General Considerations

Since the late 1920s, awareness of the importance of child health care has increased. Along with better control of infectious disease and great strides in nutrition and technology has come the recognition of the importance of the behavioral and social aspects of a child's health. Despite the many advances and the marked reduction in infant mortality rates, the neonatal period remains a time of very high risk.* In 2004, a total of 27,936 deaths occurred in children younger than 1 year, an infant mortality rate of 6.8 per 1000 live births;70% of these deaths occurred in the first month after birth, almost all of those in the first week.{ The three leading causes of neonatal death were congenital malformations, deformations, and chromosomal abnormalities (20%);disorders related to short gestation and low birth weight (16%);and maternal complications of pregnancy that affected newborns (5.4%).

Unintentional injury and sudden infant death syndrome (SIDS) are the leading causes of infant mortality after the first month of life. SIDS is the leading cause of death among infants aged 1 to 12 months and is the third leading cause overall of infant mortality in the United States. Although the overall rate of SIDS in the United States has declined by more than 50% since 1990, thanks to the ''Back to Sleep'' campaign, rates have declined less among non-Hispanic African-American and American Indian/Alaska Native infants. SIDS is defined as the sudden death of a healthy infant younger than 1 year that cannot be explained after a thorough investigation is conducted, including a complete autopsy, examination of the death scene, and review of the clinical history. Preventing SIDS remains an important public health priority. Several risk factors have been associated with SIDS, including prone sleeping, sleeping on soft

*Centers for Disease Control and Prevention and National Center for Health Statistics at www.cdc.gov/ VitalStats.

{Data from National Center for Health Statistics, 3700 East-West Highway, Hyattsville, Md 20782.

This chapter was written in collaboration with Margaret Clark Golden, MD, and Robert W. Marion, MD. Dr. Clark Golden is Clinical Associate Professor of Pediatrics and Director of the Third Year Pediatric Clerkship at the State University of New York (SUNY) Downstate College of Medicine, Brooklyn, NY. Dr. Marion is Professor of Pediatrics & Obstetrics and Gynecology and the Ruth L. Gottesman Professor of Developmental Pediatrics at Albert Einstein College of Medicine. He is also the Director of the Center for Congenital Disorders, Children's Hospital at Montefiore Hospital, Bronx, NY.

surfaces, loose bedding, overheating as a result of overdressing, smoking in the home, maternal smoking during pregnancy, bed sharing, and prematurity or low birth weight. In a small portion of cases, SIDS seems to be caused by a mutation in a gene that leads to a cardiac channel-opathy, resulting in prolonged QT interval and other arrhythmogenic states.

Unintentional injury remains the top killer of children aged 1 to 14 years,* ahead of cancer and birth defects. More than 5300 children in the United States died in 2004 from unintentional injuries—an average of 15 children each day. Motor vehicle occupant injury is the leading cause of injury-related death among all children after infancy. Death from airway obstruction is the leading cause of injury death for children younger than 1 year, and drowning follows motor vehicle injuries for children aged 1 to 14 years. Poverty is the primary predictor of fatal injury; male sex and race are additional factors. Native American and African-American children are the groups at highest risk;they are about twice as susceptible to fatal injury as are white children.

Previous chapters discussed the history and physical examination as they relate to adult patients. This chapter discusses the differences related to physical diagnosis in the pediatric age group. The field of pediatrics is broad and encompasses birth through adolescence, often defined as up to age 22. During this period, there are enormous changes in children's emotional, social, cognitive, and physical development, all of which must be discussed thoroughly.

This chapter is organized somewhat differently from the previous chapters. The first section is devoted to the pediatric history, which is similar in most pediatric age groups but differs in important ways from the adult history. The sections that follow are devoted to the physical examinations of the following age groups:

# Neonatal period (birth to 1 week of age)

Toddler and early childhood (1 to 5 years of age)

# Late childhood (6 to 12 years of age)

Most of this chapter is devoted to the first three groups because the order and techniques of examining children 6 to 22 years of age are similar to those for adults.

The reader is advised to watch the video presentation on the DVD-ROM attached to this book to review the physical examinations of the newborn and the toddler, as well as specific pointers about the neurologic assessment at these ages. The DVD-ROM also contains a demonstration of an adolescent history with a standardized patient.

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