling; diarrhea; abdominal distention; pica; size, shape, consistency, and time of last stool; rectal bleeding; painful passage of stool  Abdominal pain o Splinting of abdominal movement, resists movement, keeps knees flexed  Psychosocial stressors o Home, school, and peers PHYSICAL EXAM--Infant and Children  Inspection o Shape, contour, and movement o Pulsations and peristalsis o Umbilical cord o Muscle protrusion  Auscultation o Bowel sounds in chest as well as abdomen  Suggests diaphragmatic hernia o Bruits or hums should not be heard  Percussion o More tympany expected  Palpate o Detectable spleen tip common o Pain difficult to assess ADOLESCENT  The techniques of abdominal examination of the adolescent are the same as those used for adults.  Do not overlook the possibility of pregnancy as a cause of abdominal pain or lower abdominal mass, even in young adolescent females. ABNORMAL FACT CHECK: What are some of the classical history and physical exam findings for these diagnoses? CONSIDERATIONS FOR PEDIATRICS MRM SP 17 20 Infant  Intussusception o Prolapse, or telescoping, of one segment of intestine into another causes intestinal obstruction  Pyloric stenosis o Hypertrophy of the circular muscle of the pylorus leads to obstruction of the pyloric sphincter  Meconium ileus o Distal intestinal obstruction caused by thick inspissated impacted meconium in the lower intestine  Biliary atresia o Congenital obstruction or absence of some or all of the bile duct system resulting in bile flow obstruction o Most have complete absence of the entire extrahepatic biliary tree  Meckel diverticulum o Outpouching of the ileum that varies in size from a small appendiceal process to a segment of bowel several inches long, often in the proximity of the ileocecal valve  Necrotizing enterocolitis o Inflammatory disease of the gastrointestinal mucosa associated with prematurity and immaturity of the gastrointestinal tract Children  Neuroblastoma o Common solid malignancy of embryonal origin in the peripheral sympathetic nervous system  Wilms tumor (nephroblastoma) o Most common intraabdominal tumor of childhood; usually appears at 2 to 3 years of age  Hirschsprung disease (congenital aganglionic megacolon) o Primary absence of parasympathetic ganglion cells in a segment of the colon that interrupts intestinal motility  Hemolytic uremic syndrome (HUS) o Triad of microangiopathic hemolytic anemia, thrombocytopenia, and uremia FEMALE GENITALIA Anatomy and Physio--Infant/Children  Vagina is narrow  Cervix comprises most of uterus  Ovaries are immature  Labia majora are hairless and nonprominent  Hymen a thin diaphragm just inside the introitus  Clitoris is small  External genitalia may be swollen due to maternal estrogen Adolescent  Puberty: functional maturation of reproductive organs  External genitalia increase in size  Clitoris becomes erectile  Pubic hair develops  Vagina lengthens and secretions become acidic  Uterus, ovaries, and tubes increase in size  Uterine musculature and vascular supply increase  Endometrial lining thickens in preparation for the onset of menstruation  The average age at menarche in the United States is between 12 and 13 years  Irregular menstrual cycles are not unusual during adolescence as a result of anovulatory cycles HISTORY Infants/Children  Bleeding o Character o Associated symptoms o Parental suspicion about foreign objects o Suspicion about sexual abuse  Pain o Character o Location o Associated symptoms o Contributory problems  Vaginal discharge o Relation to diapers o Associated symptoms o Contributory problems  Urinary symptoms CONSIDERATIONS FOR PEDIATRICS MRM SP 17 21  Diarrhea, fever, or nausea and vomiting  Excessive crying that cannot be resolved by typical measures (e.g., feeding, holding)  Loss of appetite  Fever  Nausea and vomiting  Masturbation Adolescent  Same questions as any adult female  Talk with teen in private  Should not assume that youthful age precludes sexual activity or any of the related concerns  Questions should be posed in a gentle, matter-of-fact, and nonjudgmental manner PHYSICAL EXAM--Infant Inspect and palpate external genitalia only  Expected swelling  Milky discharge  Enlarged clitoris  Ambiguous appearance  Adhesions between labia minora Children Inspect and palpate external genitalia  Redness or irritation  Swelling  Discharge or bleeding Internal examination only if evidence of:  Bleeding  Discharge  Trauma or abuse Sexual abuse signs: medical concerns  Evidence of general physical abuse or neglect  Evidence of trauma and/or scarring in genital, anal, and perianal areas  Unusual changes in skin color or pigmentation in genital or anal area  Presence of STI  Anorectal problems such as itching, bleeding, pain, fecal incontinence, poor anal sphincter tone  Genitourinary problems (e.g., rash or sores in genital area, vaginal odor, pain) Sexual abuse signs: behavioral manifestations  Problems with school  Dramatic weight changes or eating disturbances  Depression  Sleep problems or nightmares  Sudden change in personality or behavior  Aggression or destructiveness  Sudden avoidance of certain