LCCW Pediatrics A - Cumulative Final
How do you test CN V in a child?
-Observe the child chewing and note bilateral jaw strength. -Touch the forehead and cheeks with cotton and watch the child bat it away.
How do you test CN VIII in a child?
-Observe the child turn to sounds. -Whisper a commonly used word behind the child's back and have them repeat the word. -Refer for audiometric testing.
How do you test CN VII in a child?
-Observe the child's face when smiling, frowning, and crying. -Ask the child to see their teeth. -Demonstrate puffed cheeks and ask the child to imitate.
How do you assess CN VII?
-Observe the infant's facial expression when crying. -Note ability to wrinkle for forehead. -Note symmetry of the smile.
What may cause prolonged capillary refill time (>2 seconds)?
-Significant dehydration. -Hypovolemic shock.
What primitive reflexes are present in the newborn? When do they go away?
-Yawn, sneeze, hiccup, blink at bright light and loud sound, pupillary constriction with light, withdrawal from painful stimuli. -General rule: disappear by 6 months.
Where does an eczematous rash typically occur in younger children? Older children/adults?
-Younger: face, elbow, knees. -Older: Hands, neck, inner elbows, back of knees, ankles, face.
APGAR Scoring System: Muscle Tone
0: limp/flaccid 1: some flexion tone 2: active motion
What is hypertelorism?
Widely spaced eyes. May be associated with mental retardation.
When should you evaluate genu valgum further?
-If there is asymmetry of the tibiofemoral angle. -If space between the ankles is >2 inches.
When should you evaluate genu varum further?
-If there is asymmetry of the tibiofemoral angle. -If the space between the knees is >1.5 inches.
What can you do if the child is ticklish?
-Use a firm touch. -Place the child's hand under your palm leaving your fingers free to palpate.
What is the rule of thumb for imaging newborns/infants?
-Use ultrasound in first 6 months of life. -Use plain film after 6 months.
What can distended veins indicate?
-Vascular obstruction -Abdominal distension -Abdominal obstruction
3 year old screening of the eye.
-Visual acuity -Red reflex -Corneal light reflex; cover-uncover. -Stereoacuity -Inspection
5 year old screening of the eye.
-Visual acuity -Red reflex -Corneal light reflex; cover-uncover. -Stereoacuity -Inspection
What should you take careful note of if there is a known heart condition?
-Weight gain or loss. -Developmental delay. -Cyanosis for defects that impede oxygenation. -Clubbing of the fingers and toes.
What is the average weight at birth? Length? Head circumference?
-Weight: 5lb 8 oz - 8lb 13oz -Length: 18-22 in (45-55cm). -Circumference: 13-14in (33-35cm).
What are we looking for upon inspection of the ears?
-Well formed with all landmarks present. -Flexible and should have instant recoil after bending. -Position: tip of auricle should cross an imaginary line between the outer canthus of the eye and the EOP. -No skin tags or preauricular pits should be present.
What are brushfield spots?
-White specks in a linear pattern around the circumference of the iris. -Suggests Down syndrome.
What does Gower sign indicate? DDX?
-Indicates muscle weakness. -DDX muscular dystrophy.
Percussion in infants may be more ________ compared to adults? Why?
-Tympanic -Because they swallow air when feeding and crying.
What is the expected motor development by 2 months?
Can raise head (prone).
Most tests for dysplasia are for ________.
Dislocation
What can spider nevi indicate?
Liver disease
What is the Landau reflex a precursor for?
The parachute response, which once present, should never go away.
What is ankyloglossia?
Tongue tie. Can interfere with feeding and talking.
What is the plantar reflex? How long is it retained?
"Babinski" sign - fanning of the toes and dorsiflexion of the great toe. -Retained until 16-24 months. -https://www.youtube.com/watch?v=mJcIUnunlNI
How do you assess hearing in a child?
-Observe response to a whispered voice, toys, etc. -If older, ask them to use a soft voice. -Weber, Rinne, and Schwabach tests are used when a child understands directions and can cooperate with the examiner.
What is the optical blink reflex?
-Shine a bright light at the infant's eyes. -Note the quick closure of the eyes and dorsiflexion of the head.
Motor maturation follows a ________ direction.
*Cephalocaudal direction*. -Control of the head and neck develops first, followed by the trunk and extremities.
What are the signs and symptoms of intracranial tumors?
*Vary by the location of the tumor* -Persistent headache -Nausea and vomiting. -Motor dysfunction -Gait disturbances, ataxia. -Change in cognition. -Memory loss and confusion. -Reduced visual acuity or visual loss. -Papilledema -Cranial nerve impairment. -Aphasia, language disorder. -Behavior or personality change. -Seizure
What are the signs and symptoms of meningitis in a young infant?
*Without the bulging fontanelle these symptoms look like a stomach virus.* -Very irritable and inconsolable. -Fever -Diarrhea -Poor appetite -Toxic appearance -Bulging fontanelle (not always there).
A detectable spleen ________ is common in well infants but increase in spleen size can indicate what?
-*Spleen tip* is common. -Increase in size can indicate: blood dyscrasias (disease) or septicemia.
What is a Nursemaid's elbow?
-AKA radial head subluxation. -Common in children 1-4 years old. -Caused by *jerking the arm upward while the elbow is extended* (tugging on child's arm, removing clothing, lifting child by grabbing hand, child falling and grabbing something on the way down).
How can the doctor use the respiratory cycle to perform an abdominal exam?
-Should be soft during inspiration. -If the abdomen remains hard during inspiration and expiration, then suspect peritoneal irritation.
How do you assess CN VIII (acoustic)?
-Acoustic blink reflex. -Clap your hands close to the infant's head and note the blink in response to sound. -Eyes move in direction of the sound. -Freezes position with high-pitched sound. -Infant will habituate to repeated testing. -https://www.youtube.com/watch?v=AlRnKt6q1T8
What are retention cysts?
-Aka Epstein pearls. -They are pearl-like retention cysts that appear along the buccal surface of the gums and disappear in 1-2 months. -They are not painful, do not cause problems, and will go away.
What is the asymmetric tonic neck reflex? Aka? When does it go away?
-Aka Fencer's. -With the infant supine, turn the head to one side and observe for ipsilateral extension and contralateral flexion of the arms and legs. -Peaks around 2-3 months and disappears by 6 months. -Most disappear before the infant can roll or bring its hands to its face.
What is coloboma?
-Aka keyhole pupil. -Loss of functional pupil. -Often associated with other congenital abnormalities.
What is torticollis?
-Aka wry neck. -May be due to birth injury. A hematoma may be palpated shortly after birth and a firm fibrous mass 2-3 weeks later. -In older children it is usually the result of trauma, muscle spasm, viral infection, drug ingestion, or subluxation.
What are some signs of nasal allergies?
-Allergic salute -Nasal crease -Allergic shiner -Allergic (adenoidal) face -Mouth breathing due to severe nasal congestion.
What are the normal findings for deep tendon reflexes in infants?
-Ankle clonus is common in infants. -Patellar reflex is present at birth. -Achilles and brachioradialis appear around 6 months.
Where do you auscultate a child?
-Aortic -Pulmonic -Tricuspid -Mitral
What games can you use as tests for a child during a neurologic exam? (Penny games)
-Ask the child to pick up a penny off the floor to test vision and balance. -Stick a moistened coin to the child's nose and ask the child to walk across the room to observe gait and posturing. -Have the child balance a penny on the nose and dorsum of each extended hand to test Romberg.
What are some strategies to get adequate expiration during auscultation of a child?
-Ask them to "blow out" our penlight. -Ask them to blow away a bit of tissue in your hand. -Listen after they run up and down the hallway.
What are you expecting to see when assessing an infant sitting?
-Assess curvature of the spine and strength of paravertebral muscles. -Kyphosis of the thoracic and lumbar spine is expected until the infant can sit without support. -https://www.youtube.com/watch?v=WkoGQldC8qU
Describe gait in a toddler. Older child.
-Beginner walker will have a wide-based gait. -https://www.youtube.com/watch?v=teliQ-Ehc6I -Older child will have feet closer together and better balance. -https://www.youtube.com/watch?v=kHjaMCp-M70
What is the proper position to perform an otoscopic exam on a child?
-Best done on parent's lap. -Parent may have to restrain the child. -Pull aurical down and back.
What is the treatment for hyperbilirubinemia?
-Bili lamp -Bili blanket
What pulses are palpable in a newborn?
-Brachial -Radial -Femoral
What are some risk factors for hyperbilirubinemia?
-Breast feeding (b-glucuronidase) has a higher chance of physiologic jaundice. -Hemolytic disease -Infection -Cephalhematoma -Cutaneous or subcutaneous bleeds.
How does a child's breath sounds differ from an adult's?
