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Pediatric Physical Exam
Adapted from Mosby’s Guide to Physical Examination, 6th Ed.
Age Descriptors
Newborn birth to 2 months
Infant 0-1 year
Toddler 1-2 years
Child 2+ years
Vitals
Pulse
Respiration
Blood pressure
Temp
Height
Weightinfants and children
Pulse
Apical pulse 5th intercostal space in
the midclavicular line
Femoral pulse use a point halfway from
the pubic tubercle to ASIS as a guide
Pulse
Age Beats per minute
Newborn 120-170
1 year 80-160
3 years 80-120
6 years 75-115
10 years 70-110
Respiration
Infants – rise and fall of the abdomen facilitates counting
Rate, regularity and rhythm Depth Respiratory Effort
Retraction (ribs, supraclavicular notch) Contraction of SCM’s Flaring of nostrils Paradoxic breathing
Respiration
Age Respirations per minute
Newborn 30-80
1 year 20-40
3 years 20-30
6 years 16-22
10 years 16-20
Blood Pressure
Cuff size (children) Width should cover ~2/3 of the upper arm
or thigh
Too wide - underestimate BP
Too narrow - artificially high BP
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Temperature
Tympanic thermometers are becoming increasingly popular Accuracy depends on correct
technique Must read tympanic membrane
Shares blood supply with hypothalamus
Temperature – Young Infants
Traditional routes may be more accurate
Newborns: axillary temp correlates well with core temp due to the infant’s small body mass and uniform skin blood flow
Height – Infant
Birth to 24-36 months
Infant measuring mat OR
mark on a sheet of headrest paper Measure from the top of the head to the
heel (foot dorsiflexed)
1. Tear a length of headrest paper
2. Lay the child on top of the paper
3. Mark the top of the child’s head
4. Ask mother to hold child in place
5. Extend leg and mark under the heel
(foot dorsiflexed)
Height - Child
Child is able to stand without support (24-36 months old)
“Stature measuring device” Heels, buttocks and shoulders
against the wall Looking straight ahead
Outer canthus of the eye should line up with the external auditory canal
Weight
Infant platform scale More accurate
(ounces or grams)
Infant may sit or lie Place paper or blank under the infant &
“weigh it out”
Head Circumference
Done at every “health visit” until 2 years of age; yearly from 2-6 years of age
Measure the largest circumference with the tape snug Occipital protuberance to the supraorbital
prominence
Chest Circumference
Measure around the nipple line to the nearest 1/8 in (0.5 cm) Firmly but not tight enough to cause
an indentation in the skin
Recording Measurements
Chart on appropriate growth curve for sex and age Identify the infant’s percentile Note any change or variation from the
population standard or the child’s norm
At Birth…
Average weight: 5 lb 8 oz – 8 lb 13oz
Average length: 18-22 in (45-55cm)
Head circumference: 13-14 in (33-35 cm)
Most babies born to the same parents weigh within 6oz of each other at birth Lower birth weight: consider an undisclosed congenital
abnormality or intrauterine growth retardation
Expected Growth
Length increases by 50%in the 1st year of life
Weight doubles by 6 months, triples by 1 year
Head & Chest Circumference Newborn to 5 months: Head may be equal or
exceed the chest by 2 cm 5 months to 2 years: Chest should closely
approximate the head circumference > 2 years: Chest should exceed head
circumference
Growth Patterns
Infancy Growth of the trunk predominates Fat increases until 9 months of age…
Childhood Legs are the fastest growing body part Weight is gained at a steady rate Fat increases slowly until 7 yrs of age when a prepubertal
fat spurt occurs before the true growth spurt
Adolescence Trunk and legs elongate About 50% of the ideal weight is gained Skeletal mass and organ systems double in size
Gender Differences
Males FemalesBroader shoulders & greater musculature
Wider pelvic outlet
Slight increase in body fat during early adolescence before the gain in lean tissue
Persistent increase in fat throughout adolescence, occuring after the peak growth spurt
Common Conditions
What might you detect by recording height, weight, head & chest circumference?
Failure to Thrive
Failure of an infant to grow at “normal rates”
May be related to: Chronic disease Congenital disorder (brain, heart, kidney) Inadequate calories and protein Improper feeding methods Intrauterine growth retardation Emotional deprivation
growth hormone levels will be low
What if…?
Head circumference increases rapidly or rises above percentile curves Increased intracranial pressure
dDX: Hydrocephalus, etc.
Head circumference grows slowly or falls off percentile curves Microcephaly
dDx: Craniosynostosis, etc.
Congenital Syndromes…
Down Syndrome & Turner Syndrome associated with short stature
Skin
Newborn – Expected Variants Transient puffiness of the hands, feet, eyelids, legs,
pubis or sacrum occurs in some newbornsNot a concern if it disappears within 2-3 days
Some newborns are bald while others are born with an inordinate amount of head hair
Sheds within 2-3 months and replaced by more permanent hair (new texture and color)
Dark-skinned newborns do not always manifest the intensity of melanosis that will be readily evident in 2-3 months
Exceptions: nail beds and skin of the scrotum
Skin may look very red the first few days of lifeSkin color is partly determined by subcutaneous fat
Cutis marmorata Transient mottling when infant is exposed to
decreased temperature Acrocyanosis
Cyanosis of hands & feet A common response to cold
An underlying cardiac defect should be suspected if acrocyanosis is persistent or more intense in the feet than hands
Vernix caseosa
Whitish, moist, cheeselike substance Mixture of sebum and skin cells
Covers the infant’s body at birth Protective
www.brooksidepress.org/Products/OBGYN_101/MyDocuments4/Text/Newborn/Vernix.jpg
Lanugo
Fine, silky hair covering the newborn shoulders and back
Shed within 10-14 days
Lanugo. This fine body hair resembling peach fuzz is present on infants of 24 to 32 weeks' gestation.
Telangiectatic nevi
aka “stork bites” Flat, deep pink, localized areas usually
seen in back of neck
Stork bite, or salmon patch. A typical light red splotchy area is seen at the nape of the neck.
Mongolian spots
Irregular areas of deep blue pigmentation usually in sacral and gluteal regions
*Seen predominantly in African, Native American, Asian or Latin descent
Erythema toxicum
Pink papular rash with vesicles superimposed thorax, back, buttocks, and abdomen
May appear 24-48 hrs after birth and resolves after several days
Common Conditions
Milia
Common during the first 2-3 months
Small white discrete papules on the face and bridge of the nose Plugged sebaceous glands
Miliaria
aka “Heat rash”
Caused by occlusion of sweat ducts during periods of heat and high humidity
“Prickly Heat” (crystaline)
Rashes
Allergic rash Contact dermatitis Medications, supplements Food sensitivity
Diaper rash Acid urine output Yeast?
Eczematous rash
Younger children Face, elbow, knees
Older children & adults Hands, neck, inner elbows,
back of knees, ankles Face (less often)
Seborrheic Dermatitis
aka “Cradle Cap” scalp Lesions are scaling, adherent,
thick, yellow, and crusted can spread over the ear and down the
nape of the neck
*Can be also be seen on back, intertriginous & diaper areas
Impetigo
“Honey colored crusts”
Highly contagious Staph. or Strep. infection
Causes pruritis, burning, and regional lymphadenpathy
Ring worm
Tinea corporis Tinea capitis
MC vector?
Strawberry hemangioma
Expected resolution:Birth: often not present or noticeable
1-2 months: becomes noticeable
1-6 months: grows most rapidly
12-18 months: begins to shrink
Trichotillomania
May be related to: Excessive emotional stress
Family circumstances, hospitalization, etc.
