PD special populations

What is a tip to making the pediatric assessment less intimidating?

try the least aversive portion of the exam first

auscultate the heart and lungs then move to more potentially disturbing portions

What are the 4 principles of pediatric development?

child development proceeds in a predictable pathway

range of normal development is wid

various physical, social and environmental factors as well as diseases can affect child development and health

the childs developmental level affects how you conduct the hx and physical exam

What is considered age appropriate guidance you can offer to children and their parents?

childs development

expected maturation changes

childhood immunizations

What are the stages of development?

newborn- birth

infancy- 0-12 months

early childhood- 1 to 4

middle childhood- 5-10

adolescence 11-20

What are the key components of pediatric health promotion?

age appropriate developmental achievements

health supervision visits

integration of physical exam findings with health lifestyles

immunizations

healthy habits

oral health

preventive methods

school, family relationships

What is the first exam of the newborn exam?

immediately after birth

determine general condition

developmental status

abnormalities in gestational development

congenital abnormalities

gestational age and weight

apgar score

What is the apgar score?

a 5 components scoring system that classifies the newborns neurological recovery from birth and immediate adaptation to extra uterine life

What is the scoring of the apgar score?

rates

appearance- color

pulse- HR

grimace - reflex irritability

activity- muscle tone

respiration

scale 0,1,2

What is a normal score for 1 minute apgar score?

8-10

What is a score of 5-7 on apgar 1 minute test indicative of?

some nervous system depression

What is a score of 0-4 on 1 minute apgar score indicative of?

severe depression, requiring immediate resuscitation

What is the normal score for an apgar 5 minute test?

8-10

What is a 5 minute apgar score of 0-7 indicative of?

high risk of subsequent CNS and other organ system dysfunction

What should you do if the apgar score is low?

repeat exam at 5 minute intervals until score is >7

What does the classification of newborns based on weight and age help predict?

medical problems and morbidity

How is gestational age determined?

ballard scoring system

estimates gestational age to within 2 weeks and is based on specific neuromuscular signs and physical characteristics that change with gestational maturity

What is considered preterm?

<34 weeks

What is considered late preterm?

34-36 weeks

What is considered term?

37-42 weeks

What is considered postterm?

>42 weeks

What is considered extremely low birth weight?

<1000 g - 2.2 lbs

What is considered very low birth weight?

<1500 g - 3.3lbs

What is considered low birth weight?

<2500 g - 5.5 lbs

What is considered normal birth weight?

> or = 2500 g

What percentile is considered small for gestational age?

SGA

<10th

What is considered appropriate for gestational age?

AGA

10-90th

What is considered large for gestational age?

LGA

>90th

What is the second exam of the newborn exams?

performed within first 24 hours of life

have parents present

start with child swaddles

undress as exam process

examine head to toe

reswaddle

What is the growth rate in the first year of life?

fastest in 1st year of life

height increase by 50%

weight triples

What is the neurological development in the first year of life?

progresses centrally to peripherally

learn head control before trunk control

arm/leg control before hands/feet control

What is the language cognition level in the first year of life?

speak 1 to 3 words by 1 year

What is the social/environmental development in the first year of life?

birth to one month- smiles and regards faces

seven months- indicates wants

one year- imitates activities, uses spoon

What does the american academy of peds recommend for childhood screening for developmental delays and and disabilities?

9 months

18 months

30 months

What is the main goal for developmental monitoring?

to help children who are low functioning but to also focus on anticipatory guidance to help promote normal development

What is the denver developmental screening test II?

125 items divided into four parts

social/personal

fine motor function

language

gross motor function

What ages are covered by the denver developmental screening test II?

2 months to 6 years

What vitals signs are taken at the infant exams?

height- every visit ( supine on measuring board for <2

weight- every visit ( naked or with diaper) + BMI or BSA

Head circumference- every visit btw birth and 2 yo

Blood pressure - after age 3

Pulse- higher in infancy

Respiratory rate-higher in infancy

Temp

What is the avg pulse in the first year of life?

115 and 140

What is the avg RR in a newborn?

30-60/min in a newborn

tachypnea>60/min- birth to 2 months

>50 min from 2 m-12 m

How do you measure temperature in an infant?

