- the opportunity to do this test should be taken whenever an infant is alert with open eyes (even during history taking)

Red reflex test

- mother's OB hx, amount/type of prenatal care, where baby was delivered, complications

History taken from parent w/ infant exam

- infants become anxious about the examination at this age

7-8 months

- begin exam with this

- note "funny looking" features, parent-child interaction, and overall appearance of health

Careful observation

- auscultate heart and lungs when infant isn't crying

- if crying, attempt to listen to heart at this time, and lungs at this time

between cries/during inspiratory part of cry

- these parts of the exam should be done last

ears, throat and hips

- heart, eyes, pulses, hips, and genitourinary

Essential parts of infant exam

- speak to child first, call them by name, then hx from parent

- w/ child on mother's lap, make exam fun (let them see your equipment)

- don't ask permission

- examine heart, lungs & abdomen first, ears/throat last

- essential for this age group is heart, eyes (strabismus) and genitourinary (undescended testicles or imperforate hymen)

- anticipatory guidance regarding diet, development and particularly safete

- lead screening

Toddler Exam (1 yr - 2 1/2 yrs)

- recognize child by name, obtain partial child hx, then finish w/ parent

- explain to child what you are doing, allow them to participate

- child will usually cooperate (top to bottom perspective)

- check about school performance, screen for hearing, vision, anemia, scoliosis

- safety should be stressed

Older toddler and school-aged child

(2 1/2 yrs to teenager)

- take history w/ both parent and teen, talking mostly to teen, emphasize that you are teens dr

- ask parent to leave the room, discuss limits for confidentiality, obtain social, school, sexual and drug histories, as well as familial relationships

- ask the pt when parent should be invited back

- address teen's concerns (acne)

History taking with Teens

- male teens should have this chaperone-required exam due to risk of cancer

Testicular exam

- these teens should have pelvic exams and Pap smears

Sexually active females

- this should be taught to teen girls

- not necessary to do exam, but needs to be taught

- be aware of pt discomfort with issues

Breast self examination

- this staging tool should be done with breast, pubic hair, and male genitourinary development

Tanner staging

- prepubertal, breast bud, increased size of breast tissue, separation of areola above breast tissue, adult breast

Breast development Tanner stages

- prepubertal, light/straight/sparse hair, darker/coarser hair, adult type pubic hair/limited to pubic area, adult pubic hair extended onto medial thighs/toward umbilicus

Pubic hair Tanner stages

- prepubertal child, enlargement of testes and scrotum, increase in penile length and testes growth, increased penile breadth and length/glans development/darkening of scrotal skin/larger testes, adult

Male Genitourinary Tanner stages

- peak height velocity occurs during these tanner stages

II-III

- menarche occurs in this tanner stage

IV

- in Tanner stage IV, this occurs for boys

Peak height velocity

- avg age for menarche in the US and the avg age for onset of puberty in girls

12/9-10 yrs

- avg age for onset of puberty in boys in US

11-12 yrs

- puberty before age 7 in caucasian girls, age 6 in African American girls, age 9 in boys

Precocious puberty

- delayed puberty is diagnosed if there are no changes by this age in girls

14

- these levels can be measured in conjunction with adrenarche or onset of pubic hair development

dehydroepiandrostenedione sulfate (DHEA-S)

- these are indicated only when there is a history of sexual activity when the child is 18 yrs of age or older or when child reports gynecologic problems

Pelvic exams

- not routinely done on any pediatric pt

- should be performed with chief complaint suggestive of GI disease (constipation or abdominal pain)

Rectal exams

- characteristic facial features with upward-slanting palpebral fissures, epicanthal folds, flat nasal bridge

- Brushfield spots, simian crease, wide space between 1st and 2nd toes, short 5th finger, small ears, flat occiput

Down's syndrome

- narrow and widespread eyes, long single philtrum, thin upper lip, short nose, and hypoplasia of the nails and distal phalanges

- microcephaly, growth deficiency, congenital heart dx, IQ 50-80, hyperactive, problems with fine motor skills

- 30-50% of chronic severe alcoholics

Fetal alcohol syndrome

- child's cry, child's alertness, interaction w/ parent, state of nutrition, symmetrical movements

General Inspection of Child

- vital signs that are generally higher than adult levels

Temp, HR, Respiratory rate

- age when oral temperature can be taken

7

- not uncommon in children

- starts and stops abruptly

- HR is usually greater than 200

- may present with irritability, decreased feeding and increased respirations

Supraventricular Tachycardia (SVT)

- common in young children

- rate increases during inspiration and decreases during expiration

- normal finding in children over age 3

Sinus arrhythmia

- this type of breathing is predominant in small children

- makes watching abdominal excursions more useful than chest when counting breathing rate

Diaphragmatic breathing

- difference between periodic breathing and apnea is a matter of this time being the indicator of apnea and the appearance of cyanosis, pallor, or HR change

>20 seconds

- should be measured in every child over 3 yrs

- increases throughout childhood

- if elevated, must measure on all 4 extremities

- if high levels found, look for cause

Blood pressure

- this should be recorded and plotted on charts at every visit

- pattern is more important than position

Height and Weight

- growth curve that falls should lead to this

Further evaluation

- most common cause of failure to thrive (growth)

Psychosocial deprivation

- weight decreases first, then height, finally head circumference

Failure to thrive

- this should be measured at every visit until 3 yrs and plotted on a chart

- macro/microcephaly need to be further evaluated

- 85% of abnormal findings (2+ sd's above/below mean) have mental retardation

Head circumference