people or places  Use of sexually provocative mannerisms  Excessive masturbation or sexual behavior  Age-inappropriate sexual knowledge or experience  Repeated object insertion into vagina and/or anus  Child asking to be touched/kissed in genital area  Sex play between children with 4 years or more age difference  Sex play that involves the use of force, threats, or bribes Adolescent  Allay anxiety for what may be first examination  Same examination and positioning as for adult  Appropriate-size speculum  Maturational changes of sexual development o Just before menarche, there is a physiologic increase in vaginal secretions o Hymen may or may not be stretched across the vaginal opening o By menarche, the vaginal opening should be at least 1 cm wide CONSIDERATIONS FOR PEDIATRICS MRM SP 17 22 ABNORMALS Infant/Children  Ambiguous genitalia o Newborns’ genitalia are not clearly either male or female  Hydrocolpos o Distention of the vagina due to accumulation of fluid due to congenital vaginal obstruction  Vulvovaginitis o Inflammation of the vulvar and vaginal tissues MALE GENITALIA Anatomy and Physio--Infant  Sexual differentiation by 12 weeks’ gestation  During the third trimester, the testes descend from the retroperitoneal space through the inguinal canal to the scrotum o Descent of testes may occur after birth  Complete separation of prepuce from the glans at about 3 to 4 years in uncircumcised males Adolescent  Puberty: functional maturation of reproductive organs  Increased size o Penis  Enlarges in length and breadth o Testes  Scrotal skin reddens, thins, and becomes increasingly pendulous  Development of pubic hair  FACT CHECK What are the Tanner stages for genitalia and hair in males? HISTORY Infants/Children  Maternal use of sex hormones  Circumcised: complications  Uncircumcised: hygiene measures  Scrotal swelling with crying or bowel movement  Congenital anomalies  Masturbation and sexual exploration  Swelling or sores on penis or scrotum  Concern of sexual abuse Adolescent  Knowledge of reproduction and sexual function  Presence of nocturnal emissions, pubic hair, enlargement of genitalia, age at time of each occurrence  Concern of sexual abuse  Sexual activity, protection used for contraception and STI prevention PHYSICAL EXAM---Infants  Inspect and palpate o Congenital anomalies o Incomplete development o Sexual ambiguity o Urethral placement o Retractability of foreskin o Descent of testicles o Masses  Transilluminate scrotum if mass found Children  Inspect and palpate o Penis  Size, lesions, swelling, inflammation, and malformation o Foreskin retraction o Scrotum  Descent of testes o Testes  Masses CONSIDERATIONS FOR PEDIATRICS MRM SP 17 23 Adolescent  Examination of older children and adolescents is the same as for adults  Allay anxiety  Protect privacy  Inspect and palpate o Expected maturational changes ABNORMALITIES FACT CHECK: What increases the risk of testicular cancer for males? Review TEXT  Review abnormalities : hernia, penis, scrotum, Klinefelter  Ambiguous genitalia o Newborn’s genitalia are not clearly either male or female o Presence or absence of male hormones controls the development of the sex organs during fetal development ANUS/RECTUM/PROSTATE Anatomy and Physio--Infant/Children  First meconium stool is ordinarily passed within the first 24 to 48 hours after birth and indicates anal patency  Common for newborns to have a stool after each feeding (the gastrocolic reflex)  Children are developmentally ready to begin toilet training at age 2 to 4 years  Prostate undeveloped until puberty HISTORY Infant/Children  Stool characteristics  Bowel movements accompanied by crying, straining, bleeding  Feeding habits  Bowel control and potty training  Associated symptoms  Congenital anomaly PHYSICAL EXAM---Infant/Children  Inspect anus, perineum, and buttocks o Redness or irritation o Tufts of hair, dimpling o Masses o Discharge or bleeding o Perirectal protrusion o Rectal abscesses o Texture and tone o Anal contraction  Examine newborn for patency of anus  Lightly touch the anal opening, which should produce anal contraction (“anal wink”) o Lack of contraction may indicate a lower spinal cord lesion  Routinely inspect the anal region and perineum o Redness, masses, or swelling  Rectal examination is not routine for infants and children; do rectal examination for: o Pain o Bleeding o Rectal protrusion or abscesses o Stool abnormalities  Rectal examination is not routine for adolescents ABNORMALS Children  Imperforate anus o Rectum may end blindly, be stenosed, or have a fistulous connection to the perineum, urinary tract, or, in females, the vagina  Enterobiasis (roundworm, pinworm) o Adult nematode (parasite) lives in the rectum or colon and emerges onto perianal skin to lay eggs while the child sleeps Other  Pilonidal cyst CONSIDERATIONS FOR PEDIATRICS MRM SP 17 24 o Loose hairs penetrate the skin in the sacrococcygeal area  Anal warts (Condyloma acuminata) o Result of infection with HPV  Anal fistula o Inflammatory tract that runs from the anus or rectum and opens onto the surface of the perianal skin or other