-Chest wall is thinner and more resonant than an adult's. -Breath sounds may sound louder, harsher, and more bronchial. -Hyperresonance is common so it is easy to miss the dullness of underlying consolidation.
How does a child present with Nursemaid's elbow?
-Child complains of pain in the elbow and wrist. -Refuses to move the arm. -Holds arm slightly flexed and pronated. -Resists supination.
What is Hirschberg's test (corneal light reflex)?
-Child stares at a penlight about 30 cm away. -Doctor looks at the reflexion from each cornea in relationship to the pupil. -Normal is symmetrical. -Strabismus is asymmetrical.
What can cause a failure to thrive (grow at a "normal" rate)?
-Chronic disease. -Congenital disorder. -Inadequate calories and protein. -Improper feeding methods. -Intrauterine growth retardation. -Emotional deprivation.
What conditions require further fundoscopic examination?
-Congenital abnormality -Retinopathy -Trauma -Suspicion of physical abuse (shaken baby syndrome/retinal hemorrhage).
How do you test CN XII?
-Coordinated sucking and swallowing ability. -Pinch the infant's nose. The mouth will open and the tip of the tongue will rise in a midline position.
What are some strategies for performing an infant mouth exam?
-Crying is an opportunity to examine the mouth. -Avoid depressing the tongue because it will stimulate the tongue thrust reflex. -Insert gloved finger into the infant's mouth with fingerpad to the roof of the mouth. -Evaluate the infant's suck. -Palpate the hard and soft palates. -Stimualte a gag reflex by touching the tonsillar pillars.
What may cause a weak or thin pulse?
-Decreased cardiac output. -Peripheral vasoconstriction.
What can mouth breathing be associated with?
-Development of a high, arched palate. -Elevated upper lip -Overbite
What are some signs of congenital issues?
-Developmental delay -Underweight or overweight -Not crying -Not feeding -Cyanosis
What should you look for when inspecting the umbilical stump?
-Discharge -Redness -Induration -Warmth -Granulomatous tissue -Serous or serosanguinous discharge once the stump has separated. -Hernia or diastasis recti.
Complete evaluation of heart function includes what exams?
-Skin -Lungs -Liver
Tenderness and pain can be difficult to detect and localize in a child. What are some strategies to be accurate in your assessment?
-Distract the child with a toy. -Start away from the suspected area. -Observe for changes as you move to identify the area of greatest pain (pitch of crying, rejection of the opportunity to such, drawing knees to abdomen, facial expression, constriction of pupils).
What are some techniques you can use to successfully complete a fundoscopic exam?
-Do not hold the child's eyelid open forcibly because it leads to more resistance. -Use a toy or picture to help them keep focused. -Have parent hold them -Lay child supine on a table and stand at the end of the table so you are not towering over them.
What are some strategies to perform an abdominal exam?
-Do what you can to keep the child relaxed and quiet. -Use a bottle/pacifier/nursing. -Use parent's lap.
How is elevated blood pressure managed in children and adolescents?
-Dynamic exercise (bicycling, running). -High intake of fruits, vegetables, and low-fat dairy products. -Reduction in dietary sodium. -Weight-reduction program (if overweight). -Pharmacotherapy if conservative approaches are not successful.
What are some signs of muscular dystrophy?
-Early signs may include clumsiness, difficulty climbing stairs, and frequent falls. -Muscle atrophy and progressive weakness. -*Pseudohypertrophy* from fatty infiltrates. (Looks like normal muscle mass, but is fat). -Gower sign
How do you examine a newborn for hyperbilirubinemia?
-Examine in natural daylight when possible. -Inspect the oral mucosa and sclera. -Inspect the whole body for dermal icterus. It starts on the face and descends. -Capillaries mix with jaundice and look tan or orange, so blanch the skin to determine if jaundiced.
What should you be aware of as you inspect skin of a baby?
-Examine skin creases to make sure they are symmetrical. -Assymetrical creases on the thighs may indicate possible hip dysplasia. -Simian line on hands and feet may indicate possible Down syndrome.
How do you evaluate cranial nerves on an infant?
-Expect the infant to focus and track through 60 degrees. -Optical blink reflex. -Corneal light reflex. -6 cardinal fields of gaze. -Peripheral vision.
What are the developmental features of the ear that make an otoscopic examination different from an adult's?
-External auditory canal is shorter and has an upward curve so you pull down on the earlobe rather than pulling up. -Eustachian tube is relatively wider, shorter, and more horizontal, making them more prone to ear infections. -Growth of adenoids may occlude the eustachial tube.
What are some risk factors for hip dysplasia?
-Family history -Female -Breach position in utero
What can a distended abdomen indicate?
-Feces -Mass -Organ enlargement
What are the signs and symptoms of meningitis?
-Fever, chills -Headache -Nuchal rigidity -Lethargy, malaise -Irritability -Seizure -Vomiting -Altered mental status, confusion
What are normal findings for a lymph exam?
-Firm, discrete, moveable, <5mm (up to 1cm in cervical or inguinal regions). -Investigate further if growing rapidly, suspiciously large, or fixed and immoveable.
What can cause stridor?
-Floppy epiglottis -Congenital defects -Croup -Edematous response to infection, allergen, smoke, chemicals, aspirated foreign body.
What should you suspect if there is dullness with a distended abdomen?
-Fluid -Solid mass
How do you evaluate respiration in infants? Children?
-For infants, look at the rise and fall of the abdomen. -For children, look at the rise and fall of the chest.
How can you test light touch, vibration, and superficial pain in a child?
-For light touch ask the child to close their eyes and point to where you touch. Discriminate between rough and soft. -For vibration use a tuning fork and ask kids what they think it feels like, then ask them to describe how they feel it. -Superficial pain is not routinely tested in kids.
What natural compensations are in place to help bypass the non-functional fetal lung?
-Foramen ovale -Ductus arteriosus
How can you test the cranial nerves associated with vision (II, III, IV, VI) in an infant?
-Gazes intensely at a close object or face. -Can focus on and tracks an object with both eyes. -Optical blink reflex. -Doll's eye maneuver.
What are the clinical markers of KISS II (fixed retroflexion)?
-Hyperextension (during sleep). -Asymmetrical occipital flattening. -Shoulders pulled up. -Fixed supination of the arms. -Cannot lift trunk from ventral position. -Orofacial muscular hypotonia. -Breastfeeding difficult on one side.
When must you investigate a murmur further?
-If it persists beyond the 2nd or 3rd day of life. -If it is intense. -It it fills systole. -If it occupies diastole to *any* extent. -If it radiates widely.
When should fixed masses be investigated with special studies?
-If laterally mobile. -If pulsatile (palpate the aorta for signs of enlargment). -If located along the vertebral column.
What are the clinical findings associated with femoral anteversion?
-Increased internal rotation of the hip (*>70 degrees*) and decreased external hip rotation. -Femurs twist medially, patella facing inward. -In-toeing of the feet increases up to 5-6 years of age, and the tibias may twist laterally to compensate. -More common in *females*. -Associated with reverse tailor sitting.
What are you looking for when inspecting the spine of a toddler standing?
-Increased lumbar lordosis. -Protruberant abdomen
A smaller chest circumference compared to the head bay be due to what? Larger?
-Intrauterine growth retardation. -Poorly controlled gestational diabetes.
What are some additional signs and symptoms of intracranial tumor seen in children?
-Irritability -Lethargy -Weight loss -Growth failure -Precocious puberty
What is physiologic jaundice?
-It is an inability of the liver to conjugate the bilirubin present in the blood and occurs in 50% of newborns. -It usually disappears in 8-10 days, but may persist for up to 3-4 weeks.
How is skin turgor evaluated? What is the purpose?
-It is best evaluated by gently pinching a fold of the abdominal skin. -Tenting of the skin indicates dehydration and/or malnutrition.
How is blood pressure measured?
-It is the same as in an adult after 3 years. -Width of the cuff should cover 2/3 of the upper arm. Too wide underestimates BP, too narrow raises it.
If blood pressure is consistently above the 95th percentile, what should you consider?
-Kidney disease -Renal arterial disease -Coarctation of the aorta
What is genu valgum?
-Knock knees common in children *2-4 years*. -Note variation in tibiofemoral angle and increased space between the ankles.
With regards to clinical presentation, what is the differentiation between LCP and SCFE?
-LCP occurs in 2-10 year olds. -SCFE occurs in 8-16 year olds.
How do you assess for metatarsus adductus?
-Lateral border of the foot is convex. -Crease is sometimes apparent on the medial border of the foot. -Midline of the foot may bisect the 3rd and 4th toes, 2nd and 3rd toes as they get older. -There is angulation at the tarsometatarsal joint that can be seen on x-ray.
What is the proper position to perform an otoscopic exam on an infant?