Obsessive Compulsive Disorder
External Clues to Internal Problems
Faun tail nevus
Tuft of hair overlying the spinal column usually in the lumbosacral area
Associated with spina bifida occulta
Café au lait spots
Evenly pigmented patches light, dark brown, or black in dark skin
Present at birth or shortly thereafter
May be related to: Neurofibromatosis Pulmonary stenosis Temporal lobe dysrhythmia Tuberous sclerosis
Suspect neurofibromatosis if you note >5 patches
with diameters >1cm in a child under 5
Axillary Freckling orInguinal Freckling
May occur in conjunction with café au lait spots
Associated with neurofibromatosis
Facial port-wine stain
When it involves the opthalmic division of the trigeminal nerve it may be associated with: Sturge-Weber syndrome
seizures Occular defects
Supernumerary nipples
Especially in the presence of other minor abnormalities… associated with renal abnormalities
Examining the Newborn for Hyperbilirubinemia
*Natural daylight is preferred
Examine the oral mucosa and sclera Inspect the whole body for “dermal icterus”
Starts on the face and descends Bilirubin level is not high if only the face
(5mg/dl) May be at a worrisome level if jaundice
descends below the nipples (>12 mg/dl)
Risk Factors
Breast feeding b-glucuronidase
Cephalhematoma or other cutaneous or subcutaneous bleeds
Hemolytic disease Infection
Physiologic Jaundice
Present in 50% of newborns appears to be an inability of the liver to conjugate
the bilirubin present in the blood
Starts after the first day of life Usually disappears in 8-10 days May persist for 3-4 weeks
Treatment “Bili lamp” & “Bili Blanket” (blue lights), or direct
sunlight (conjugate the bilirubin) Seldom rises above the 20mg/dl necessitating
transfusion
Pathological Jaundice
If jaundice is present in the first 24 hours or it is intense and/or persistent, you must consider pathological jaundice…
RBC abnormalities & sensitivity Hemorrhage Impaired hepatic function Infections
Toxoplasmosis Rubella Herpes Syphilis
Inspection
Careful inspection of all skin Develop a pattern Don’t overlook body parts
Examine skin creases Assymetrical creases on thighs
Possible hip dysplasia
Simian Line (hands & feet) possible Down syndrome
Schamroth Technique
Place nail surfaces of corresponding fingers together
A. Normal: diamond shaped window
B. Clubbed: angle between distal tips increases
Clubbing of the Nails
Associated with: Respiratory disease Cardiovascular disease Thyroid disease Cirrhosis Colitis
Skin Turgor
Best evaluated by gently pinching a fold of the abdominal skin
“Tenting” indicates: Dehydration Malnutrition
Immune and Lymphatic
Immune & Lymphatic System
Lymph nodes in the neonate react quickly to any mild stimulus especially cervical and postauricular chains
Theory: compensate for lack of antibodies by increased filtration and phagocytosis Ability to produce antibodies is still immature at
birth but lymphoid tissue is plentiful
Palatine Tonsils
Much larger during early childhood than after puberty
Enlargement of the tonsils in children is not necessarily an indication of a problem may obstruct nasopharynx ~> sleep apnea
Obstructive Sleep Apnea
Periodic cessation of breathing during sleep d/t airflow obstruction Can be seen in children with excessively
large tonsils
Loud snoring, restless sleep Daytime sleepiness Morning headaches
Developmental delay Frequent infection
Lymph Exam
It is not uncommon to find enlarge lymph nodes that may even be visible from a distance…
“Normal” Firm, discrete, moveable, <5mm Up to 1cm in cervical or inguinal regions
Investigate further if: Growing rapidly or suspiciously large (>2-3 cm) Fixed and immoveable
Expected Regions of Lymph Node Enlargement
<1 year <2 years >2 years
postauricular and occipital
common common uncommon
cervical and submandibular
uncommon common
It is NEVER normal for supraclavicular lymph nodes to be
enlarged!
Common Conditions
Infectious Mononucleosis
Epstein-Barr virus
*May occur at any age (MC in teens)
Initial symptoms: Pharyngitis, fever, fatigue, malaise
Exam Findings: Enlarged anterior and posterior cervical chains Splenomegaly, hepatomegaly, and/or a rash
may be noted
Strep Pharyngitis
Symptoms: Sore throat and runny nose Headache, fatigue, &
abdominal pain
Exam Findings: Palatal petichiae Enlarged anterior cervical nodes
*Throat culture needed to confirm
McIsaac Modification of the Centor Strep Score
Likelihood:-1/0 = 1%; 1 = 10%; 2 = 17%; 3 = 35%; 4/5 = 51%
Diagnosing Strep Throat: Are There Reliable Clues? - July 1, 2001 - American Academy of Family Physicians. Available at www.aafp.org/afp/20010701/tips/2.html
Symptom or sign Points
Temperature >38°C (100.4°F) 1
Absence of cough 1
Tender anterior cervical adenopathy 1
Tonsillar swelling or exudates 1
Age less than 15 years 1
Age at least 45 years -1
Head and Neck
Inspect the Head
Scaling, crusting (seborheic dermatitis) Dilated veins (increased ICP) Excessive hair or unusual hairline
Note symmetry of shape, bulging or swelling…
Cranial Molding During a vaginal birth the cranial
bones shift and overlap Expect the skull to resume a “normal”
shape and size within 1 week
Caput succedaneum CephalhematomaSubcutaneous edema Subperiosteal bleed
Crosses suture lines Does not cross sutures
MC occiput MC parietal
Soft, poorly defined margins Firm, well-defined edges
Unusual contour may be related to a variety of causes: Irregular closing of suture lines
(craniosynostosis) Positional head deformity (PHD) Preterm infants: soft cranial bones flatten
with the positioning and weight of the head
Inspect the Face
Spacing of features Symmetry Skin color Texture Paralysis
Observe…
Head control? Position? Movement?
Note any: Jerking Tremors Inability to move head in one direction
Palpate the Head
Note any tenderness over the scalp
Suture lines slight groove up to 6 months
Fontanels should feel slightly depressed; some pulsation is
expected
Post. fontanel closes ~2 monthsAnt. fontanel closes by 24 months
Bulging? Infection Increased intracranial pressure
Depressed? Dehydration
Measure the Fontanels Anterior fontanel should
not exceed 4-5 cm
(<6 months)
Not a sensitive indicator
Transilluminate
Dark room Transilluminator firm against scalp Begin at the midline frontal region and inch
over the entire head Observe the ring of illumination; note
asymmetry
A ring <2 cm is expected on all regions of the head except the occiput (should be <1 cm) Illumination beyond these parameters suggest…
Excess fluid Decreased brain tissue in the skull
Transillumination should be done on every infant and on an older child if there is a suspected intracranial lesion or rapidly increasing head circumference
Inspect the Neck
Symmetry, size, shape Edema Distended veins Pulsations Masses Webbing Excess skin
To inspect the newborn’s neck…
Place the infant supine Elevate the upper back and let the
head fall back into extension
Palpate the Neck
Sternocleidomastoid Note tone; hematoma
Trachea
Thyroid Difficult to palpate unless it’s enlarged
Goiter Intrauterine deprivation of thyroid hormone May cause respiratory distress
Common Conditions
Torticollis (“Wry Neck”)
Birth injury Hematoma
May be palpated shortly after birth
Firm fibrous mass 2-3 weeks later
Older children Result of trauma, muscle
spasm, viral infection, drug ingestion, __________
Management
First, consider the underlying cause Spinal cord tumor or congenital spinal anomoly? Birth trauma? Subluxation?