tissue o Caused by drainage of a perianal or perirectal abscess  Pruritus ani o Commonly caused by fungal infection in adults and by parasites in children MUSCULOSKELETAL Anatomy and Physio---Infant/Children  Long bones increase in length and thickness throughout childhood  Cartilage in smaller bones ossifies  Ligaments are stronger than bones until adolescence o Fractures common  Muscle fibers lengthen  Skeletal system grows Adolescent  Rapid growth in puberty results in: o Decreased strength in epiphyses o Increased risk for injury  Bone growth completed about age 20  Peak bone mass achieved at age 35 HISTORY Infant/Children  Birth history o Presentation, large for gestational age, birth injuries (may result in fractures or nerve damage), type of delivery (vaginal vs. cesarean section), use of forceps o Low birth weight, premature, resuscitation efforts, required ventilator support (may result in anoxia leading to muscle tone disorders)  Fine and gross motor developmental milestones, appropriate for chronologic age  Overweight or obese  Quality of movement: spasticity, flaccidity, cog wheel rigidity  Arm or leg pain o Character o Onset o Participation in organized or competitive sports, weightlifting FACT CHECK: What are the expected fine/gross motor milestones for the first 12 months? PHYSICAL EXAMINATION--Infants  Inspect general o Posture o Spontaneous generalized movements  Inspect back o Hair tufts and dimples o Discolorations o Cysts or masses near spine o Curvature of spine  Inspect extremities o Symmetry o Movement o Equality o Deformity  Palpate bones o Fractures or dislocations o Crepitus o Masses o Tenderness  Palpate spine o Shape o Formation o Splitting  Palpate muscles and joints o Tone CONSIDERATIONS FOR PEDIATRICS MRM SP 17 25 o Mobility o Subluxation or dislocation  Assess motor development o Fine o Gross  Assess ROM  Assess muscle strength  Assess tibial torsion Barlow-Ortolani maneuver to detect hip dislocation or subluxation should be performed each time you examine the infant during the first year of life Barlow maneuver  Position yourself at the supine infant’s feet, and flex the hip and knee to 90 degrees  Grasp the leg with your thumb on the inside of the thigh, the base of the thumb on the knee, and your fingers gripping the outer thigh with fingertips resting on the greater trochanter  Adduct the thigh and gently apply downward pressure on the femur in an attempt to disengage the femoral head from the acetabulum  A positive sign is when a clunk or sensation is felt as the femoral head exits the acetabulum posteriorly Ortolani maneuver  Slowly abduct the thigh while maintaining axial pressure  With your fingertips on the greater trochanter, exert a lever movement in the opposite direction so that your fingertips press the head of the femur back toward the acetabulum center  If the head of the femur slips back into the acetabulum with a palpable clunk when pressure is exerted, suspect hip subluxation or dislocation Children Assess motor development o Fine o Gross Assess ROM Inspect o Spine curvature o Sitting posture o Foot arch o Alignment of feet and legs  Evaluate for the following: o Bowlegs (genu varum) o Knock-knees (genu valgum)  Palpate bones, muscles, and joints  Evaluate rising from seated position Adolescent  Same examination procedures as for adult  Note presence of scoliosis  Note slight kyphosis or rounded shoulders COMMON ABNORMALS Infants/Children Clubfoot (talipes equinovarus) Fixed congenital defect of the ankle and foot Metatarsus adductus Most common congenital foot deformity Metatarsus adductus can be either fixed or flexible Legg-Calvé-Perthes disease Avascular necrosis of the femoral head Osgood-Schlatter disease o Traction apophysitis (inflammation of a bony outgrowth) of the anterior aspect of the tibial tubercle Slipped capital femoral epiphysis o Disorder in which the capital femoral epiphysis slips over the neck of the femur Muscular dystrophy o Group of genetic disorders involving gradual degeneration of the muscle fibers Scoliosis CONSIDERATIONS FOR PEDIATRICS MRM SP 17 26 o Concave curvature of the anterior vertebral bodies, convex posterior curves, and lateral rotation of the thoracic spine Radial head subluxation o Known as nursemaid’s elbow, this is a dislocation injury SPORTS INJURIES  Muscle strain o Can be due to excessive stretching or forceful contraction beyond the muscle’s functional capacity  Dislocation o Complete separation of the contact between two bones in a joint  Fracture o Partial or complete break in the continuity of a bone  Tenosynovitis (tendonitis) o Inflammation of the synovium-lined sheath around a tendon  Rotator cuff tear o Microtrauma and tearing of the rotator cuff muscles; most often the supraspinatus PEDIATRIC EXAM Newborns Hx General  Apgar score  Gestational age  Congenital anomalies  Degree of awareness or apathy  Posture o Flaccidity, tension, spasticity  Skin color  Facies Physical examination Palpate  Head and fontanels (best done with baby upright)  Extremities  Abdomen  Rest of the baby Older Infants  No “right” sequence to the examination o Want