-Lay them supine or prone. -Turn head to the side. -Hold otoscope so the the ulnar surface of your hand rests against the infant's head. -Outer hand stabilizes infant's head. -Pull auricle down to straighten the canal.
What may cause a bounding pulse?
-Left to Right shunt. -Patent ductus arteriosus (PDA).
What postural observations might there be with scoliosis?
-Leg length discrepancy. -Uneven shoulder and hip levels. -Scapular asymmetry. -Rib humping and flank asymmetry on forward flexion. -Physiologic alterations in the spine, chest, and pelvis.
What is the expected normal growth for a child regarding length and weight?
-Length increases by 50% in the 1st year of life. -Weight doubles by 6 months and triples by 1 year.
What variants may be present upon otoscopic examination of the newborn?
-Limited mobility. -Dullness and opacity of a pink or red tympatic membrane. -Light reflex may appear diffuse. -Canal may be obstructed with vernix.
Pain over mastoid with palpation idicates what? Tragus? Pulling pinna?
-Mastoiditis -Otitis externa -Otitis media
A narrow, flat palate roof or a high, arched palate may result in what? Associated with what?
-May result in feeding and speech problems. -Associated with congenital anomalies.
What are you looking for upon inspection of the nose?
-Movement of the nares. -Symmetric appearance. -Positioned in the ventrical midline on face. -Congenital abnormalities.
What are you observing during abdominal inspection?
-Movement with respiration (abdominal and chests movements should be synchronous). -Shape (should be rounded an dome shaped). -Contour -Pulsations
What is the expected normal growth for a child regarding head and chest circumference at 5 months? 2 years? 2+ years?
-Newborn to 5 months: Head may be equal or exceed the cest by 2 cm. -5 months to 2 years: Chest should closely approximate the head. -2+ years: Chest should exceed head circumference.
Where should the lower liver margin be in a newborn? Infants and toddlers?
-Newborn: just below the right costal margin. -Infants/toddlers: 1-3cm below the right costal margin.
What exam findings are associated with hip dysplasia?
-Notable leg length inequality (Allis' test). -Decrease or difference in fat folds. -Decreased *abduction* (one of the most reliable screening findings). -Barlow's and Ortolani's done in combination.
What are you feeling for when palpating the head?
-Note tenderness over scalp. -Suture lines have a slight groove up to 6 months. -Fontanels should feel slightly depressed with some pulsation expected.
How do you check the alignment of legs and feet in toddlers and older children?
-Note the wear of the child's shoes. -Ask the parent about their favorite sitting posture. -Reverse tailor position.
What are you feeling for when you palpate the neck?
-Note tone of SCM, hematoma. -Palpate trachea -Thyroid is difficult to palpate unless enlarged. Goiter may occur if there is intrauterine deprivation of thyroid hormone and can cause respiratory distress.
What is plagiocephaly?
-Oblique skull. -Can look like a parallelogram with frontal bulging or trapezoid with no frontal bulging and even ears. - Left image is Positional plagiocephaly - Right image is Synostosis (lambdoid) plagiocephaly
What are you looking for when observing the hands and feet?
-Observe palmar and phalangeal creases. -Look for simian crease. -Count fingers and toes (polydactyly, syndactyly).
How do you differentiate between paralytic and nonparalytic strabismus?
-Paralytic has impairment of extraocular muscles or their nerve supply. -Nonparalytic has no primary muscle weakness so they can focus with either eye, but not with both simultaneously. There is a concern of developing amblyopia (reduced vision in an eye that appears structurally normal).
How does Erb's palsy present?
-Paralyzed arm (*waiter's tip*). -Absent moro, biceps, and radial reflexes. -No *deltoid, biceps, or brachioradialis.* -Grasp reflex is *intact*. -May have fractured clavicle, facial palsy, medical subluxation of cervical spine, cervical ford injury, ipsilateral phrenic nerve paresis (5%).
What are some things that parents might report that indicate KISS?
-Parents will say stuff like the baby is really rigid and doesn't like to snuggle. The baby is really independent and likes to face out and see the world. -Will have figured out that the best way to hold the baby is on arm facing down. -Baby doesn't like being placed in cradle because the mattress is firm and doesn't allow the head to stay in extension. -If baby is placed on pillow top mattress, they will stay asleep. -"Football" hold while breast feeding is the easiest way for baby to nurse because it allow them to keep their head extended.
What is the cross-cover test?
-Patient stares at penlight. -Doctor covers one eye and observes the uncovered eye for movement. -Normal is no movement. -Exotropic eye moves lateral to medial. -Esotropic eye moves medial to lateral.
What is the cover-uncover test?
-Patient stares at the penlight. -Doctor covers one eye and then observes as it is uncovered. -Normal is no movement. -Exotropic eye moves lateral. -Esotropic eye moves medial.
What can cause an unusual contour of the head?
-Perterm infants may have soft cranial bones that flatten with the positioning and weight of the head. -Irregular closing of the suture lines (craniosynostosis). -Positional head deformity (PHD).
When inspecting alignment of the legs and feet, what may you see in infants that is related to intrauterine constraint?
-Pes planus -Metatarsus adductus -Tibial torsion.
What is the Schamroth technique for evaluating nails?
-Place nail surfaces of corresponding fingers together. -Normal is a diamond shaped window. -Clubbed is when the angle increases.
What are you looking for when doing a physical exam on a newborn? (arm, hand position?)
-Place the newborn in the fetal position and note any asymmetry of flexion, position, or shape. -Newborn will show some *resistance to full extension*. (https://www.youtube.com/watch?v=97I03A8eg_Y). -The *hand may be fisted*, with the *thumb positioned inside the fingers*. (https://www.youtube.com/watch?v=Wq2050UF3M8). -Hands should open periodically with fingers fully extended.
When does the posterior fontanel close? Anterior fontanel?
-Posterior by 2 months. -Anterior by 2 years (24 months).
What vitals should be taken?
-Pulse -Respiration -Blood pressure (>3 yo) -Temp -Height -Weight
10 to 12 months expected hearing response.
-Recognizes and localizes source of sound. -Imitates simple words and sounds.
What is the most accurate way to take temperature? Next? Last?
-Rectal temperature is the most reliable in infants. -Temporal artery thermometers are less accurate and may underestimate fevers or overestimate low temp. -Tympanic thermometers are not accurate for infants and smaller patients.
6 months to 1 year screening of the eye.
-Red reflex -Corneal light reflex -Differential occlusion -Fix and follow with each eye. -Inspection
Newborn to 3 months screening of the eye.
-Red reflex -Corneal light reflex -Inspection
What are some clinical considerations for physiologic jaundice?
-Regular bowel movements are necessary to clear bilirubin. -Jaundice makes babies sleepy so they may have difficulty nursing and the parents might not even realize there is a problem because they are just happy to be sleeping through the night even though the baby should be nursing every couple of hours.
What is clubbing of the nails associated with?
-Respiratory disease -Cardiovascular disease (seeing clubbing in a child may indicate a heart defect since birth and that they have been hypoxic for months). -Thyroid disease -Cirrhosis -Colitis
6 to 10 months expected hearing response.
-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.
What are some indicators of respiratory effort?
-Retraction (look at ribs and supraclavicular notch). -Contraction of SCM's. -Flaring of the nostrils. -Paradoxic breathing.
What can indicate increased respiratory effort?
-Retraction of the supraclivicular notch -Contraction of the SCMs -Flaring of the nostrils -Obvious intercostal exertion (retractions). -Tachypnea -See-saw respirations -Tri-pod position
What features about the nose can indicate possible congenital abnormality?
-Saddle-shaped with and low bridge and broad base. -Short small -Large
What are you looking for when inspecting the head?
-Scaling or crusting (seborheic dermatitis). -Dilated veins (increased ICP). -Subcutaneous edema -Excessive hair or unusual hairline. -Cranial molding
What has KISS-induced Dyspraxia and Dysgnosia (KIDD) syndrome been associated with?
-Slow development of fine and gross motor skills. -Poor posture and equilibrium. -Delayed language development. -Restlessness, ADHD, and insecurity in older children.
What are the newborn classifications for gestational age?
-Small for gestational age (SGA): <10th percentile -Appropriate for gestational age (AGA): 10-90th percentile -Larger for gestational age (LGA): >90th percentile
How do you test CN II in a child?
-Snellen eye chart (can use the shapes of the E's). -Visual fields (child may need the head immobilized).
What are you observing when inspecting the face?
-Spacing of features -Symmetry -Skin color -Texture -Paralysis
Birth to 3 months expected hearing response.
-Startle reflex -Crying -Cessation of breathing or movement in response to sudden noise. -Quiets to parent's voice
What can a sustained increase in blood pressure indicate in a newborn?