Chiropractic care Mechanical adjustments Increased “tummy time” Exercises/stretches
Plagiocephaly
Positional Head Deformity
Craniosynostosis (lambdoid)
No ridging Palpable ridge
Ear on flat side migrates forward
Ears even or ear on flat side appears to be more posterior
Forehead protrudes (same side as occipital flattening)
Forehead does not protrude
Bald spot on side of flattening
No bald spot or central bald spot
Positional Parallelogram Frontal bulging Ear migrates anterior
Synostosis (lambdoid) Trapezoid No frontal bulging Ears even
Craniosynostosis
Premature union of cranial sutures
Small head circumference (microcephaly) Rigid sutures Misshapen skull
Usually not accompanied by mental retardation
Microcephaly
Related to: Craniostenosis Cerebral dysgenesis
Associated with mental retardation and failure of brain to develop normally
Hydrocephalus
Enlarged head Bossing of the skull Widening of sutures and fontanels Lethargy, irritability, weakness Sclera visible above the iris
“Sunsetting sign”
Craniotabes
Softening of the skull Demonstrated by pressing the bone along
the suture line… bone pops in and out
Associated with: Rickets and hydrocephalus Can be a “normal” finding
up to 1/3 of all newborn infants more common in premature infants
Bell’s palsy (facial palsy)
Asymmetry of facial features
Eyelid will not
close completely Drooping corner of
mouth Loss of labonasial fold
Down Syndrome
Depressed nasal bridge Epicanthal folds Mongolian slant of eyes Low set ears Large tongue
Fetal Alcohol Syndrome (FAS)
Smooth philtrum Widespread eyes
Inner epicanthal folds Mild ptosis
Hirsute forhead Short nose Thin upper lip
Eyes
Development Table 11-1(Mosby)
By 2-3 months… Voluntary control of eye muscles
By 8 months… Can differentiate colors
By 9 months… Eye muscles coordinate; a single image
is percieved
Tips – Infant Eye Exam
To encourage the infant to open their eyes… Use a dimly lit room Hold the infant upright, suspended under
its arms facing you Have parent hold infant over a shoulder
Inspect External Eye
Size of eyes (symmetry?) Distance between the eyes
Hypertelorism (widely spaced eyes) may be associated with mental retardation
Slant of palpebral fissures Epicanthal folds
Prominent in Asian populations, Down syndrome?
Inspect Eyelids
To detect the “Setting Sun Sign”… Rapidly lower the infant from upright
to supine position Look for sclera above the iris
Differentials include: Expected variant in newborn Hydrocephalus Brainstem lesion
Clinical Note
Newborn… eyelids may be swollen or edematous,
accompanied by conjunctival inflammation and drainage as a consequence of routinely administered antibiotics
Beyond the newborn period… redness, hemorrhage, discharge, granular
appearance may indicate infection, allergy, or trauma
Inspect
Sclera Pupil Iris Conjunctiva
Coloboma
aka “Keyhole pupil” Loss of functional pupil Often associated with other
congenital abnormalities
Brushfield spots White specks in a linear pattern around the
circumference of the iris Suggests Down syndrome
Strabismus?
Exoptropic vs. Esotropic
Tests include: Corneal light reflex (Hirschberg’s Test) Cross-Cover Test Cover-Uncover Test
Corneal Light Reflexaka Hirschberg’s Test
Child stares at a penlight about 30 cm away
Doctor looks at the reflection from each cornea In relationship to the pupil
Normal: symmetricalStrabismus: asymmetrical
Pseudostrabismus Symmetrical corneal light
reflex Common in Asian and
Native American populations (prominent epicanthal folds)
Disappears by 1 yoa
Strabismus (esotropic) Asymmetrical light reflex
Cross-Cover Test
Patient stares at penlight Doctor covers one eye and observes
the uncovered eye for movement
Normal: no movement
Exotropic eye: moves lateral to medial
Esotropic eye: moves medial to lateral
Cover-Uncover Test
Patient stares at the penlight Doctor covers one eye and then
observes as it is uncovered
Normal: no movement (remains fixed on the light)
Exotropic eye: moves lateralEsotropic eye: moves medial
Help to differentiate…
Paralytic Strabismus Impairment of extraocular muscles or their nerve
supply
Nonparalytic Strabismus No primary muscle weakness Can focus with either eye but not both
simultaneously… concern of developing amblyopia
Infant Cranial Nerves (II, III, IV, VI)
1. Expect the infant to focus and track through 60 degrees
2. Optical blink reflex Shine a bright light at the infant’s eyes Note the quick closure of the eyes and
dorsiflexion of the head
3. Corneal light reflex (Hirschberg’s)
Extraocular Movements - Child
Six cardinal fields of gaze Peripheral vision
Parent may hold the child’s head still Use a teddy bear or toy Have child sit on parent’s lap
Visual Acuity
Infant Grossly examined by observing the the
infant’s preference for looking at certain objects
Younger Children Observe play with toys - stacking, building,
or placing objects inside of others If tasks are performed well, vision difficulties are
unlikely
Snellen E Chart*
Tested when a child can cooperate with the exam Usually ~3 years of age
Ask which way the “legs” are pointing
*Also available with different shapes
Tips – Snellen E Chart
1. Make it a “game”
2. Instruct the child to point finger in the direction of the legs of the E
3. Allow the child to practice following instructions before you administer the test
4. Parent may assist with covering eye
Snellen E Chart
Remember: Test each eye seperately With and without corrective lenses
20/25 +2 Means that they can read all on the 20/25 line and 2 from the 20/20 line
“When testing visual acuity in the child, any difference in the scores between
the eyes should be detected.”
A 2 line difference (20/50 and 20/30) may indicate amblyopia Reduced vision in an eye that appears
structurally normal In strabismus, the eye may be “unused”
Anticipated Visual Activity
Age Visual Acuity
3 years 20/50
4 years 20/40
5 years 20/30
6 years 20/20
Red Reflex
*Performed from birth on… should be elicited in every newborn!
Observe for opacities, dark spots, or white spots within the circle of red glow Congenital cataracts Retinoblastoma
Congenital Cataracts
Requires a full metabolic, infectious, systemic, and genetic workup…
Common causes: Infectious diseases
TOxoplasmosis, Rubella (MC), Cytomegalovirus, & Herpes
Hypoglycemia Trisomies Prematurity Etc.
Retinoblastoma
Congenital malignant tumor
<2 years old
Initial sign: “white” reflex
Fundoscopic exam: Ill-defined mass arising from the retina Chalky-white areas of calcification
Fundoscopic Examination
Difficult to perform on a newborn or young infant…consider referral
Often deferred until 2-6 months unless the patient presentation suggests a need
Eg. premature infant (retinopathy)
Retinopathy of Prematurity
Blood vessels are straightened and diverted temporally
Cicatricial changes may be severe
Retinal detachment Glaucoma Blindness
Tips – Fundoscopic Exam
Do not hold the child’s eyelid open forcibly Leads only to more resistance
Often unable to keep eyes still and focused on a distant object Use a toy, picture, etc.
Results may be better if the child sits on the parent’s lap
May want to do the exam with the patient supine…
Fundoscopic Exam – Supine
Child laying supine on the exam table with head near the end
Stand at the end of the table Use Rt. eye to examine the child’s Lt.
