Ppt18

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 18
Assessing Children: Infancy
Through Adolescence

Areas of Assessment
• Physical development
– Assessed in depth at each visit
• Cognitive development
– Assessed generally at each visit
• Social and emotional development
– Assessed generally at each visit

Stages of Development
• Newborn (birth)
• Infancy (0 to 12 months)
• Early childhood (1 to 4 years)
• Middle childhood (5 to 10 years)
• Adolescence (11 to 20 years)
– Early
– Middle
– Late

Vital Signs Throughout Development
• Height – every visit
• Weight - every visit
– Calculate BMI (body mass index) at every visit
• Head circumference – birth to 36 months
• Blood pressure – start measuring at age 2
• Pulse – higher in infancy; slows down with aging
• Respiratory rate – higher in infancy; slows down with
aging
• Temperature
– <2 months of age: rectal temperature
– >= 2 months of age: tympanic temperature

Newborn Assessment
• General assessment – Apgar score
• Sequence of examination:
– Careful observation of
activity
– Head, neck, heart, lungs,
abdomen, genitourinary
system
– Lower extremities, back
– Ears, mouth
– Eyes whenever they open
spontaneously
– Skin (throughout the exam)
o Vernix caseosa: present
at birth
o Lanugo: shed within the
first few weeks of life
– Nervous system
– Hips
The Apgar Scoring System
Assigned Score
Clinical
Sign
0 1 2
Heart rate Absent <100 >100
Respiratory
effort
Absent Slow and irregular Good; strong
Muscle tone Flaccid Some flexion of
the arms and legs
Active movement
Reflex
irritability
No
response
Grimace Cry vigorously,
sneeze, or cough
Color Blue, pale Pink body, blue
extremities
Pink all over
1–Minute Apgar Score 5–Minute Apgar Score
0-4 Severe depression,
requiring immediate
resuscitation
0-7 High risk for
subsequent central
nervous system and
other organ system
dysfunction5-7 Some nervous
system depression
8-10 Normal 8-10 Normal

Infancy: 0 to 12 months
• Most rapid rate of growth
– Birth weight triples, height increases by 50%
by the end of year one
• Sequence of examination
– Perform non-disturbing maneuvers early
– Perform potentially distressing maneuvers near
the end; e.g., ears, mouth, and abdomen

Infancy: Physical Examination Features
• Head
– Inspect for symmetry
– Palpate:
o Anterior fontanelle –
closes between 4 and
26 months of age
o Posterior fontanelle –
closes by 2 months
of age

(cont.)
• Eyes:
– Inspect sclerae, pupils, irides,
extraocular movements, and
presence of red reflex
• Ears:
– Inspect position, shape,
landmarks, patency of ear canal
– Acoustic blink reflex
• Nose and paranasal sinuses:
– Infants are obligate nasal
breathers for first the 2 months
of life
– Only the ethmoid sinuses are
present at birth
– Inspect for position of nasal
septum
• Mouth/pharynx:
– Inspect mucosa, tongue,
gums, palate, tonsils, and
posterior pharynx
– Palpate gums and teeth
o Teeth: 6 to 26 months of
age, 1 tooth per month
o Central and lateral
incisors erupt first,
molars last
• Neck:
– Inspect for masses
– Palpate for presence of
adenopathy: unusual in
infancy
– Assess mobility of neck

Question
A mother presents to the pediatrician concerned that
her 8-month-old child is not developing appropriately.
She bases this concern on the fact that the posterior
fontanelle closed 6 months ago, but the anterior
fontanelle is still open and soft. Your response to this
concern is based on which fact?
a. The anterior fontanelle closes between 4 to 26
months of age
b. Both fontanelles should close within 2 to 4
months of each other
c. The posterior fontanelle has closed early
d. None of the above are true

Answer
a. The anterior fontanelle closes between 4 to 26
months of age
• The posterior fontanelle closes by 2 months of
age

(cont.)
• Thorax:
– Inspect respiratory rate,
color, nasal component of
breathing, and listen for
audible breath sounds
– Palpate tactile fremitus if
infant is crying or making
noise
– Percussion is not helpful
in infants
o Thorax is more
rounded in infants than
in older children and
adults
• Lungs - auscultation:
– Generally, sounds are louder
and harsher
– Distinguish between upper
and lower airway sounds
o Upper airway: loud,
symmetric transmission
throughout the chest -
loudest as stethoscope is
moved upward; coarse
during inspiratory phase
o Lower airway: loudest
over site of pathology;
asymmetric; often has an
expiratory phase