-Stenosis of the renal artery. -Coarctation of the aorta. -Cystic disease of the kidney. -Neuroblastoma -Wilm's tumor (kidney). -Hydronephrosis -Adrenal hyperplasia -CNS disease
What are you looking for when inspecting the nipples?
-Symmetry in size -Swelling -Discharge -Supernumerary (extra nipples) -Breast development due to maternal hormonal influences (transient and will go away). -Distance between them should be 1/4 chest circumference.
What are you looking for when you inspect the neck?
-Symmetry, size, shape -Edema -Distended veins -Pulsations -Masses -Webbing -Excess skin
What may be the underlying cause of generalized seizure disorder?
-Systemic disease -Head trauma -Toxins -Stroke -Tumor -Hypoxic syndromes
-Talipes Equinovarus occurs in 1/____ live births in the USA. -It affects twice as many ________ as it does ________. -There is bilateral involvement in ________% of cases. -There is ____% chance of a subsequent child being affected.
-Talipes Equinovarus occurs in *1/1000* live births in the USA. -It affects twice as many *males* as it does *females*. -There is bilateral involvement in *30-50%* of cases. -There is *10%* chance of a subsequent child being affected.
What is the Rooting reflex? Cranial nerve?
-Tests CN V (and XI). -Touch the corner of the mouth (V). The infant should open its mouth and turn its head toward the stimulation (XI).
What is the Doll's eye maneuver?
-Tests CN VIII. -If you move the infants head one way, their eyes will go the opposite way. This is also assessing the vestibular apparatus. -If you do the reflex a few times, then the response starts to decrease (habituate). -https://www.youtube.com/watch?v=htGRKE8tGa4
What are the characteristics of craniosynostosis (lambdoid).
-There is a palpable ridge. -The ears are even or the ear on the flat side appears to be more posterior. -Forehead does not protrude. -There is no bald spot or central bald spot.
What are the characteristics of positional head deformity?
-There is no ridging. -The ear is flat on the side that migrates forward. -Forehead protrudes. -Bald spot on side of flattening.
Are bulging fontanels a good indicator of increased intracranial pressure? Why might they be depressed?
-They are an indicator but not a good one, they are not a sensitive indicator for intracranial pressure. -May be depressed due to dehydration.
What is the treatment for Talipes Equinovarus?
-This condition requires *surgery.* -Ponseti method is a series of manipulation and casting, usually 4-6 full leg casts. Also requires an achilles tendon tenotomy and foot abduction brace.
What are some strategies to complete a mouth exam on a child?
-To reduce fear, let the child hold and manipulate the tongue blade and light. -Start by asking to see their teeth. -To raise the palate, ask the child to pant like a puppy. -Have them sit on a parent's lap. -If they actively resist, lay them supine and have parent hold their arms above their head while doctor stabilizes their torso. -If child refuses to open mouth, insert a tongut blade through the lips to the back molars and insert between the back molars to stimulate the gag reflex and get a brief view of the mouth and oropharynx.
What are the clinical markers of KISS I (fixed lateroflexion)?
-Torticollis -Unilateral microsomia -Asymmetry of the skull. -C-Scoliosis of neck and trunk. -Asymmetry of gluteal area. -Asymmetry of motion of the limbs. -Retardation of motor development of one side. -Positive Fencer's.
What are the signs and symptoms of KISS syndrome?
-Torticollis, scoliosis, plagiocephaly, facial asymmetry. -Frequent vomiting, problems swallowing. -Colic with excessive crying.
What are some normal variants of a newborn with regard to appearance?
-Transient puffiness of the hands, feet, eyelids, legs, pubis or sacrum. -No hair to a lot of hair. -Dark-skinned newborns may take a few months to darken. -Skin may look very red for a few days because color is partly determined by subcutaneous fat which they typically lack at birth.
What are you looking for when inspecting the torso?
-Tufts of hair, discoloration, cysts, masses. -Spine should be smooth with balanced concave and convex curves, no lateral curvature, and no rib humping. -Shoulder and scapulae should be level (within 1/2 inch) and 3-5 inches apart.
4 to 6 months expected hearing response.
-Turns head toward source of sound but may not always recognize location of sound. -Responds to parent's voice. -Enjoys sound producing toys.
What are signs of sinusitis in children?
-Upper respiratory symptoms -Nasal discharge -Low-grade fever -Daytime cough -Malodorous breath -Cervical adenopathy -Intermittent painless morning eye swelling. -*No* facial pain or headache
What can a distended bladder indicate?
-Urethral obstruction -CNS defects
How can you encourage an infant to open their eyes for an eye exam?
-Use a dimly lit room. -Hold them upright, suspended under their arms facing you. -Have parent hold them over a shoulder.
APGAR Scoring System: Heart Rate
0: absent 1: <100 2: >100 **normal: 100-120 bpm
APGAR Scoring System: Respiratory Effort
0: absent 1: slow/irregular 2: easy; good, crying
APGAR Scoring System: Color
0: blue/pale 1: acrocyanosis (extremity cyanosis) 2: pink
APGAR Scoring System: Reflex irritability
0: no response 1: grimace 2: vigorous cry
When is APGAR completed?
1 and 5 minutes.
>____ degrees is fever in infants. Most concerning however is ________.
103 degrees. Dehydration
How long does brain growth continue for?
12-15 years
Fundoscopic examination is difficult to perform on a newborn or young infant so is often deferred until ______ months unless patient presentation suggests a need.
2-6
How many baby teeth come in? When? What order?
20 deciduous teeth between 6-24 months. It is most common for bottom front to come in first then top midline, then working outwards.
At birth, functional closure of the foramen ovale and the ductus arteriosus closes within ________ hours.
24-48 hours.
What is the peak age of incidence for intracranial tumors?
3-12 years 50-70 years
Where do you feel for the apical impulse?
3rd-5th left intercostal space in the midclavicular line. -The apex of the heart in a newborn is higher and lies more horizontal. -Adult heart position is reached by age 7.
The anterior fontanel should not exceed _________ cm.
4-5
Most babies born to the same parents weigh within ____oz of each other at birth.
6
Respirations continue to be abdominal until ________ year of age.
6-7
APGAR Scoring System: 5-minute Apgar score
8-10: normal 0-7: high risk for subsequent CNS & other organ system dysfunction
APGAR Scoring System: 1-minute Apgar Score
8-10: normal 5-7: some nervous system depression 0-4: severe depression, requiring immediate resuscitation
What percentile blood pressure is considered significant? Severe?
90th is significant. 95th is severe.
What is normal capillary refill time up to 2 years of age?
<1 second.
What is developmental hip dysplasia?
A common congenital defect affecting females 6x more than males. -Associated with intrauterine constraint (breech). -Can have varying degrees of involvement: dysplasia, subluxation, dislocation.
What is Talipes Equinovarus?
A congenital defect of the ankle and foot where there is inversion of the foot at the ankle and plantarflexion due to a contracted triceps surae.
What is muscular dystrophy?
A group of genetic disorders that results in gradual degeneration of muscle fibers. -Ranges from mild disability (normal life span) to severe disability, deformity, and death.
What is stridor?
A high pitched, piercing sound that cannot be dismissed as inconsequential, especially when inspiration is longer than expiration.
Congestive heart failure in an infant may present with what?
A large firm liver (hepatomegaly) first, then pulmonary crackles (unlike in an adult).
When palpating the rib cage and sternum, what are you feeling for?
A loss of symmetry, unusual masses, crepitus. -Baby may have a fractured clavicle due to birth trauma and may not show any evidence of pain.
What is periodic breathing?
A sequence of relatively vigorous respiratory efforts followed by apnea of as long as 10-15 seconds.
What is vernix caseosa?
A whitish, moist, cheeselike substance that is a mixture of sebum and skin cells. It is a protective covering at birth.
What does APGAR Score stand for?
A: activity P: pulse G: grimace A: appearance R: respiration
Abdominal and chest movements should be ________ with a slight ________ of the abdomen at the beginning of respiration.
Abdominal and chest movements should be *synchronous* with a slight *bulge* of the abdomen at the beginning of respiration.
What can a scaphoid abdomen indicate?
Abdominal contents are displaced.
What can cause intracranial space-occupying lesion/tumors?
Abnormal growth of neural or nonneural tissue within the cranium. -May be primary or metastatic cancer.
What is macroglossia? What can cause it?
Abnormally large tongue. -Congenital hypothyroidism, congenital abnormalities, Down syndrome.
How do you differentiate between structural and functional scoliosis?
Adams test
What is miliaria?
Aka Heat rash. This is not normal and tends to be in areas that are hot and sweaty such as neck fat folds. -It is caused by occlusion of sweat ducts during periods of heat and high humidity.
How do you test CN VIII (Vestibular)?
Doll's Eye maneuver.
