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Chapter 18 Assessing Children: Infancy Through Adolescence

Chapter 18 Assessing Children: Infancy Through Adolescence. Areas of Assessment. Physical development Assessed in depth at each visit Cognitive development Assessed generally at each visit Social and emotional development Assessed generally at each visit. Stages of Development.

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Chapter 18 Assessing Children: Infancy Through Adolescence

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  1. Chapter 18Assessing Children: Infancy Through Adolescence

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

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

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

  5. General assessment – Apgar score Sequence of examination: Careful observation of activity Head, neck, heart, lungs, abdomen, genitourinary system Lower extremities, back Ears, mouth Eyes whenever they open spontaneously Skin (throughout the exam) Vernix caseosa: present at birth Lanugo: shed within the first few weeks of life Nervous system Hips Newborn Assessment

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

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

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

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

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

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

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

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

  14. Infancy: Physical Examination Features (cont.) • Musculoskeletal • Inspect the spine • Palpate the clavicle, hips, legs, and feet • Bowlegged growth to age 18 months is normal

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

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

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

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

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

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

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

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

  23. Middle Childhood (5 to 10 years):Physical Examination Unique Features • Physical examination is more straightforward; the same sequence that is used in adults can be used starting in this age group

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

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

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

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