<2 months - rectal temp- 99F

>= 2 months- tympanic membrane - ( fluctuates up to 3 deg)

What is included in the inspection of pediatric skin exam?

benign birth marks vs more insidious findings

salmon patch

cafe-au-lait

mongolian spots

eyelid patch

How do you check for jaundice in a infant exam?

apply pressure to skin to press out normal color

yellow blanching = jaundice

What is breast feeding jaundice?

common source of jaundice in the first couple of weeks of life

resolves around 10-14 days

What is normal physiologic jaundice in infants?

occurs in up to 1/2 of all newborns and appears on the 2nd and third day and peaks around the 5th day- usually disappears within 1 week

What is a salmon patch?

stork bite or angel kiss

common vascular marking most common ar the nape of the neck

fades with age

What is a cafe au- lait spot?

light brown pigmented lesions

if more than 5 consider pathognomonic for neurological disease

What is an eyelid patch?

birthmark

fased within first year of life

What is a mongolian spot (slate blue patch)?

common in newborns of African, asian and mediterranean descent

results from pigmented cells in the deep layers of the skin

document these areas to avoid later concern about bruising

What is a lanugo?

fine downy growth of hair over the entire body, especially shoulders and back

prominent in premature infants- this hair is generally shed in the first few weeks

What is neonatal acne?

red pustules and papules prominent over the cheeks and nose

due to maternal or infant androgens usually clears within 4 months

What is miliaria rubra?

scattered vesicles on an erythematous base

results from obstructed sweat glands

disappears spontaneously within weeks

What is erythema toxicum?

usually appears on days 2-3 of life

erythematous macules with central pinpoint vesicles scattered diffusely over entire body

appears similar to flea bites

cause unknown

disappear within 1st week

What is pustular melanosis?

occurs in 5% black newborns and <1% of white newborns

presents at birth as small vesiculopustular lesions with a brown macular base

all areas of the body may be affected

What are milia?

pinhead sized smooth white raised areas without surrounding erythema on nose,chin, foreheat

usually appear within first few weeks and dissapear over several weeks

What do you assess during skin palpation in the infant exam?

turgor

roll skin of abdominal wall to determine hydration

usually due to insufficient intake or excess loss (ask about # of wet diapers)

What is important to note when inspecting the infant head?

symmetry

overall shape

look from all sides to see any abnormalities, flattening

examine shape of head from behind

inspect scal veins for dilation

What is positional plagiocephaly?

occurs when infant lies on one side more than the other

disappears as baby becomes more active

What are the characteristics of the infant head?

1/4 of body length and 1/3 of body weight

What is the size of the anterior fontanelle at birth and when does it close?

4-6 cm in diameter

closes btw 2-26 months

what is the size of the posterior fontanelle at birth and when does it close?

1-2 cm

closes within 2 months

What is included when palpating the infant scull?

assess fontanelles for fullness - reflects intracranial pressure

ant fontanelle is soft and flat

palpate while child is sitting or held upright

be gentle as the bones are soft and pliable

measure circumference

What is bulging fontanelle concening for?

increased ICP

What does a depressed fontanelle suggest?

dehydration

What is included in facial exam for infants?

compare child's face to head of parent

if abnormal does the feature fit any recognizable syndrome

What is included when examining an infant's eyes?

try dimming light so they open them

presence of red reflex

inspect clear, pupils, EOM

ophthalmic exam is difficult

can asses VA- use reflexes to assess vision

What reflexes can you use when assessing the eyes instead of visual acuity?

direct and consensual light

blink response to bright light or object moving quickly towards eyes

What is included in the inspection of infant ears?

determine position, shape and features of the ear to detect abnormalities

imaginary line drawn across the inner and outer canthus of the eyes should cross the pinna or the auricle

How do you do an otoscope exam on an infant?

ear canals directed down

pull auricle down not up

What is included in the hearing exam with an infant?

acoustic blink reflex

blinking infants eyes in response to sharp sudden noise

What are the signs that an infant can hear?

What are the steps to inspecting the nose and the paranasal sinuses?

nasal patency

only maxillary and ethmoid sinuses are present at birth

inspect for nasal positioning and septum

What is important to inspect in the mouth/pharynx of an infant?

inspect tongue with blade and flashlight

insect mucosa tongue, gums, palate, tonsils, posterior pharynx

inspect frenulum for tightness that may produce angyloglossie or tongue tie

palpate gums and teeth

pharynx best seen when baby cries

listen for quality of the cry

How many teeth should babies have?