NOTE: Retinal findings will appear “upside down” Inspect the optic disc, fovea, and vessels as
they pass by
Newborn – 3 months
Screening Method Require Further Evaluation
Red reflexAbnormal
Asymmetric
Corneal light reflex Asymmetric
Inspection Structural abnormality
6 months – 1 year
Screening Method Require Further Evaluation
Red reflex Abnormal or Asymmetric
Corneal light reflex Asymmetric
Differential occlusionFailure to object equally to covering each eye
Fix and follow with each eye
Failure to fix and follow
Inspection Structural abnormality
~3 years old
Screening Method Require Further Evaluation
Visual acuity<20/50; 2 lines of difference between the eyes
Red reflex Abnormal or asymmetric
Corneal light reflex; Cover-uncover
Asymmetric; ocular refixation movements
Stereoacuity Failure to appreciate random dot stereogram
Inspection Structural abnormality
~5 years old
Screening Method Require Further Evaluation
Visual acuity 20/30 or worse
Red reflex Abnormal or asymmetric
Corneal light reflex; Cover-uncover
Asymmetric; ocular refixation movements
Stereoacuity Failure to appreciate random dot stereogram
Inspection Structural abnormality
Modifying Your Instruments
Oto/ophthalmoscope Decorative covers
http://quickmedical.com/ pediapals/products
Ears
Developmental Features
External auditory canal – shorter, has an upward curve infant otoscopic exam – “pull downward”
Eustachian tube – relatively wider, shorter and more horizontal Reflux of nasopharyngeal secretions
Growth of adenoids may occlude the eustachian tube Interferes with aeration of the middle ear
Inspect the Ear
Well formed all landmarks present
Flexible should have instant recoil after bending
Position the tip of the auricle should cross an imaginary
line between the outer canthus of the eye and the prominent portion of the occiput (EOP)
No skin tags or preauricular pits should be present
Clinical Note
Low or poorly shaped auricles… associated with renal disorders and congenital abnormalities
Palpate
Lymph nodes Pinna Tragus Mastoid
Tenderness? Warmth?
*If pain is noted with palpation of the mastoid, suspect mastoiditis…
Otoscopic Exam – Infant
1. Lay the infant supine/prone
2. Turn head to the side
3. Hold otoscope so that the ulnar surface of your hand rests against the infant’s head
*Prevent trauma to auditory canal
4. Other hand stabilizes infant’s head
5. Pull auricle down to straighten the canal
Newborn Variants
You may note… Limited mobility Dullness and opacity of a pink or red tympanic
membrane Light reflex may appear diffuse
Tympanic membrane is not conical for several months Auditory canal may be obstructed with vernix
*Otoscopic exam should be performed within the first few weeks of life
Otoscopic Exam – Child
Pull auricle either down and back OR up and back best view of the tympanic membrane
Postpone until the end of the visit Best done on parent’s lap Be prepared to use restraint if encouraging
the child fails Ask the parent to restrain the child
Restraining a Child - Otoscope
Face the child sideways with one arm placed around parent’s waist
Parent holds the child firmly against his/her trunk One arm restrains the head One arm restrains the body
Doctor further stabilizes the child’s head while inserting the otoscope
Clinical Note
“Red reflex”
If the child is crying or has recently cried vigorously… dilation of blood vessels in the tympanic membrane can cause redness
You cannot assume that redness of the membrane alone is a middle ear infection!
Pneumatic Otoscopy
Assesses mobility of the tympanic membrane needed to differentiate
Crying – Red Reflex
Red Moveable
Infection RedNo mobility
Tympanometry
Accurate way to identify middle ear effusion Ear piece must be sealed in the canal to provide
accurate reading Wax, ruptured membrane, tubes
Acoustic Reflectometry (newer technology) Cheaper Easier to get accurate results
Assessing Hearing
Observe response to a whispered voice, toys, etc. As they get older, ask child to perform tasks in a
soft voice… Use words that have meaning for them May want to have a parent do it Make sure they’re not responding to air
movement or visual stimulus
Weber, Rinne, and Schwabach tests Used only when a child understands directions
and can cooperate with the examiner Usually 3-4 years of age
Expected Hearing Response
Birth to 3 months
Startle reflex, crying, cessation of breathing or movement in response to sudden noise; quiets to parent’s voice
4 to 6 months Turns head toward source of sound but may not always recognize location of sound; responds to parent’s voice; enjoys sound producing toys
6 to 10 months Responds to own name, telephone ringing, and person’s voice, even if not loud; begins localizing sounds above and below, turns head 45 degrees towards sound
10 to 12 months Recognizes and localizes source of sound; imitates simple words and sounds
Common Conditions
Otitis Externa
Infection of the auditory canal
History of trauma or moist environment Itching in the ear canal Intense pain with movement of pinna; chewing Discharge may be watery at first, then purulent
& thick mixed with pus and epithelial cells Musty, foul-smelling
Conductive hearing loss (exudate and swelling) Canal is red, edematous; tympanic membrane
obscure
Bacterial Otitis Media
Infection of the middle ear MC infection in childhood Often follows or accompanies URTI
Fever, feeling of blockage, tugging earlobe, anorexia, irritability, dizziness, vomiting & diarrhea
Deep-seated earache Discharge if tympanic membrane ruptures or through
tympanostomy tubes; foul-smelling Conductive hearing loss (fills with pus) Tympanic membrane may be red, thickened, bulging;
full, limited, or no movement
Otitis Media with Effusion
Collection of liquid (effusion) in the middle ear
Associated with: Allergies Enlarged lymph tissue Obstructed or dysfunctional eustachian tube
Sticking or cracking sound on yawning or swallowing; no signs of acute infection
Pain is uncommon; feeling of fullness Discharge is uncommon Conductive hearing loss as middle ear fills with
fluid If chronic, may delay speech development
temporarily Tympanic membrane is retracted, impaired
mobility, yellowish; air fluid level and/or bubbles
Otitis Media with Effusion
Nose
Development
Maxillary and ethmoid sinuses present at birth, though very small
Sphenoid sinus tiny cavity at birth not fully developed until
puberty
Frontal sinus develops by 7-8 years
Inspection
Symmetric appearance Positioned in the vertical midline on the face Only minimal movement of the nares with
breathing should be apparent
Possible congenital abnormality if… Saddle-shaped nose with a low bridge and
broad base Short small nose Large nose
“Adenoidal” or “Allergic Salute”
Transverse crease at the juncture between the cartilage and the bone of the nose
Children often wipe their noses with an upward sweep of the palm of the hand If repeated often enough, causes a crease
Internal Nose
Usually adequate to tilt the nose tip upward
Inspect by shining a light inside Largest otoscopic speculum may be used
Clinical note: some say that a “greyish” membrane may indicate chronic allergies
Nasal Patency
Must be determined at the time of birth…
Mouth closed, occlude one naris and then the other
Observe the respiratory pattern With total obstruction, the infant will not be able
to inspire or expire through the noncompressed naris
dDx: Septal deviation, choanal atresia
Choanal Atresia
Congenital nasal obstruction of the posterior nares Junction between nasal
cavity and nasopharynx
Newborns may experience respiratory distress and difficulty feeding Obligatory nose breathers
Copyright © 2006 University of Washington.
*Will breathe when crying
Sinuses
Infant Maxillary and ethmod sinuses are small Few problems arise in these areas and
examination is generally unnecessary
Child Maxilary sinuses should be palpated Few sinus problems occur since the sinuses
are still developing
There is wide variation however... do not rule out sinusitis simply on the basis of age!