The prevalence of elevated blood pressure in children and adolescents has _________ along with the increase in ________ in these age groups.
Increased. Obesity.
What is Erb's palsy?
Brachial plexus injury in a newborn due to birth trauma. -Possibly due to a large infant, shoulder dystocia. -C5/C6
How can you manage hip dysplasia?
Bracing, surgery. -If using a brace, need to stay in brace 23/7.
What are primitive reflexes?
Appear and disappear in a sequence corresponding with CNS development. They are used to evaluate posture and movement of the developing infant.
How do you test CN XI and XII?
Ask child to stick out tongue and shrug shoulders.
What is a pneumatic otoscopy?
Assesses mobility of the tympanic membrane. It is required to differentiate between crying/red reflex and infection. With infection there will be decreased mobility.
What is Legg-Calve-Perthes?
Avascular necrosis of the femoral head. -Most common in boys 2-10 years old. -Referred pain to the medial thigh, knee, or groin. -Painless limp (antalgic). -Loss of internal rotation. -Abduction and decreased ROM. -Muscle weakness of the upper thigh may develop.
What is seborrheic dermatitis?
BABY DANDRUFF -Scalp lesions that are scaling, adherent, thick, yellow, and crusted. -Can spread over the ear and down the nape of the neck. -Can also be seen on the back, intertriginous, and diaper areas. -Aka cradle cap.
What is milia?
Baby acne common during the first 2-3 months. -Small white discrete papules on the face and bridge of the nose are plugged sebaceous glands.
What is the most common infection in childhood?
Bacterial otitis media. Often follows or accompanies urinary tract infection.
What is the expected motor development by 9 months?
Begins creeping.
What is genu varum?
Bowed legs. -Common finding in toddlers up to *18 months* of age. -Note any increase on future examination. -Tibiofemoral angle should stay *symmetrical*.
What is shaken baby syndrome?
Due to child abuse, violent shaking of infants. -Shaking causes the brain to move around in the head, stretching and tearing nerve tissue and blood vessels, resulting in brain damage, subdural hematoma, and damage to the spinal cord.
What is cranial molding?
During a vaginal birth the cranial bones shift and overlap. -The skull should resume a normal shape and size within 1 week.
What are the problems associated with preterm LGA infants?
May experience difficulties during birth and metabolic abnormalities shortly after birth.
What can cause flattened edges on teeth?
Bruxism (unconscious grinding of the teeth). -Can be due to an upper cervical subluxation.
How do you determine the size of an umbilical hernia.
By measuring the *diameter*, NOT the vertical height of the protrusion.
How do you test deep tendon reflexes in an infant?
Can use a pediatric reflex hammer or fingers to tap the tendon. -Normal: https://www.youtube.com/watch?v=GyUDa2-zZLI -Abnormal: https://www.youtube.com/watch?v=qn5qFwjPFbE
If you have a positive Adam's test and are wondering whether you should take films, what should you use?
Can use a scoliometer to measure degree of curvature. If it measures greater than 5-7 then order films.
How do you test CNs III, IV, and VI in a child?
Cardinal planes of gaze. Have the child follow an object with their eyes. Immobilize head if necessary. -https://www.youtube.com/watch?v=MaIIg66uT7Q
What do you do with all of the height, weight, and length measurements?
Chart on an appropriate growth curve for sex and age. -Helps to identify the infant's percentile and allows you to note any change or variation from the population standard OR from the child's norm.
If the roundness of a child's chest persists past the 2nd year, then suspect a possible _________.
Chronic obstructive pulmonary problem.
What may cause a difference in pulse amplitude between the femoral and radial pulses?
Coarctation of the aorta.
Describe otitis media with effusion.
Collection of liquid in the middle ear. -Associated with allergies, enlarged lymph tissue, obstructed or dysfunctional eustachial 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 retracteded, impaired mobility, yellowish; air fluid level and/or bubbles.
Pulsations are ________ in infants.
Common
When is myelinization of the brain and nervous system completed? What implications does this have for a neurologic exam?
Completed during the first year of life. -This means that we expect to have some different test results from an adult. Ex// Positive babinsky is normal in a newborn.
After age 5 the abdomen may become ________ while laying supine.
Concave
What is an allergic rash?
Contact dermatitis. -Can be caused by medications, food sensitivity, supplements.
True/false: A sustained increase in blood pressure (hypertension) is almost never significant in a newborn.
False. It is almost always significant.
True/false a 3 year old with a sinus infection is likely to have facial pain and headache.
False. There won't be pain or headache until 7-9 years old so cannot rely on the finding to held diagnose.
Fever ________ heart rate in children by ________ beats for each degree temperature rises.
Fever *increases* heart rate in children by *10-20* beats for each degree temperature rises.
What is lanugo?
Fine, silky hair covering the newborn. It is present on infants of 24-32 weeks gestation and sheds within 10-14 days.
Upon inspection, the tongue should...
Fit will in the floor of the mouth and protrude beyond the alveolar ridge.
What is acrocyanosis?
Cyanosis of the hands and feet in response to cold. -An underlying cardiac defect should be suspected if it is persistent or more intense in the feet than hands.
Transillumination can be used to distinguish what from solid masses?
Cystic
What is an allergic shiner.
Dark circles under the eyes.
What is a soft sign finding for visual tracking? Latest expected age of disappearance?
Difficulty following object with eyes when keeping the head still. Nystagmus. -5 years
What is a soft sign finding for two-point discrimination? Latest expected age of disappearance?
Difficulty in localizing and discriminating when touched in one or two places. -6 years
What is a soft sign finding of motor-stance? Latest expected age of disappearance?
Difficulty maintaining stance (arms extended in front, feet together, and eyes closed), drifting of arms, mild writhing movements of hands or fingers. -3 years
What is a soft sign finding for heel walking? Latest expected age of disappearance?
Difficulty remaining on heels for a distance of 10 feet. -7 years
What is a soft sign finding for tip-toe walking? Latest expected age of disappearance?
Difficulty remaining on toes for a distance of 10 feet. -7 years
What is a soft sign finding for tandem gait? Latest expected age of disappearance?
Difficulty walking heel-to toe, unusual posturing of arms. -7 years
Fixed tachycardia may indicate what?
Difficulty.
Why do lymph nodes in the neonate react quickly to a mild stimulus?
Possibly to compensate for a lack of antibodies by increasing filtration and phagocytosis.
A toddler abdomen protrudes slightly and described as ________.
Pot-bellied
Palatine tonsils are much larger during ________ than after ________ so enlargement may not be an indication of a problem
Early childhood. Puberty.
How do you test CNs IX and X in a child?
Elicit a gag reflex. Tip// Ask the child to just hold the popsickle stick. At some point they will likely put it in their mouth so that when you go to do the test, they are already familiar with it.
What can cause mottled or pitted teeth?
Enamel displasia due to tetracycline treatment during tooth development. -Can cause white spots and can be due to untrauterine exposure.
What is generalized seizure disorder?
Episodic, sudden, involuntary contractions of a group of muscles caused by excessive discharge of cerebral neurons. -75% of new cases develop during childhood and adolescence.
What is the most common brachial plexus injury in a newborn?
Erb's Palsy
What is Telipes Calcaneovalgus?
Exaggerated dorsiflexion that allows the dorsum of the foot to come into contact with the anterior aspect of the lower leg. -There is limited plantarflexion (90 degrees or less). -Results from uterine positioning with the foot against the wall of the uterus, forcing it into dorsiflexion. -May resolve spontaneously.
What is polydactyly?
Extra digits.
What is pseudostrabismus?
Eyes appear to be asymmetical due to facial features such as prominent epicanthal folds. -There is a symmetrical corneal light reflex.
Bilirubin level is not high if dermal icterus in only on the ________, but may be worrisome if it descends below the ________.
Face (5mg/dl). Nipples (>12mg/dl).
When looking for rebound tenderness you should observe the child's ________ and ________.
Facial expression and pupils.
T/F: Infants do not demonstrate nuchal rigidity until 3-6 months of age.
False. 6-9 months.
What is telangiectatic nevi?
Flat, deep pink, localized areas usually seen in the back of the neck. -Aka stork bites or salmon patch. -They are birth marks.
Crackles and Ronchi are common immediately after birth because________.
Fluid has not completely cleared yet.
What is metatarsus adductus?
Forefoot adduction that may be fixed or flexible. -Related to intrauterine positioning. -Heel and ankle are *uninvolved*. -Usually *self-resolving.* -Feet will often pronate slightly until ~30 months of age, but should be resolved in the toddler.
What is the foramen ovale?
Fossa in atrial septum that allows blood to pass directly from the right to left atrium.
What is one of the most easily missed findings in a newborn?
Fractured clavicle. -Eventually may notice a lump as the callus forms.