(cont.)
• Heart
– Inspect for cyanosis
– Palpate:
o Peripheral pulses, especially brachial
o PMI is not always palpable; 1 interspace higher than in
adults
o Thrills
– Auscultate:
o S1, S2 (split is normal but fuse together as single sound
during deep expiration)
o S3 is frequently heard and is normal
o Murmurs – functional murmurs vs. pathologic

(cont.)
• Breasts
– Inspect – enlarged in
newborns secondary to
maternal estrogen
– Palpate for masses
• Male genitalia
– Inspect
– Palpate for descent of
testes into scrotal sac
• Female genitalia
– Inspect
• Abdomen
– Inspect – umbilical cord
remnant is gone by 2
weeks of age
– Auscultate bowel sounds
– Palpate - liver edge 1-2
cm below costal margin is
normal; palpable spleen
tip is normal
– Rectal – generally not
done

(cont.)
• Musculoskeletal
– Inspect the spine
– Palpate the clavicle, hips, legs, and feet
o Bowlegged growth to age 18 months is
normal

(cont.)
• Nervous system
– Inspect motor tone
– Palpate motor tone through passive ROM of major
joints
– Normal reflexes
o Newborn:
 Palmar grasp, plantar grasp, moro reflex,
asymmetric tonic neck reflex, positive support
reflex, anal reflex, positive Babinski
o Infancy:
 Triceps, brachioradialis, and abdominal reflexes
present starting at age 6 months

Tips for Examining the Young Child
• Use a reassuring voice throughout the examination
• Let the child see and touch the examination tools you
will be using
• Avoid asking permission to examine a body part because
you will do the examination anyway; instead, ask the
child which body part he or she would like to have
examined first
• Examine the child in the parent’s lap; allow the parent to
undress the child
• If unable to console the child, allow a short break
• Make a game out of the examination

Early Childhood (1 to 4 years):
Physical Examination Features
• Rate of growth slows to 50% of that of infancy
• Tips for examination sequence:
– Start with the child seated – examine the eyes,
palpate neck, percuss/auscultate
– Move child to supine position – examine
abdomen, musculoskeletal, nervous system;
examine genitalia last
– End the examination with the patient upright;
look at the throat and ears

Early Childhood: Unique Physical
Examination Features
• Vital signs:
– Measure blood
pressure starting at
age 2
• Neck:
– Palpate for lymph
nodes; adenopathy is
common
• Eyes:
– Cover and uncover
test for position and
alignment of eyes
• Ears:
– Visualization of tympanic
membrane is the greatest
challenge
• Nose/sinuses:
– Maxillary sinuses present by
age 4

Examination Features (cont.)
• Heart
– Brachial pulses still easier to feel than radial
• Abdomen
– Protuberant abdomen still normal
– Liver span 1-2 cm below costal margin is still normal
– Spleen edge 1-2 cm below costal margin is normal
– Use the scratch test to palpate for the liver size

Examination Features (cont.)
• Male genitalia:
– Testes undescended in
scrotal sac by age 1 is
abnormal and need to refer
• Musculoskeletal system:
– Knock-knees from 18
months to 4 years of age
– Inspect spine for scoliosis
in any child who can stand

Question
You enter the room of a 2-year-old female who is
visibly upset and afraid of being at the clinic. To
facilitate the examination, which of the following
actions would be most appropriate?
a. Leave the room and return when the child is
calm
b. Have the parent leave the room since his or her
presence is making the “acting out” worse
c. Ask the child’s permission to examine a body
part
d. Examine the child in the parent’s lap

Answer
d. Examine the child in the parent’s lap
• Do not ask the child for permission to begin
the examination on a part of the body. The
examination will take place whether the child
gives permission or not.

Middle Childhood (5 to 10 years):
Physical Examination Unique Features
• Physical examination is more straightforward; the same
sequence that is used in adults can be used starting in
this age group
Nose and paranasal
sinuses
Sphenoid sinuses present by age 8
Frontal sinuses present by age 6-7
Tonsils Peak growth is between ages 8-16
years
Breasts Development in girls is the first sign of
puberty; may start as early as age 6
Musculoskeletal system Inspect legs and feet
Inspect spine for scoliosis

Adolescence: Unique Features
• Puberty
– Tanner stages to
determine stage
of puberty

Adolescence: Unique Features (cont.)
• Male puberty
– Tanner stages
to determine
stage of puberty

Adolescence: Unique Features (cont.)
• Female puberty
– Tanner stages to
determine stage
of puberty

Ppt18

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