Sinusitis
Infection of one or more paranasal sinuses May be a complication of a viral URTI, dental infection,
allergies, or a structural defect of the nose
Signs in children include: upper respiratory symptoms nasal discharge low-grade fever daytime cough malodorous breath cervical adenopathy intermittent painless morning eye swelling NO facial pain or headache
Mouth & Throat
Developmental Features
Salivation increases by 3 months Infant drools until swallowing is learned
Teeth 20 deciduous teeth appear (6-24 months) Eruption of permanent teeth begins about 6
years of age and is completed by 14-15 yrs 3rd molar (“wisdom tooth”) ~18 years old
Inspection
Tongue should fit well in the floor of the mouth protrude beyond the alveolar ridge
Frenulum usually attaches midway between the
ventral surface of the tongue and its tip
Macroglossia
(abnormally large tongue) Congenital hypothyroidism Congenital abnormalities Down Syndrome
Short Frenulum Feeding problems Speech difficulties
Gums smooth; serrated edge along the buccal
margins
Teeth count deciduous teeth note any unusual sequence of eruption
Natal Teeth Teeth or tooth buds in
a newborn Potential for aspiration May be removed
Retention Cysts
(aka Epstein Pearls) Appear along the buccal
margins of the gums Pearl-like retention cysts Disappear in 1-2 months
Baby bottle syndrome Multiple brown caries on upper
and lower incisors
d/t bedtime bottle of juice/milk
Black or grey colored teeth Pulp decay
d/t oral iron therapy
Mottled or pitted teeth Enamel dysplasia
d/t tetracycline treatment during tooth development
Flattened edges on the teeth Bruxism – unconscious grinding of the teeth
Buccal mucosa Should be pink and moist, no lesions Scrape any white patches with a tongue blade
Nonadherent = milk deposits
Adherent = candidiasis (thrush)
Palate Should be well-formed with no cleft
Infant Narrow, flat palate roof or a high, arched palate?
may result in feeding and speech problems associated with congenital anomolies
Child Highly arched palate?
seen in chronic mouth breathers
Cleft Lip and Palate
Congenital malformation Fissure in the upper lip and/or palate
Complete cleft – extends through the lip and hard and soft palates to the nasal cavity
Partial Cleft – any of the tissues
Long term issues: feeding problems speech difficulties improper tooth development and alignment chronic otitis media hearing loss
Tonsils Should blend with the color of the pharynx Peak size between 2 - 6 years Should retain unobstructed passage
Graded to describe their size1+ visible2+ halfway between tonsillar
pillars and the uvula3+ nearly touching the uvula4+ touching each other
Tonsillitis
Inflammation or infection of the tonsils Frequently caused by streptococci
Sore throat, referred pain to the ears, dysphagia, fever, fetid breath, and malaise
Tonsils appear red and swollen; purulent exudate yellow follicles are associated with strep.
Anterior cervical lymph nodes enlarged
Peritonsillar Abscess
Infection of the tissue between the tonsil and pharynx
Complication of tonsillitis
Dyphagia, drooling, severe sore throat with pain radiating to the ear, muffled voice, fever
Tonsil, tonsillar pillar and adjacent soft palate become red and swollen
Tonsil may appear pushed forward or backward, possibly displacing the uvula
Drooling Normal in infancy
If it persists past 12 months… consider a neurologic disorder
If acute… consider epiglotitis
Epiglottitis
Suspected with… Sudden high fever Drooling Croupy cough Sore throat Apprehension & focus on breathing
Tripod position, neck extended
*Impending airway obstruction d/t acute inflammation of the epiglottis Inserting tongue blade may result in complete airway
obstruction Treat this as a medical emergency
NO TONGUE BLADE!
Tips – Infant Mouth Exam
Crying provides an opportunity to examine the mouth
Avoid depressing the tongue Stimulates the “Tongue Thrust Reflex” Makes visualization of the mouth difficult
Insert your gloved finger into the infant’s mouth, fingerpad to the roof of the mouth
Evaluate the infant’s suck Should have a strong suck, tongue pushing
vigorously upward against the finger Palpate the hard and soft palates
Palatal arch should be dome shaped No palpable clefts Soft palate should rise symmetrically when the
infant cries Stimulate a gag reflex by touching the
tonsillar pillars
Tips – Child Mouth Exam
To reduce fear, let the child hold and manipulate the tongue blade and light
Start by asking to see their teeth Usually not threatening
Ask the child to protrude the tongue and say “ah”, a tongue blade is often unnecessary
To raise the palate, ask the child to pant “like a puppy”
If child refuses to open mouth…
Insert a tongue blade through the lips to the back molars
Gently but firmly insert the tongue blade between the back molars and press the blade to the tongue
This should stimulate the gag reflex Gives you a brief view of the mouth and
oropharynx
“Children of any age who are not too big to sit on a parent’s lap are better examined there
than on the examining table.”
Restraining a Child – Oral Exam
Seated in the parent’s lap, back to the parent and legs between the adult’s legs
Parent can reach around to restrain the child’s arms with one arm and control the child’s head with the other
Can usually be accomplished without forcing Force only makes them more angry…
Restraining a Child - Supine
If the child actively resists… Place child supine on the exam table Parent holds arms extended above the head
and assists in restraining the head Doctor lies across the child’s trunk and
stabilizes the child’s head Third person may need to hold the child’s
legs
Chest and Lungs
A ctivity
P ulse
G rimace
A ppearance
R espirations
Newborn Apgar Score
Subjective qualitative evaluation done at 1 and 5 minutes determine “survivability” of the newborn by
observing the level of function of 5 components
Muscle tone Heart rate Reflex irritability Color Respiratory rate
Apgar Score
0 1 2
Heart rate Absent <100 >100
Respiratory effort
Absent Slow/irregularEasy; Good crying
Muscle tone LimpSome flexion of extremities
Active motion
Reflex irritability No response Grimace, slow Lusty cry
Color Blue/pale Acrocyanosis Pink
Depressed Respiration
Maternal environment during labor Sedatives Compromised blood supply to the child
Mechanical obstruction by mucus Neurological damage (birth trauma)?
Infants rely primarily on the diaphragm for respiratory effort (C3,4,5…)
Development
Bony structure is more prominent than the adult d/t a relatively thin chest wall
More cartilaginous and yielding How will this affect the adjustment?
Xiphoid process is often more prominent and a bit more moveable
Inspection
Chest is generally round A-P diameter approximately the same as
the transverse
If the “roundness” of a child’s chest persists past the 2nd year, suspect a possible chronic obstructive pulmonary problem…
Cystic Fibrosis
Autosomal recessive disorder of exocrine glands Sweat glands
Salt loss in sweat (“taste salty”) Lungs
Frequent and progressive pulmonary infections (thick mucus)
Pancreas Sticky, foul smelling stool
Intrauterine growth retardation Smaller chest circumference compared to
the head
Poorly controlled diabetes Relatively larger chest circumference
Nipples
Symmetry in size Swelling Discharge Supernumerary
Measure distance between the nipples Should be ¼ chest circumference
Breast development in a newborn d/t hormonal influences
Respiratory Rate
Count for 1 minute Average: 40-60 rpm (80 rpm is not
uncommon)
If room temp is very warm or cool, variation in the rate occurs Most often tachypnea Sometimes bradypnea
Respiratory Rhythm
Note regularity of respiration Premature infants are more likely to have
irregular respiratory patterns
Periodic breathing sequence of relatively vigorous respiratory
efforts followed by apnea of as long as 10-15 seconds
Periodic Breathing
Cause for concern if … Apneic episodes tend to be prolonged Baby becomes centrally cyanotic
In the term infant periodic breathing should wane a few hours after birth
Persistence in preterm infants is relative to gestational age Apneic periods should diminish in frequency
as they approach term status
Observe Chest Expansion
If asymmetric, suspect inability to fill one of the lungs
Pneumothorax Presence of air/gas in
the pleural cavity
Diaphragmatic hernia mayl hear “clicks & gurgles”
Palpate
Rib cage and sternum Loss of symmetry Unusual masses Crepitus
Fractured clavicle (birth trauma) May show no evidence of pain
Xiphoid Mobile and prominent
Auscultation – Infant
Localization of breath sounds is difficult Breath sounds are easily transmitted
from one segment to another
*Difficult to detect absence of breath sounds in any given area
Auscultation – Child
May not be able to give enough of an expiration to satisfy you (<5 years old) Especially with subtle wheezing
Ask them to “blow out” your penlight Ask them to blow away a bit of tissue in
your hand Listen after they run up and down the
hallway
Chest wall is thinner and more resonant than adult’s
Breath sounds may sound louder, harsher, and more bronchial
Hyperresonance is common Easy to miss the dullness of underlying
consolidation (percussion)
“If you sense some loss of resonance, give it as much importance as you would give frank dullness in the adult.”
