Measure the occipitofrontal head circumference, as indicated previously, and chart it on the standard growth charts (see Fig. 24-24). A head that is growing too rapidly should be evaluated for hydrocephaly. Microcephaly is a defect in which the head size is three standard deviations below the normal mean and is related to a defect in brain growth. Check for asymmetry.

Is the face symmetric? An easy way to detect facial paralysis is to observe the child when he or she cries. The weakened or paralyzed side appears expressionless in comparison with the normal side.

Immersion Burn
Figure 24-32 Hot water immersion burns.

As mentioned previously, asymmetry of the skull and face may be the result of a deforma-tional process: that is, environmental forces acting on normal tissue. It has been found that infants who are put to sleep on their backs are less prone to SIDS. However, sleeping in the same position may cause the skull to become lopsided, or plagiocephalic; this shift in head shape also causes an asymmetry of the facial structures. This asymmetry is self-limited, however, and resolves soon after the infant begins to sit upright.


In an infant older than 3 weeks of age, check the pupillary responses. A sluggishly reacting pupil is suggestive of congenital glaucoma.

The production of tears during crying begins at about 2 to 3 months of age, but the nasolacrimal duct is not fully patent until 5 to 7 months of age. If chronic tearing is present, the nasolacrimal duct may not be patent. In this case, massaging over the nasolacrimal sac may yield a purulent or mucoid discharge, which is suggestive of nasolacrimal obstruction.

Visual acuity is assessed by qualitative observations. By 4 weeks of age, the infant's eyes should be able to fixate on and follow a target through a brief arc. By 8 weeks of age, the child

Figure 24-33 Appearance of specific types of burns.

Figure 24-34 Retina of shaken infant. Note the massive hemorrhages.

Figure 24-34 Retina of shaken infant. Note the massive hemorrhages.

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