What are you looking for when doing an inspection of a child?
Fully undress the patient and offer a gown if age appropriate. -Arms and legs should be *freely moveable* (passive ROM). -Note symmetric flexion of extremities in a newborn. -Note symmetric *axillary, gluteal, femoral, and popliteal* creases. -Note symmetry of limb length or circumference.
What is syndactyly?
Fusion of digits.
What should you suspect if there is tympany with a distended abdomen?
Gas
What will deaden the neck righting reflex?
Gentle support on the abdomen. -Useful for if you are trying to adjust an atlas.
Risk factor for LGA infants.
Gestational diabetes
How do you test muscle strength in an infant?
Hold the infant upright with your hands under the axillae. -If the infant maintains the upright position then then have adequate should muscle strength (https://www.youtube.com/watch?v=Y4ev8PkfTv0). -If the infant slips through your fingers then they have muscle weakness (https://www.youtube.com/watch?v=tw6hhPD-3Aw).
What are you looking for when you ask a child to stand up from sitting?
Gower sign. -Child rises from a sitting position by placing hands on the legs and pushing the trunk up.
Have the parents assist you in the exam. If the baby won't open their eyes you can _______________________ Note their c___________, S_____, b________________, n_____________, p__________, r___________ & m__________ Note spontaneous activity between arms and legs limited hip abduction is a sign of ________
Have the parents assist you in the exam. If the baby won't open their eyes you can *dim the lights and hold the newborn upright* Note their *color, size, body poroprtions, nutritional status, posture, respirations and movements * Note spontaneous activity between arms and legs limited hip abduction is a sign of *hip dysplasia*
Heart rate is ________ on inspiration and ________ on expiration.
Heart rate is *faster* on inspiration and *slower* on expiration.
What is an alternate way to elicit the Moro reflex?
Hold the baby in front of you with the head supported and then just bend your knees quickly to elicit the reflex.
What is the parachute reflex?
Hold the infant suspended prone and slowly lower it head first toward a surface. Observe the infant extend its arms and legs (protecting itself). -The reflex should not disappear once developed. -If you don't have a parachute reflex and are learning how to walk then you are hitting your head a lot. -https://www.youtube.com/watch?v=eqDrMBGUqxc
What is the placing reflex? When does it go away?
Hold the infant upright and touch the dorsum of the foot to the edge of a flat surface. Observe flexion of the hips and knees and lifting of the foot (as if stepping up). -Age of disappearance varies.
What is the stepping reflex? When does it go away?
Hold the infant upright under the arms and allow the soles of the feet to touch the surface of the table. Observe for alternate flexion and extension of the legs (walking). -Disappears before voluntary walking. -https://www.youtube.com/watch?v=PfhbxYXqsY4
What should you be concerned about if the infant can't lift their head while prone at 2 months?
Hypertonia -DDX clavicle fracture, SCM or Trap spasm (torticollis), not getting enough tummy time.
What is the optical blink reflex?
Shine a light at the infant's open eyes and observe the quick closure of the eyes and dorsal flexion of the infant's head. -If there is no response then they have poor light perception. -https://www.youtube.com/watch?v=htGRKE8tGa4
What is caput succedaneum?
Subcutaneous edema. -Crosses suture lines. -MC in occiput region. -Soft, poorly defined margins.
When is periodic breathing problematic?
If apneic episodes are prolonged or if the baby becomes centrally cyanotic. -Persistence in preterm infants is relative to gestational age and apneic periods should diminish in frequency as they approach term status.
What is pathological jaundice?
If it is present in the first 24 hours or it is intense or persistent. -There may be RBC abnormalities and sensitivity, hemorrhage, impaired hepatic function, or infections such as toxoplasmosis, rubella, herpes, syphilis.
How do you measure height in a child?
If the child is able to stand without support use a stature measuring device. -Heels, buttocks and shoulders against the wall looking straight ahead.
What can cause a red reflex aside from your examination?
If the infant is crying or has recently cried vigorously, dilation of blood vessels can cause redness. So you cannot assume the reness is a middle ear infection.
What is the reflex to open hands?
If you stroke the ulnar side of their palm, then will open their fingers.
When observing chest expansion, what should you suspect if asymmetric?
Inability to fill one of the lungs due to possible pneumothorax or diaphragmatic hernia.
Describe otitis externa.
Infection of the auditory canal. -History of trauma or moist environment. -Itching in the ear canal. -Intense pain with movement of pinna such as chewing. -Discharge may be watery at first, then purulent and thick mixed with pus and epithelial cells. Foul smelling. -Conductive hearing loss. -Canal is red, edematous. Tympanic membrane obscure.
Describe bacterial otitis media.
Infection of the middle ear. -Fever, feeling of blockage, tugging earlobe, anorexia, irritability, dizziness, vomiting and diarrhea. -Deep-seated earache. -Discharge if tympanic membrane ruptures or through tympanostomy tubes. Foul smelling. -Conductive hearing loss due to pus. -Tympanic membrane may be red, thickened, bulging. -Full, limited, or no movement of TM.
What is meningitis?
Inflammatory process in the meninges. Can be bacterial, viral, or fungal. -Often colonizes in the upper respiratory tract.
Newborns may have a ________ murmur until the foramen ovale and ductus arteriosus close.
Innocent
Innocent murmers typically disappear within ______ days, are a Grade ____ intensity, are systolic, and are ________ by other signs and symptoms.
Innocent murmers typically disappeas within *2-3* days, are Grade *I-II* intensity, are systolic, and are *unaccompanied* by other signs and symptoms.
The umbilical stump should be dry and odorless. It is usually ________, but can ________ with increased abdominal pressure.
Inverted. Evert.
What is dermal melanocytosis?
Irregular areas of blue-gray pigmentation usually in the sacral and gluteal regions. -Aka Mongolian spots (not p.c.). -Seen predominantly in African, Native American, Asian, or Latin descent.
What is a soft sign finding for rapid alternating movements of the hands? Latest expected age of disappearance?
Irregular speed and rhythm with pronation and supination of hands patting the knees. -10 years
What is the white reflex?
It is abnormal. Indicates congenital cataracts or retinoblastoma.
What is cephalhematoma?
Subperiosteal bleed. -Does not cross suture. -MC in parietal region. -Firm, well-defined edges.
What are some common causes of SGA?
Substance abuse, smoking, maternal health, teen moms.
It is never normal for ________ lymph nodes to be enlarged.
Supraclavicular
What is subluxation dysplasia?
It is an incomplete dislocation where the femoral head remains in contact with the acetabulum but the joint ligaments and capsule are stretched, allowing displacement of the femoral head. -Femur is in acetabulum, but is sliding around.
Why is the position of the ear important?
It is assocaited with some congenital syndromes and kidney function/development.
How often is head circumference measured?
It is done at every health visit until 2 years of age and then yearly from 2-6.
Where is the spleen palpable?
It is palpable 1-2 cm below the left costal margin for the first few weeks after birth.
What is acetabular dysplasia?
It is the *mildest form* of dysplasia and is a delay in ossification of the acetabulum. The acetabulum is oblique and shallow.
Why should you limit palpation of a mass is suspicion of neoplasm exists?
It may cause injury or spread of malignancy.
What is Biedermann KISS?
Kinetic Imbalance due to Suboccipital Strain. -Can be in KISS I (fixed lateroflexion) or KISS II (fixed retroflexion). -SUBLUXATION. Correction is to ADJUST the upper cervical complex.
What are you looking for when observing the head and neck?
Looking for head control, position, movement, jerking, tremors, torticollis.
Which sinuses are present at birth?
Maxillary and ethmoid, although they are very small. -Sphenoid sinus is a tiny cavity and not full developed until puberty. -Frontal sinus develops by 7-8 years.
What is a diaper rash?
May be due to acid urine output, yeast, etc. -Pictured here is bacterial (red areas) and yeast (shiny white areas).
How do you measure chest circumference?
Measure around the nipple line to the nearest 1/8 inch or .5 cm.
What does peristalsis sound like in a newborn?
Metalic tinkling.
What is the most common congenital foot deformity?
Metatarsus adductus
What is distasis recti?
Midline separation (1-4cm) of the rectus abdominus between the xiphoid and umbilicus.
Where does the frenulum normally attach?
Midway between the ventral surface of the tongue and its tip.
What are the problems associated with preterm AGA infants?
More prone to: respiratory distress syndrome, apnea, patent ductus arteriosus, & infection.
Who gets idiopathic structural scoliosis?
Most common in girls. Progresses during early adolescence.
What is the treatment for Talipes Calcaneovalgus?
Most resolve spontaneously. -Gentle plantar flexion stretching with mild inversion of the foot repeated 10 times a day or with each diaper change may help. -Occasionally serial casting is needed.
What is baby bottle syndrome?