Tips – Lung Exam
Percussion is usually unreliable in the infant Examiner’s fingers may be too large
A sob is frequently followed by a deep breath Allows the evaluation of vocal resonance Feel for tactile fremitus
Whole hand, palm and fingers
Crackles and Ronchi Not uncommon immediately after birth (fluid
has not completely cleared) If asymmetric, a problem should be suspected…
dDx: aspiration of meconium
Respiratory Grunting Infant tries to expel trapped air or fetal lung
fluid while trying to retain air and increase oxygen levels If persistent, cause for concern
Stridor High pitched, piercing sound
Cannot be dismissed as inconsequential… especially when inspiration is longer than expiration
Floppy epiglottis Congenital defects Croup
Edematous response Infection Allergen Smoke Chemicals Aspirated foreign
body
Increased Respiratory Effort
Retraction at the supraclavicular notch Contraction of the SCM’s Flaring of the nostrils Obvious intercostal exertion
(retractions) Tachypnea
“See-saw” respirations
Does a loss of synchrony between L and R occur during the respiratory effort? Is there a lag in movement of the chest on one side? Atelectasis? Diaphragmatic hernia?
Is there stridor? Croup? Epiglottitis?
Is there retraction at the suprasternal notch, intercostally, or at the xiphoid process?
Do the nares dilate and flare with respiratory effort? Is pneumonia present?
Is there an audible expiratory grunt? Is it audible with the stethoscope only or without? Is there lower airway obstruction? Focal atelectasis?
Is there paradoxic breathing?
Common Conditions
Tracheomalacia
Floppiness of the trachea Trachea changes in response to varying
pressures of inspiration and expiration resulting in “noisy breathing” Wheezing, inspiratory stridor
*Generally benign and self-limiting with age
dDx: vascular lesion, tracheal stenosis, foreign body
Also: Laryngomalacia & Laryngotracheomalacia
Bronchiolitis
Viral RSV (respiratory syncytial virus)
Most common <6 months
Expiration becomes difficult due to hyperinflation of lungs
Exam findings: Increased A-P diameter of thoracic cage Hyperresonant percussion
Coughing Comes in “fits” and tends to be harsh
Tachypnea Rapid, short breaths; expiratory phase prolonged
Possible wheezing and crackles
Infant appears anxious Generalized retraction Perioral cyanosis
Influenza
Generalized febrile illness (viral) Mild cases may just seem like a cold BUT the
very young are at higher risk Respiratory tract may be over-whelmed
(interstitial inflammation and necrosis)
Cough Fever Malaise Headache Coryza Mild sore throat
Crackles Rhonchi Tachypnea Substernal pain
Pneumonia
Inflammatory response of the bronchioles and alveolar space to an infective agent Bacterial, fungal , or viral
Exudates lead to lung consolidation Dyspnea, tachypnea, and crackles Diminished breath sounds; dullness to
percussion
INSPECTION Tachypnea
Shallow breathing
Flaring of nostrils
Occasional cyanosis
Limited movement; splinting
PALPATION Increased fremitus (consolidation)
PERCUSSION Dullness (consolidation)
AUSCULTATION Variety of crackles
Occasional rhochi
Bronchial breath sounds
Egophony, bronchophony, whispered pectoriloquy
Bronchitis
Inflammation of the mucus membranes of the bronchial tubes
Acute bronchitis Fever and chest pain
Chronic bronchitis Variety of causes Excessive secretion of
mucus
Both can show varying degrees of involvement
Obstruction Atelectasis
Most often quite mild
INSPECTION Occasional tachypnea
Occasional shallow breathing
Often no deviation from expected findings
PALPATION Tactile fremitus undiminished
PERCUSSION Resonance
AUSCULTATION Breath sounds may be prolonged
Occasional crackles
Occasional expiratory wheezes
Asthma
COPD characterized by airway inflammation mucosal edema increased secretions bronchoconstriction
Hyperreactivity to allergens, anxiety, URTI, smoke, exercise, cold air, etc.
INSPECTION Tachypnea
Dyspnea
PALPATION Tachycardia
Diminished fremitus
PERCUSSION Hyper-resonance
Limited diaphragmatic descent; lower diaphragmatic level
AUSCULTATION Prolonged expiration
Wheezes
Diminished lung sounds
Croup
Viral Particularly parainfluenza viruses
Most commonly: Very young children (1 ½ to 3 years old) Boys > girls Some are prone to recurrent episodes
dDx: epiglottitis, aspirated foreign body
Often begins in the evening after the child has gone to sleep Awakens suddenly, frightened
Harsh stridorous cough “Bark of a seal”
Labored breathing Retraction Inspiratory stridor NOT always fever
Epiglottitis
Haemophilus influenzae type B Incidence appears to have reduced…
MC: 3-7 years old
Acute, life-threatening Begins suddenly and progresses rapidly to full
obstruction of the airway
Treat this as a medical emergency
Inserting tongue blade may be deadly!
Child sits straight up with neck extended, head held forward
Appears very anxious and ill Unable to swallow Drooling from the open mouth
Cough is NOT common
Heart
Fetal Circulation
Compensates for the non-functional fetal lung Blood passes directly from
the R to L atrium through the foramen ovale
Right ventricle pumps blood through the ductus arteriosus
At birth... functional closure of foramen ovale and the ductus arteriosus closes within 24-48 hours
Patent Ductus Arteriosus Blood flows through the ductus during
systole and diastole Increases pressure in the pulmonary circulation Increased workload for the right ventricle
Small shunt: may be asymptomatic
Large shunt: may have dyspnea on exertion
“Machinery murmer” Harsh, loud, continuous murmur 1st - 3rd intercostal spaces & lower sternal border Usually unaltered by postural changes
Patent Foramen Ovale
Allows blood to flow between the right and left atria
Usually asymptomatic May exhibit cyanosis with exertion (especially if
other congenital heart defects are present)
Heart Exam
Examine within the first 24 hours and again at 2-3 days of age Changes from fetal to systemic and pulmonary
circulation
Complete evaluation of heart function includes skin, lungs, & liver… Congestive heart failure in the infant may
present with a large, firm liver (hepatomegaly) Unlike adults, this finding may be noted
before pulmonary crackles
Inspection
Color: should be “pink”
Purplish?dDx: polycythemia
Ashy, white?dDx: shock
Central cyanosis?dDx: congenital heart disease
Distribution & intensity of discoloration.
Extent of change after exertion.