6-26 months of age= 1 tooth per month - up to max of 20 primary teeth

central and lat erupt first, molars last

What should be inspected and palpated in the infant neck exam?

masses

palpate: while infant is supine, check position of thyroid and trachea

palpate clavicle for fracture

assess mobility of neck

What is included in the thorax infant exam?

the thorax is more rounded in infants than in older children and adults

assess RR, breathing pattern and color of child

assess component of breathing- flaring nares

listen for audible breath sounds and work of breathing

How do you palpate the infant thorax>

tactile fremitus if infant is crying or making noise

look for symmetry

percussion nor helpful- hyperresonance

What is heard during the infant auscultation of the infant thorax?

generally sounds are louder and harsher than adults

wheezes and rhonchi are common

distinguish btw upper and lower airway sounds

What should be inspected in the infant heart exam?

general signs of health- nutritional status, responsiveness, irritability, fatigue,

RR and pattern

cyanosis

mouth, tongue, conjunctivae

What should you palpate during the infant heart exam?

peripheral pulses esp brachial

PMI not always palpable

What should you auscultate for in the infant heart exam?

easier to assess heart rhythm in peripheral pulses

S1 and Se

S3 heard frequently and normal

S4 not usually heard

murmurs

What are the benign infant murmurs and where can you hear them?

What are common non cardiac findings with cardiac disease?

poor feeding

failure to thrive

irritability

tachypnea

hepatomegaly

clubbing

poor overall appearance

weakness

what does central cyanosis indicate?

abnormality

congenital cardiac abnormalities

respiratory disease

acrocyanosis - may be normal in early infancy

What is normal skim color and what is abnormal skin color in infants?

strawberry pink- normal

raspberry red - abnormal- desaturation

What do you insect for in the infant breast exam?

enlarged in newborns secondary to maternal estrogen, can last several months

may be engorged with white liquid- 1-2 weeks

palpate for masses

Hoand what do you inspect the infant abdomen for?

infant lying supine and hopefully asleep

abdomen is protuberant due to poorly developed abdominal muscles

umbilical cord dries and falls off within 2 weeks

may see diasrasis recti

What do you inspect the umbilical cord for?

2 thick walled arteries and 1 larger but thin walled vein

inspect for redness or swelling

umbilical hernias are detectable by a few weeks- most disappear within 1 year of buy age 5

how do you percuss the infant abdomen?

may percuss as a normal adult but it may be more tympanic

palpating abdomen may be easier if you hold legs flexed at the hips and knees and palpate

pulsations are common from aorta

kidneys may be palpable

descending colon is sausage like mass in LLQ

What is included in the palpation of the infant abdomen exam?

palpable spleen tip is normally 1-2cm below costal margin

liver edge is generally 1-3 cm below costal margin - make sure to start lower in abdomen to avoid missing enlarged liver

may use scratch test to evaluate for enlarged liver

When would you do an infant rectal exam?

typically not done unless there is concern for patency of anus or abdominal mass

What do you inspect for in the infant male genitalia?

note appearance of penis, testes and scrotum

foreskin covers glans and is not retractable at birth but it loosesn over months to years

What is included in the palpation of infant male genitalia?

descent of testes into scrotal sac

evaluate for masses - apply gentle pressure to reduce or try to transilluminate

What do you inspect in the infant female genitalia?

genitalia is prominent in newborns due to moms estrogen levels

assess all structures - note opening

What is included in the inspection fo infant MSK?

focus on detecting congenital abnormalities particularly in the hands, spine, hips, legs and feet

extend fingers to examine them

inspect spine for pigmented spots, hairy patches, deep pits

What should you suspect if there are any pigmented spots, hair patches or deep pits noted within 1 cm of the midline?

external openings of sinus tracts into spinal canal- DO NOT probe risk introducing infection

What do you palpate during the infant MSK exam?

clavicle- lumps, tenderness, and crepitus

hips, legs, feet

T/F bowlegged growth to age 18 months is normal

True

How do you check for hip dysplasia in infants?

look for dislocation or subluxation using barlow or ortolani

soft click should prompt careful exam for dislocated hip

test best done before 3 m

What are the steps to the barlow test?

•Place your index/middle fingers over greater trochanter and your thumbs over the lesser trochanter

•Adduct the legs at a 90 degree angle with gentle posterior force applied to hips

•Assess the ability to sublux or dislocate an intact but unstable hip

•No movement is NORMAL

What are the steps of the ortolani test?

•Flex legs to form right angle at hips and knees

•Place index finger over great trochanter

•Abduct legs until reach table, applying forward pressure to the greater trochanters

•Testing for the presence of a posteriorly dislocated hip - an audible "clunk" is considered positive