Transcript Pediatric Physical Exam

Pediatric Physical Exam
Adapted from Mosby’s Guide to
Physical Examination, 6th Ed.
Age Descriptors
Newborn
Infant
Toddler
Child
birth to 2 months
0-1 year
1-2 years
2+ years
Vitals
Pulse
Respiration
Blood pressure
Temp
Height
infants and children
Weight
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

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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Blood Pressure
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.
2.
3.
4.
5.
Tear a length of headrest paper
Lay the child on top of the paper
Mark the top of the child’s head
Ask mother to hold child in place
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



Childhood




Growth of the trunk predominates
Fat increases until 9 months of age…
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
Females
Broader 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 newborns
Not 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 life
Skin 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
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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 or
Inguinal 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.
B.
Normal: diamond shaped
window
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
Developmental delay
Morning headaches
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
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
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
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
Cephalhematoma
Subcutaneous edema
Crosses suture lines
Subperiosteal bleed
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 months
Ant. 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 Reflex
aka 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: symmetrical
Strabismus: 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 lateral
Esotropic 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


3.
Shine a bright light at the infant’s eyes
Note the quick closure of the eyes and
dorsiflexion of the head
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.
2.
3.
4.
Make it a “game”
Instruct the child to point finger in the
direction of the legs of the E
Allow the child to practice following
instructions before you administer the
test
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


Often unable to keep eyes still and focused
on a distant object



Leads only to more resistance
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
Red reflex
Corneal light reflex
Inspection
Require Further Evaluation
Abnormal
Asymmetric
Asymmetric
Structural abnormality
6 months – 1 year
Screening Method
Red reflex
Corneal light reflex
Require Further Evaluation
Abnormal or Asymmetric
Asymmetric
Failure to object equally to
Differential occlusion
covering each eye
Fix and follow with
Failure to fix and follow
each eye
Inspection
Structural abnormality
~3 years old
Screening Method
Visual acuity
Red reflex
Corneal light reflex;
Cover-uncover
Stereoacuity
Inspection
Require Further Evaluation
<20/50; 2 lines of difference
between the eyes
Abnormal or asymmetric
Asymmetric; ocular refixation
movements
Failure to appreciate random
dot stereogram
Structural abnormality
~5 years old
Screening Method
Visual acuity
Red reflex
Corneal light reflex;
Cover-uncover
Stereoacuity
Inspection
Require Further Evaluation
20/30 or worse
Abnormal or asymmetric
Asymmetric; ocular refixation
movements
Failure to appreciate random
dot stereogram
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


Eustachian tube – relatively wider, shorter
and more horizontal


infant otoscopic exam – “pull downward”
Reflux of nasopharyngeal secretions
Growth of adenoids may occlude the
eustachian tube

Interferes with aeration of the middle ear
Inspect the Ear

Well formed


Flexible


should have instant recoil after bending
Position


all landmarks present
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.
2.
3.
Lay the infant supine/prone
Turn head to the side
Hold otoscope so that the ulnar surface of
your hand rests against the infant’s head
*Prevent trauma to auditory canal
4.
5.
Other hand stabilizes infant’s head
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
Infection
Red
Moveable
Red
No 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
4 to 6 months
Startle reflex, crying,
cessation of breathing or
movement in response to
sudden noise; quiets to
parent’s voice
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
10 to 12 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
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
Otitis Media with Effusion






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
Nose
Development

Maxillary and ethmoid sinuses


Sphenoid sinus



present at birth, though very small
tiny cavity at birth
not fully developed
puberty
Frontal sinus

develops by 7-8 years
until
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
Copyright © 2006 University of Washington.

Newborns may experience respiratory
distress and difficulty feeding
 Obligatory nose breathers
*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
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
a
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 size
1+
2+
3+
4+
visible
halfway between tonsillar
pillars and the uvula
nearly touching the uvula
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
NO
TONGUE
BLADE!
*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
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


Palpate the hard and soft palates




Should have a strong suck, tongue pushing
vigorously upward against the finger
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
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
A ctivity
P ulse
G rimace
A ppearance
R espirations
Apgar Score
0
1
2
Heart rate
Absent
<100
>100
Respiratory
effort
Absent
Slow/irregular
Easy; Good
crying
Limp
Some flexion
of extremities
Active
motion
Muscle tone
Reflex irritability No response
Grimace, slow Lusty cry
Color
Acrocyanosis
Blue/pale
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


Lungs


Salt loss in sweat (“taste salty”)
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




Breast development in a
newborn d/t hormonal
influences
Should be ¼ chest circumference
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
 Edematous response
Floppy epiglottis
 Infection
Congenital defects
 Allergen
Croup
 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
PALPATION
Tachypnea
Shallow breathing
Flaring of nostrils
Occasional cyanosis
Limited movement; splinting
Increased fremitus (consolidation)
Dullness (consolidation)
PERCUSSION
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
PALPATION
Occasional tachypnea
Occasional shallow breathing
Often no deviation from expected
findings
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


Harsh stridorous cough





Awakens suddenly, frightened
“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:
Always



Transposition of the great vessels
Tetralogy of Fallot (blue)
Tricuspid atresia




cyanotic
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
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


Diaphragmatic hernia



Shifts apical pulse away from the area of
pneumothorax
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

h HR 10-20 beats for each degree temp. h
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 hum
Caused 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



Inflate cuff to a pressure above the systolic
reading you expect
Lower the arm and remove the bandage


Empty veins and capillaries
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
Severe
90th percentile
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.
2.
3.
4.
VSD
Pulmonary valve stenosis
Overriding aorta
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, Creactive 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
shaped
Distended 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


No need to repair in most cases


between the xiphoid and umbilicus
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 Scratch test
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
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
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Outpouching of the ileum
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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
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Intestine present in the umbilical cord or
protruding from the umbilical area
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Visible through a thick transparent membrane
Necrotizing Enterocolitis
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Inflammatory disease of the gastrointestinal
mucosa
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Associated with prematurity
 Immaturity of the GI tract
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Abdominal distention
Occult blood in stool
Respiratory distress
Often fatal: perforation and septicemia
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