Severe cyanosis evident at birth or shortly after suggests:
Transposition of the great vessels Tetralogy of Fallot (blue) Tricuspid atresia
relies on ASD & VSD for oxygenation of blood Severe septal defect Severe pulmonic stenosis
Cyanosis that does not appear until after the neonatal period suggests:
Pure pulmonic stenosis Eisenmenger complex - only develops in some cases
right-to-left shunting (VSD is MC) combined with pulmonary hypertension
Tetralogy of Fallot (pink) Septal defects
Always cyanotic
Bulging? Precordium tends to bulge over an
enlarged heart if the enlargement is long-standing Thoracic cage is more cartilaginous and
yielding in children
Capillary Refill
Capillary refill time is very rapid up to 2 yrs < 1 second (normal)
Prolonged capillary refill time (> 2 seconds) dDx: Significant dehydration Hypovolemic shock
Apical Impulse
4th - 5th left intercostal space, medial to the midclavicular line Apex of the heart is higher, heart lies
more horizontal
*Adult heart position is reached by age 7
Enlargement? Position?
Pneumothorax Shifts apical pulse away from the area of
pneumothorax
Diaphragmatic hernia MC on the left side Shifts the heart to the right
Dextrocardia Apical impulse on the right
Dextrocardia & Sinus Invertus
Dextrocardia Right thoracic heart & normally placed stomach
and liver May be associated with other anomolies
Sinus Invertus Heart and stomach are on the right, liver on the
left Not very common
Pulses
Brachial, radial, and femoral pulses are palpable
Weak or thin pulse dDx: Decreased cardiac output Peripheral vasoconstriction
Bounding pulse dDx: L to R shunt; PDA (patent ductus arteriosus)
Difference in pulse amplitude between femoral and radial pulses dDx: Coarctation of the Aorta
Heart Rate
Heart rate is more variable Infants: eating, sleeping, and waking Children: exercise, tension, fever
HR 10-20 beats for each degree temp.
Sinus arrhythmia is common in children Rate varies in a cyclical pattern
Faster on inspiration Slower on expiration
Fixed tachycardia may indicate difficulty
Heart Rate
Age Beats per minute
Newborn 120-170
1 year 80-160
3 years 80-120
6 years 75-115
10 years 70-110
Auscultation
Murmers Relatively frequent in the first 48 hours Most are innocent; transition from fetal to
pulmonic circulation
“Innocent mumers” Disappear within 2-3 days (“short”) Grade I or II intensity (“soft”) Systolic Unaccompanied by other signs and
symptoms
“S”
A murmur is usually NOT a significant congenital anomaly. Paradoxically, a significant congenital anomaly may be unaccompanied by a murmur…
Must investigate if… persists beyond 2nd or 3rd day of life is intense fills systole occupies diastole to any extent
almost always significant
radiates widely
Venous humCaused by turbulence of blood flow in the internal jugular vein Continuous low-pitched sound Louder during diastole Common in children Usually has no pathologic significance
Ask child to sit with head turned away & tilted slightly upward Auscultate supraclavicular space
Blood Pressure
Flush Technique (Infant) Place cuff on upper arm (or leg) Elevate and wrap the arm firmly with an elastic
bandage from fingers to antecubital space Empty veins and capillaries
Inflate cuff to a pressure above the systolic reading you expect
Lower the arm and remove the bandage Arm will be pale
Diminish pressure gradually until you see a sudden “flush” and return to usual color
Blood Pressure
Blood pressure is measured the same as in the adult after 2 years
To facilitate the exam… Explain the process Let them explore the sphygmomanometer
Make sure to use the correct cuff size! Cover 2/3 of arm
Hypertension – Infant
A sustained increase in BP is almost always significant in the newborn Stenosis of renal artery Coarctation of the aorta Cystic disease of the kidney Neuroblastoma Wilms tumor Hydronephrosis Adrenal hyperplasia CNS disease
Hypertension – Child
Do not make the diagnosis of hypertension based on one reading
An elevated systolic but normal diastolic may be d/t transient anxiety
Significant 90th percentileSevere 95th percentile
*If consistently above the 95th percentile, dDx include: Kidney disease Renal arterial disease Coarctation of the aorta
If there’s known heart disease…
Take careful note of: Weight gain (or loss) Developmental delay Cyanosis
Congenital heart defects that impede oxygenation
Clubbing fingers and toes
Congenital Defects
Ventricular Septal Defect
Allows oxygenated blood to leak from the left ventricle into the right Smaller defects may heal on their own; may
be asymptomatic Larger defects may require surgery
Heart failure Pulmonary hypertension Endocarditis Arrhythmias Delayed growth
*Murmur tends to be holosystolic
Atrial Septal Defect
Allows oxygenated blood to leak from the left atrium into the right Minor cases may be asymptomatic Larger defects may require surgery
*May not sound particularly impressive
(especially in an overweight child) More apt to be significant if…
Palpable thrust Radiation through to the back
Coarctation of the Aorta
Narrowing in a portion of the aorta MC: descending aortic arch near
the origin of the left subclavian artery and ligamentum arteriosum
Can cause several life-threatening complications Severe hypertension Aortic aneurysm, dissection or rupture Endocarditis Brain hemorrhage Stroke Heart failure and premature coronary artery disease
*Repair is typically recommended before age 10
Compare radial and femoral pulses Normal: peak at the same time (or femoral
slightly earlier) Coarctation: delay and/or decreased amplitude
of the femoral pulse (noted bilaterally) Compare blood pressure in arms and legs
Normal: BP legs = arms, or BP legs > arms Coarctation: BP arms > legs
Systolic murmur Audible over the precordium and sometimes the
back
Tetralogy of Fallot
1. VSD2. Pulmonary valve stenosis3. Overriding aorta4. Right ventricular hypertrophy
Cyanosis: lips, fingers and toes Poor eating Inability to tolerate exercise Arrhythmias Delayed growth and development
*Surgical repair of the defects is required early in life
Infants may have… “Tet spells”, central cyanosis Paroxysmal dyspnea with loss of consciousness
As they get older… Clubbing of fingers and toes
Exam findings: Parasternal heave Precordial prominence Systolic ejection murmur heard over the 3rd
intercostal space Sometimes radiating to the left side of the neck
Common Conditions
Acute Rheumatic Fever
Complication of strep. pharangitis (or skin infection) ~> connective tissue disease
May result in serious cardiac valve involvement MC mitral or aortic valves
MC children between 5-15 years of age
Prevention is the best therapy i.e. adequate treatment for strep. infections
Recent strep infection Fever Migratory polyarthritis Erythema marginatum
Pink margins, pale centers Chorea (jerky body movements) Firm, painless subcutaneous nodules
Elbows, knees, wrists
Murmur Mitral regurgitation; aortic insufficiency
Friction rub (pericarditis) Congestive heart failure Cardiomegaly
Jone’s Criteria – Diagnosis of Rheumatic Fever 2 major manifestations or 1 major + 2 minor manifestations
High probability of acute rheumatic fever
*If there’s evidence of a preceding strep infection
Major Manifestations Minor Manifestations
Carditis
Polyarthritis
Chorea
Erythema marginatum
Subcutaneous nodules
Clinical
-Previous rheumatic fever or rheumatic heart disease
-Arthralgia
-Fever
Laboratory
-Acute phase reactions: ESR, C-reactive protein, leukocytosis
-Prolonged P-R interval on ECH
Kawasaki Disease
Acute illness (fever) Etiology unknown
Infectious? Carpet cleaners? MC children under 5; males > females
Can be self-limiting, recover in a few days Complications: vasculitis ~> aneurysms
Critical concern: cardiac involvement (vasculitis of the coronary artery)
Signs & symptoms: Fever (few days – 3 weeks) Conjunctivitis (red eyes) Rash (stomach, chest, genitals)
Desquamation
Strawberry tongue Chapped lips Lyphadenopathy Edema of hands and feet
