Inspect for cyanosis. If cyanosis develops within the first few days to weeks of life, there is probably a serious anatomic anomaly such as tetralogy of Fallot.*

Inspect for evidence of congestive heart failure. The most important signs are persistent tachycardia, tachypnea, and an enlarged liver. A persistent tachycardia of more than 200 beats per minute in newborns or more than 150 beats per minute in children up to 1 year of age should alert the examiner. Feeding problems are often the first sign that an infant has heart failure. Such infants take a long time to feed, often more than an hour to take 2 or 3 ounces. The parent describes the child becoming ''tired'' or ''out of breath'' during feeding and as having to stop to catch his or her breath after every two or three sucks. Persistent diaphoresis and failure to thrive are also important signs associated with congestive heart failure. Observing a feeding may be extremely useful if heart failure is suspected. If heart failure develops within the first week or two, a structural defect such as a ventricular septal defect, patent ductus arteriosus, or coarctation of the aorta should be suspected. A truncus arteriosus also produces heart failure during this period, often with minimal cyanosis.

Palpate for the point of maximum impulse.

Auscultate as in newborns. S3 and S4 may be normal in this age group. As previously noted, the clinical significance of a murmur, especially in the first few weeks of life, must be carefully assessed. (A summary of pathologic murmurs heard in the pediatric age group is given in Table 24-4 later in this chapter.)

Palpate for the femoral pulses as discussed above.

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