Multiple brown caries on upper and lower incisors due to bedtime bottle of juice or milk. -Breast-fed babies don't usually get this because of the antimicrobial properties of the fresh milk.
What is coarctation of the aorta?
Narrowing in a portion of the aorta just past the branches that go to the extremities and the head. Most commonly the descending aortic arch near the origin of the left subclavian artery and ligamentum arteriosum. -This results in a bounding pulse in the arms and a barely palpable pulse in the legs. -They will have elevated blood pressure in the head and cold feet all the time.
Age descriptors for: Neonatal Newborn Postneonatal Infant Toddler Child
Neonatal: 1-28 days Newborn: birth to 2 months Postneonatal: 29 days- 1 year Infant: 0-1 year Toddler: 1-2 years Child: 2+ years
What must you do if a child has a first time headache or a headache that is not getting better?
Neuro exam, cause we're doctors.
Once the plantar reflex has gone it should ________.
Never come back. Ex// If a 1 year old does not have it that is normal. If you do subsequent exams a few months later and it is back, then you need to investigate further for other neurologic issues.
What are neurological soft signs?
Nonfocal, functional neurologic findings that provide subtle cues to an underlying CNS deficit or a neurological maturation delay. -Children with multiple soft signs are often found to have learning problems. -One sign alone is not indicative of anything. When there is a patter of signs is when you need to look further.
How does normal pulse change with age?
Normal for a newborn is 120-170 and it slowly decreases as the child ages. By 10 years normal is 70-110.
How does normal respiratory rate change with age?
Normal for a newborn is 30-80, then it steadily decreases to 16-20 by 10 years. -In a newborn, take respiratory rate over a longer time because it is normal for them to stop for a little bit and then play catch-up.
When doing a neurologic exam on a child, when should you be looking for during your observation?
Observe the child at play to assess fine motor coordination. Observe skill in reaching for, grasping, and releasing toys. -There should be no tremors or constant over shooting. -https://www.youtube.com/watch?v=8uVdI6WLeLk
What is esotropic strabismus?
One or both eyes are turned inwards. -Asymmetrical light reflex.
What is oral candidiasis?
Oral thrush. -Scrape any white patches with a tongue blade. -Nonadjerent = milk deposits. -Adherent = candidiasis and can bleed if scraped too hard.
What should you do if you suspect hip dysplasia?
Order imaging, either ultrasound or plain film depending on age.
How do you examine the bladder?
Palpate and percuss over the suprapubic area. Determine the size. -Distended will be firm, central, and dome-shaped.
What are you looking for when palpating?
Palpate for fractures, dislocations, crepitus, masses, and tenderness.
What is obstructive sleep apnea?
Periodic cessation of breathing during sleep due to airflow obstruction. -Can be seen in children with excessively large tonsils. -May result in loud snoring, restless sleep, daytime sleepiness, morning headaches, developmental delay, and frequent infection.
What is the infantile Head-lag?
Place the infant supine and elevate the upper back to let the head fall back into extension. -Helps with neck inspection.
What is the liver scratch test?
Place the stethoscope where you know there is liver and with the other hand begin below the liver and scratch the skin while moving upwards towards the liver. When the scratching sound becomes audible, you are over the liver. https://www.youtube.com/watch?v=DBif1jjAfKk
What is the sucking reflex?
Place your finger in the infant's mouth. Should feel a sucking action and the tongue should push up against your finger with good strength.
What is the reverse tailor position?
Places stress on joints and is related to intoeing and femoral anteversion.
What does it mean if head circumference grows slowly or falls off percentile curves?
Possible microcephaly. DDX craniosynostosis.
What is the purpose of the tongue thrust reflex?
Prevents them from choking.
What are epicanthal folds?
Prominent in asian populations, down syndrome.
What is an umbilical hernia?
Protrusion of the omentum and intestine through the umbilical opening.
What can cause black or grey colored teeth.
Pulp decay due to oral iron therapy.
What is a soft sign finding for rapid thumb-to-finger? Latest expected age of disappearance?
Rapid touching thumb to fingers in sequence is uncoordinated. Unable to suppress mirror movements in contralateral hand. -8 years
________ reflex should be elicited in every newborn to observe for opacities, dark spots, or white spots within the circle of red glow.
Red
What is the expected motor development by 4 months?
Rolls from prone to supine.
How long does drooling persist?
Salivation increases by 3 months and infants drool until swallowing is learned. -If it persists past 12 months, consider a neurologic disorder. -If drooling is acute in an older child, consider epiglotitis.
Gums should be smooth and have a _________ edge along the buccal margins.
Serrated.
How should a newborn look upon inspection during a heart exam? What are some abnormal findings?
Should be pink in color. -Purplish: think polycythemia. -Ashy white: think shock. -Central cyanosis: think congenital heart disease.
What is the ductus arteriorsus?
Shunt that connects the main pulmonary artery to the proximal descending aorta. It allows most of the blood from the right ventricle to bypass the fetus's fluid-filled non-functioning lungs.
What is a simian crease?
Single crease extending across the entire palm. -Indicative of down syndrome or other congenital syndromes.
Sinus arrhythmia is ________ and rate varies in a ________ pattern.
Sinus arrhythmia is *common* and rate varies in a *cyclical* pattern.
What "homework" can you give a child that sits in the reverse tailor position?
Sit criss cross apple sauce.
What is the expected motor development by 6 months?
Sits using tripod position.
What is tibial torsion?
Slight varus curvature of the tibia related to fetal positioning. -Expected to resolve after months/years of weight bearing.
What is Ortolani's test?
Slowly abduct the thighs, maintaining axial pressure and with the fingertips on the greater trochanter, exert a lever movement in the opposite direction. -If there is a *palpable clunk*, the femur head has slipped back into the acetabulum. -*Clicks are ok, clunks are bad.*
Small for gestational age can be caused by things like _____________, ___________ Large for gestational age can be caused by things like __________
Small for gestational age can be caused by things like *pre-eclampsia, smoking* Large for gestational age can be caused by things like *diabetes*
A ________ is frequently followed by a deep breath in an infant, allowing for evaluation of vocal ________ and feeling for ________.
Sob. Resonance. Tactile Fremitus.
What is the expected motor development by 12 months?
Stands without support momentarily.
What is a soft sign finding of walking/running gait? Latest expected age of disappearance?
Stiff-legged with a foot slapping quality, unusual posturing of the arms. -3 years.
What should you do if you make the decision to refer out while you are doing an exam?
Stop the exam because whoever you are referring to is going to repeat all of the tests and once a child has experienced palpation or other test that is too intense, a subsequent examiner has little chance for easy access to the abdomen.
What is the Landau reflex? When does it disappear?
Suspend the infant prone over both hands and observe the infant's ability to lift its head and extend its spine on a horizontal plane. -Diminishes by 18 months, disappears by 3 years. -https://www.youtube.com/watch?v=XSS0GibDyBk
What is the Galant reflex?
Suspend the infant prone over your hand and stroke *paraspinally* from the shoulder to the sacrum. The trunk should curve toward the side stroked. -If you don't get a symmetrical response, then switch the hand that you are holding them with because it may be interfering with the response. -https://www.youtube.com/watch?v=Yy9R3pF1rJc
What is the Perez reflex?
Suspend the infant prone over your hand and stroke over the *spinous processes* from sacrum to occiput. The infant extends the head and brings knees to chest. May urinate. -(Pee for Perez) is an incidental finding.
How do you test CN IX and X?
Swallowing, gag reflex.
How should pulse be taken?
Take UE and LE pulse in case of coarctation of the aorta. -Apical pulse at the 3rd-5th intercostal space in the midclavicular line. -Femoral pulse (halfway from the pubic tubercle to ASIS).
What are natal teeth?
Teeth or tooth buds in a newborn. There is the potential for aspiration so they may be removed.
What is Slipped Capital Femoral Epiphysis?
The capital femoral epiphysis slips over the neck of the femur. -Most common in 8-16 year olds. -Affected girls tend to be younger than boys. -75% are unilateral, with the left side more commonly involved. -Presents with knee pain and limp. -Commonly obese, taller than most. -Leg weakness and reduced internal hip rotation.
When does diastasis recti require surgery?
Where there is herniation through the rectus abdominus.
What is dislocation dysplasia?
The femoral head loses contact completely with the acetabular capsule and displaces over the fibrocartilaginous rim.
What is respiratory grunting?
The infant tries to expel trapped air or fetal lung fluid while trying to retain air and increase oxygen levels.
The longitudinal arch of the foot is obscured by a ________ until about ____ years of age. What is this called?
The longitudinal arch of the foot is obscured by a *fat pad* until about *3* years of age. -*Pes planus* is normal in the infant.
If a palpable mass is found in children that is non-pulsatile, non-moveable, and firm then what should you suspect?