Systemic vasculitis
Medical Management: Gamma globulin, Aspirin
Abdomen
Tips – Abdomen Exam
Relaxation and quiet Bottle/pacifier/nursing On parent’s lap
Dr. sits facing the parent, knees touching
Use the respiratory cycle Abdomen should be soft during inspiration If abdomen remains hard during both inspiration
and expiration, suspect peritoneal irritation
Ticklish? Firm touch Place the child’s hand under your palm leaving
your fingers free to palpate
Tenderness and pain can be difficult to detect and localize Distract the child with a toy Start away from the area suspected Observe for changes… as you move to identify
the area of greatest pain Change in pitch of crying Rejection of the opportunity to suck Drawing the knees to the abdomen Facial expression Constriction of pupils
Inspection
Movement with respiration Shape Contour Pulsations
Pulsations: common in infants Distended veins dDx: vascular obstruction,
abdominal distension or abdominal obstruction Spider nevi dDx: liver disease
Infant… Abdomen should be rounded and dome
shapedDistended abdomen? Feces, mass, organ enlargement
Scaphoid abdomen? Abdominal contents are displaced
Abdominal and chest movements should be synchronous slight bulge of the abdomen at the beginning of
respiration
Toddler Abdomen protrudes slightly
“pot-bellied”
After age 5… Abdomen may become concave
when laying supine
Respirations continue to be abdominal until 6-7 years of age In young children, restricted abdominal
respiration may be related to peritoneal irritation
Umbilical stump should be dry and odorless
Inspect all skin folds for: Discharge Redness Induration Skin warmth Granulomatous tissue
Granuloma
Serous or serosanguinous discharge once the stump has separated
No other signs of infection
Umbilicus is usually inverted Often everts with increased abdominal
pressure
Note any protrusion through the umbilicus or rectus abdominus muscle Hernia Diastasis recti
Umbilical Hernia
Protrusion of omentum and intestine through the umbilical opening
Common in infants Reach maximum size by 1 month Generally close spontaneously by 1-2 years
To determine size, measure the diameter of the opening (not the protruding contents)
Should “reduce” with light pressure
Diastasis Recti
Midline separation (1-4 cm) of the rectus abdominus between the xiphoid and umbilicus
No need to repair in most cases herniation through the rectus abdominus
does require surgery Usually resolves by 6 years of age
Peristaltic Waves Use tangential lighting Observe abdomen at eye level
Usually not visible Sometimes seen in thin, malnourished
babies Suggests intestinal obstruction
Auscultation
Peristalsis (“metalic tinkling”) Heard every 10-30 seconds Bowel sounds should be present 1-2
hours after birth
No bruits or venous hum should be detected
Light Palpation
Knees flexed Place your hand gently on the abdomen
Thumb at the right upper quadrant Index finger at the left upper quadrant
Press very gently at first, only gradually increasing pressure
Identify the spleen, liver, and masses close to the surface
Spleen Palpable 1-2 cm below the left costal margin
for the first few weeks after birth
A detectable spleen tip is common in well infants but increase in spleen size may indicate: blood dyscrasias septicemia
Liver (lower border) Newborn: just below the right costal margin Infants & toddlers: 1-3cm below Children: 1-2cm below
Hepatomegaly: lower border >3 cm below the right costal margin Infection Cardiac failure Liver disease
Liver Scratch test
Deep Palpation
Palpate all quadrants for masses Location Size Shape Tenderness Consistency
Transillumination can be used to distinguish cystic from solid masses…
Fixed masses should be investigated with special studies if… Laterally mobile Pulsatile
Palpate the aorta for signs of enlargement Located along vertebral column
If any suspicion of neoplasm exists, limit palpation of the mass May cause injury or spread of malignancy!
Nephroblastoma (Wilms Tumor)
MC intraabdominal tumor of childhood
(2-3 years of age) Malignant
Firm, non-tender mass deep within the flank Only slightly moveable Not usually crossing the midline; sometimes bilateral Possibly:
Low-grade fever Hypertension
Neuroblastoma
Frequently appears as a mass in the adrenal medulla
Malignancy in early childhood Firm, fixed, non-tender, irregular and nodular
abdominal mass Malaise Loss of appetite Weight loss Protrusion of eye(s) Other symptoms may occur with:
compression of the mass or metastasis to adjacent organs
Percussion
May be more tympanic (vs. adults) Swallow air when feeding & crying
Tympany with distended abdomen? Gas
Dullness with distended abdomen? Fluid, solid mass
Examine the Bladder
Palpate and percuss over the suprapubic area
Determine size Distention?
Rebound Tenderness
Observe child’s facial expression and pupils
Be cautious…
Once a child has experienced palpation that is too intense, a subsequent examiner has little chance for easy access to the abdomen
Common Conditions
What if you find… ?
Sausage-shaped mass in the left lower quadrant
…Feces in the sigmoid colon
…Constipation
Midline, suprapubic mass
…Feces in the rectosigmoid colon
…Hirschsprung disease
Hirschsprung Disease aka Congenital Aganglionic Megacolon
Absence of parasympathetic ganglion cells in a segment of the colon… no peristalsis
Newborn: May fail to pass meconium in the first 24-48 hrs
Older infants and young children: Intestinal obstruction or severe constipation Failure to thrive Abdominal distention Episodes of vomiting and diarrhea
What if you find… ?
Sausage-shaped mass in the left or right upper quadrant
…Intussusception
Intussusception Prolapse of one segment of
intestine into another resulting in intestinal obstruction
MC 3-12 months old; cause is unknown
Acute intermittent abdominal pain Abdominal distention Vomiting Stools mixed with blood and mucus
Red current jelly appearance Sausage-shaped mass in R or L upper quadrant R lower quadrant feels empty (Dance sign)
Intussusception – “ABCDEF”
A bdominal or anal “sausage”
B lood from the rectum
C olic: babies draw up their legs
D istention, dehydration, and shock
E mesis
F ace pale
What if you find… ?
Olive-shaped mass in the right upper quadrant (deep palpation) immediately after the infant vomits
…Pyloric stenosis
Pyloric Stenosis
Hypertrophy of the circular muscle of the pylorus or obstruction of the pyloric sphincter
Regurgitation ~> projectile vomiting Feeding eagerly (even after vomiting) Failure to gain weight Signs of dehydration Small, rounded mass palpable in the R upper
quadrant especially after the child vomits
Gastroesophageal Reflux (GER)
Relaxation or incompetence of the lower esophagus persisting beyond the newborn period
Regurgitation and vomiting Weight loss and failure to thrive Respiratory problems
aspiration Bleeding from esophagitis
Biliary Atresia
Congenital obstruction or absence of some or all of the bile duct system
Jaundice Becomes apparent at 2-3 weeks
Hepatomegaly Abdominal distention Poor weight gain Pruritis Stools become lighter in color Urine darkens
Meconium Ileus
Thickening and hardening of meconium in the lower intestine ~> intestinal obstruction
Failure to pass meconium 1st 24 hrs after birth
Abdominal distention
*Must consider cystic fibrosis
Meckel Diverticulum
Outpouching of the ileum MC congenital anomaly of
the GI tract Varies in size & presentation
May be asymptomatic Intestinal obstruction? Diverticulitis?
Bright or dark red rectal bleeding Little abdominal pain
Symptoms like those of acute appendicitis
Omphalocele
Intestine present in the umbilical cord or protruding from the umbilical area Visible through a thick transparent membrane
Necrotizing Enterocolitis
Inflammatory disease of the gastrointestinal mucosa Associated with prematurity
Immaturity of the GI tract
Abdominal distention Occult blood in stool Respiratory distress Often fatal: perforation and septicemia
