Examination of the Infant

Infants 1 week to 6 months of age can be examined on the examination table with a parent standing nearby. It may be easier to perform part of the examination while the infant is in the parent's arms or lap. Infants 6 months to 1 year of age are best examined on the parent's lap. The examiner should also be seated, at the child's level.

The more difficult portions of the examination, such as the evaluation of the pharynx and the otoscopic examination, should be performed last. To listen to the lungs and heart, take advantage of any time when the infant is quiet. Observation is a key element of the examination; the most meaningful assessments of the child's respiratory state, or use of arms and legs, are often obtained when the child is unaware of being observed.

The information for the review of systems for an infant comes entirely from the parent or another adult. Children this age cannot tell you that they have pain except by crying or being irritable;thus, a major challenge in examining a child of this age is to localize the pain.

Inquire about the following:

General: fever, activity level, sleeping, feeding.

Head, eyes, ears, nose, and throat (HEENT): bulging or sunken fontanelle, nasal discharge, stuffiness, drooling, ear pulling or rubbing, ear discharge. Does child see? hear? have crossed eyes? Is there excessive or decreased tearing?

Heart: history of murmur, cyanosis; trouble feeding, sweating during feedings, squatting (in older infants and toddlers: this is a symptom in children with tetralogy of Fallot, because squatting increases peripheral resistance and decreases the right-to-left shunting across the ventricular septal defect).

Respiratory: cough, difficulty breathing (fast or effortful breathing);noisy breathing, hoarseness.

Abdomen: Feeding pattern, stool pattern, diarrhea, distention, mass, jaundice, crying and drawing up legs (characteristic of intussusception).

Genitourinary: frequency of voids/wet diapers;strength of urinary stream;crying with voiding, vaginal discharge, skin irritation in diaper area. In the older infant, there should be periods when the diaper is dry, indicating the development of an increased bladder capacity.

Skin: Is there a rash? itching? easy bruising? change in birth marks?

Musculoskeletal: Is there equal use of both hands? of both legs? Is there pain or deformity of an extremity?

Neurologic: Is there any seizure activity or other abnormal movements? How is the child's developmental progress (described previously)? Has there been loss of previously attained milestones?

Before starting the examination, wash your hands in warm water. General Assessment

Observe the infant's activity, alertness, and social responsiveness.

Is any distinctive body odor present? Some inborn errors of metabolism are associated with characteristic odors, such as the odor of maple syrup in branched-chain aminoacidopathy, sweaty feet in isovalericacidemia, fish in methionine metabolism aberrations, and acetone in diabetic ketoacidosis. These odors, however, are rarely observed.

The infant's temperature is usually measured by the nursing staff. It should be done rectally, as described for the newborn, until the child is at least 6 months of age.* After that, there are a number of devices for estimating the child's temperature in a less invasive way. For the first 3 months after birth, a temperature of 100.4° F, or 38° C, is considered elevated and may indicate that the child has a serious bacterial infection.

The average heart rate of a child during the first 6 months of life is 130 beats per minute, with a range of 80 to 160 at rest. The average resting heart rate during the second 6 months of life is 110 beats per minute, with a range of 70 to 150. The normal respiratory rate varies from 20 to 40 breaths per minute. Blood pressure is difficult to assess in this age group but may be determined by the flush method. In this technique, the arm is elevated while the uninflated infant cuff is applied to the arm. The examiner then presses on the arm from the fingers to the elbow so that blanching is noted. The cuff is inflated to just beyond an estimated blood pressure. The pale arm is then placed at the infant's side, and the cuff pressure is allowed to fall slowly. A sudden flush of color occurs at a level slightly lower than the true systolic pressure. The systolic blood pressure of a 1-day-old infant determined by the flush method is 50 mm Hg. By the second week after birth, the systolic blood pressure has risen to 80 mm Hg. By the end of the first year, the systolic blood pressure is 95 mm Hg. A more accurate Doppler blood pressure assessment is available for critical determinations.

Determine the infant's length and weight. Plot these measurements on the standard growth charts. Growth charts are used to determine whether a child is growing according to a group of standards. More important than a single value is the use of these charts to follow the rate of change at subsequent examinations. The National Center for Health Statistics publishes a variety of growth charts for boys and girls in two age groups: birth to 36 months and 2 to 20 years. Examples of these charts are shown in Figures 24-24 and 24-25, and the charts are available at the web site of the Centers for Disease Control and Prevention, www.cdc.gov (accessed June 26, 2008). Note that the current growth charts also include a chart for body mass index (BMI), which varies by age; specifically, preschool children have much lower BMI than do infants or older children. Growth charts are now available for children with trisomy 21, achondroplasia, and Turner's syndrome. For children with these syndromes, growth should be plotted on the disease-specific curves whenever possible.

Somatic growth is one of the most important parts of the pediatric examination. These parameters must be determined at every visit. Deviations from the standard curves are often early sensitive indicators of a pathologic process

Getting Back Into Shape After The Pregnancy

Getting Back Into Shape After The Pregnancy

Once your pregnancy is over and done with, your baby is happily in your arms, and youre headed back home from the hospital, youll begin to realize that things have only just begun. Over the next few days, weeks, and months, youre going to increasingly notice that your entire life has changed in more ways than you could ever imagine.

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