Wilm's tumor or nephroblastoma.
What is the allergic salute?
Wiping the nose with an upward sweep of the palm of the hand. If repeated enough, causes a nasal crease.
The A-P diameter of the chest is approximately _______ compared to the transverse measurement.
The same as.
What does it mean if head circumference increases rapidly or rises above percentile curves?
There may be increased intracranial pressure. DDX hydrocephalus.
What should you suspect if the infant does not turn their head to the left or right when you test the rooting reflex?
They recently ate.
How are tonsils assessed?
They should blend with the color of the pharynx. -Peak size is between 2-6 years of age. -They are graded to describe their size. 1+ = Visible 2+ = Halfway between tonsillar pillars and the uvula. 3+ = Nearly touching uvula. 4+ = Touching each other.
What may be a sign of neurodevelopmental delays with the neck righting reflex.
They should turn in a corkscrew pattern (head, then shoulders, then hips, then legs). -If there are altered patterns (ex// belly, then leg, then head) there may be neurodevelopmental delays. Also associated with Autism.
What should you suspect if there is a unilateral decreased response to the rooting reflex?
Think something impeding that side such as clavicle fracture, torticollis, TMJ injury.
What must you do when you have a child with a first-time seizure?
Thorough neurologic exam.
What is an allergic (adenoidal) face?
Tired and droopy appearance (due to swelling of the adenoids).
What is the plantar grasp reflex? When does it go away?
Touch the plantar surface of the infant's feet at the base of the toes. Toes should curl downward. -Strong up to 8 months. -https://www.youtube.com/watch?v=BF1j1PXRq-I
What is Osgood-Schlatter?
Traction apophysitis. -Develops in association with inflammation of the anterior patellar tendon. -Self-limiting. -Most common in boys 9-15 years old. -Pain and swelling of the tibial tuberosity aggravated by activity (especially involving quadriceps). -May present with a limp.
What is cutis marmorata?
Transient mottling when the infant is exposed to decreased temperature.
Localization of breath sounds is difficult in an infant because they are easily ________ from one segment to another.
Transmitted
T/F: Hip dysplasia is commonly seen along with torticollis.
True
True/false: A murmur may not indicate a significant congenital anomaly.
True
True/false: A significant congenital anomaly may be unaccompanied by a murmur.
True
True/false you should never rule out sinusitis based on age.
True. There is wide variation in sinus development.
True/false: In most cases of diastasis recti, there is no need to repair it.
True. Usually resolves by 6 years of age (self-limiting).
How should light palpation be performed on a newborn?
With baby's knees flexed, place your hand gently on the abdomen with the thumb at the RUQ and the index finger at the LUQ. Press very gently at first, only gradually increasing pressure. -Identify the spleen, liver, and masses close to the surface.
How do you assess for genu varum?
With child standing, ankles together, keep your eyes at their knee level and measure the distance between the knees. -Genu varum is 1 inch between the knees.
Umbilical hernia is ________ in infants, reaches maximum size by ____ month, and generally closes spontaneously by ________ years.
Umbilical hernia is *common* in infants, reaches maximum size by *1* month, and generally closes spontaneously by *1-2* years. -It should reduce with light pressure.
What is a soft sign finding for finger-nose test? Latest expected age of disappearance?
Unable to alternately touch examiner's finger and own nose consecutively. -7 years
What is a soft sign finding for hopping in place? Latest expected age of disappearance?
Unable to hop rhythmically on each foot. -6 years
What is a soft sign finding for stereognosis? Latest expected age of disappearance?
Unable to identify common objects placed in their hand. -5 years
What is a soft sign finding for graphesthesia? Latest expected age of disappearance?
Unable to identify geometric shapes you draw in child's open hand. -8 years
What is a soft sign finding for right-left discrimination? Latest expected age of disappearance?
Unable to identify right and left sides of their own body. -5 years
What is a soft sign finding of one-foot standing? Latest expected age of disappearance?
Unable to remain standing on one foot longer than 5-10 seconds. -5 years
Percussion is usually ________ in an infant.
Unreliable. Because the examiner's fingers are too large.
Upon abdominal auscultation of a newborn, bowel sounds should be present ____ hours after birth and peristalsis should be heard every ____ seconds. No ________ or ________ should be detected.
Upon abdominal auscultation of a newborn, bowel sounds should be present *1-2* hours after birth and peristalsis should be heard every *10-30* seconds. No *bruits* or *venous hum* should be detected.
How do you assess deep tendon reflexes in a child?
Use the same technique and grading as for an adult. -Responses should be the same. -May use a finger instead of reflex hammer as it is less threatening. -This doctor does a terrible job: https://www.youtube.com/watch?v=Q33761f1T50
What is Allis' sign?
Used to detect a shortened femur. -With the infant supine, flex both knees keeping the feet flat on the table and femurs aligned. Observe the height of the knees. -Positive test is unequal height.
How do you measure weight in an infant?
Using an infant platform scale.
Heart rate in infants and children is extremely ________.
Variable
Infection of one or more paranasal sinuses may be a complication of what?
Viral UTI, dental infection, allergies, structural defect of the nose, or foreign object.
What is an easy way to examine a child's ROM, joint function, bone stability, and muscle strength?
Watch the child play. Suggest that they jump, hop, climb, play with toys, etc.
When performing deep palpation of the abdomen, what are we looking for?
We are palpating all quadrants for masses and noting the location, size, shape, tenderness, and consistency.
After 3, the longitudinal arch should be apparent when not ________.
Weight bearing.
What to ask on a past medical history Neonatal... Age they where able to.... Breast or bottle.... Diet and appetite...
What to ask on a past medical history Neonatal - Congenital anomolies - APGAR/Hospital stay - Jaundice, prescriptions, bleeding Age they where able to.... - Hold head erect - Roll/Stand/Walk - Use words/sentences - Dress self, - Toilet trained - Dentition - Growth Breast or bottle.... - Formula/breast milk - Frequency - Amt consumed - Weight gain/growth Diet and appetite - When intro solids - 3 feedings per day? - age weaned - Food preference - Ability to feed self Illnesses/Vaccines Maternal gestational history
When observing posture and movement, movements should be ________, with no ________.
When observing posture and movement, movements should be *symmetric*, with no *twitching*.
How do you test for nasal patency?
With 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 throught the noncompressed naris. -DDX septal deviation, choanal atresia.
How do you assess for tibial torsion?
With the child prone, flex the knees to 90 degrees and align the midline of the foot parallel to the femur. Using the thumb and index finger, grasp the medial and lateral malleoli. Place the other thumb and index finger on either side of the knee. -If your thumbs are not parallel to each other then there is tibial torsion.
How do you assess for genu valgum?
With the child standing and knees together, measure the distance between the medial malleoli. -Genu valgum is 1 inch of space between the ankles.
What is Barlow's test?
With the infant supine, flex the hips and knees to 90 degrees, grasp a leg with each hand, adduct the thighs to the maximum and apply downward pressure on the femur. -The doctor's thumbs should touch. -Attempts to disengage the femoral head form the acetabulum.
What is the neck righting reflex? When does it appear?
With the infant supine, turn the head to the side and observe the infant turn its whole body in the direction the head is turned. -Appears around 3 months after the asymmetric tonic neck reflex disappears. -https://www.youtube.com/watch?v=ArhL_1Q9icg
What is the Moro reflex? When does it go away?
With the infant supported in a semi-seated position, allow the head and trunk to drop back to a 30 degree angle and observe symmetric abduction and extension of the arms. -Fingers fan out and the thumb and index finger form a C. -The arms then adduct in an embracing motion, followed by relaxed flexion. -Legs follow a similar pattern. -Diminishes in strength by 3-4 months. -https://www.youtube.com/watch?v=7oD6set72lo
What is the palmar grasp reflex? When does it go away?
With the infant's head midline, touch the palm of the infant's hand from the ulnar side and note the strong grasp around your finger. -*Sucking fascilitates the grasp*. -Strongest between 1-2 months. -Disappears by 3 months. -https://www.youtube.com/watch?v=BF1j1PXRq-I
How do you test sensory function in an infant?
Withdrawal of limbs to a painful stimulus. -We are looking at *gross response* to stimulus. -Can also use primitive reflexes.
When should a heart exam be performed?
Within the first 24 hours and again at 2-3 days of life because there are changes from fetal to systemic and pulmonic circulation that need to be evaluated.
What are the normal pulse rates for infants? Newborn 1 yr 3yrs 6yrs 10yrs Respiration?
newborn: 120-170 1 yr: 80-160 3 yrs: 80-120 6 yrs: 75-115 10 yrs: 70-110 Respiration 1yr: 30-80 3yrs: 20-40 6 yrs: 16-22 10yrs: 16-20
