12 Infants and children

One of the challenges of paediatric medicine and child health is dealing with a range of patients, from the preterm newborn weighing less than 1 kg to the postpubertal 15-year-old weighing 55 kg. The younger the child, the more often he or she is brought to see the doctor, and the more different the consultation is from that described in previous chapters.

‘Children are not just small adults – their needs are different and have to be recognised.’

When examining children, the general principles of history-taking and examination also apply, although the manner and order in which they are approached differ: the convention of taking a history, inspecting, palpating, percussing and auscultating remain the cornerstones of all consultations but the emphasis is different in children.

Trainee doctors need basic skills to begin to feel confident in dealing with the child patient and their families.

For convenience, this chapter divides the child patient into five age categories, although these groups tend to merge into one another:

• Newborn and very young baby (0–8 weeks)

• Older baby and toddler (2–24 months)

• Preschool child (2–5 years)

• School child (5–10+ years)

• Adolescent (10+ to approximately 16 years).

In each section of this chapter, the discussion of growth, development, history-taking and examination of systems will take into account important age-related differences.

Taking a history

History-taking is the key part of an assessment of a child’s condition. The diagnosis is often revealed by a well-taken history, with the examination findings confirming or refuting the working diagnosis revealed during the history. In previous chapters, advice was given on how to approach patients who provide their own histories of complaints and symptoms; children come to the doctor with their parents and it is the parents who usually supply these details, although older children will often make important contributions.

Listen to the parents: they know their child best and, generally, if they describe a problem then there is a diagnosis to be made. The younger the child the more reliant you will be on the parents’ account of the problem. Sometimes acute anxiety about a child’s well-being, coupled with parental exhaustion, leads to difficulties in effective communication between parent and doctor but if you can empathise with the parents’ perspective it will help you to be a more understanding and compassionate doctor.

The older the children, the more you can communicate with them. The challenges lie in communicating effectively with children of different ages and abilities. This skill takes time to acquire; some will acquire it faster than others.

It is important to establish a rapport with the child and his or her parents and siblings. Introduce yourself to the child and other family members as you welcome them into the consulting area. Try and allow the children (including the siblings) to feel relaxed and comfortable during the consultation; this is more likely if there are a variety of toys and games lying about the room. Children up to and including school age may well prefer to be on a parent’s lap, eventually feeling confident enough to explore the room during the history-taking.

After the presenting complaint has been defined, information about the child’s previous well-being and that of the family and their circumstances need to be recorded.

In the very young child, history-taking should include information about the pregnancy, labour and delivery as well as the condition at birth and early feeding progress, details of immunisations and a developmental history. These details may become less relevant in the older child. Previous illnesses, hospital or doctor attendances as well as recent and previous medications are required in any child’s history.

The family history is important and can be clearly presented by using a two- or three-generation family tree. Include details about parents’ and siblings’ medical histories and make direct queries in line with the presenting problems. Include history of previous pregnancies and relevant pregnancy and prenatal problems (Fig. 12.1). If an autosomally recessive condition is being considered, it may be necessary to ask if the parents are consanguineously related. Although a large proportion of the world’s families involve cousin marriages, this is a delicate subject that should be dealt with in a tactful way. One approach is to enquire if the parents have any relatives in common (e.g. grandparents or cousins) (Fig. 12.2).

Fig. 12.1 These identical twins have myotonic dystrophy, as does their mother. This picture shows the phenomenon of ‘anticipation’, in which the condition is worse in each successive affected generation.

Fig. 12.2 The three-generation family tree.

At first it can seem intrusive to ask about the child’s family and any surrounding issues. One approach is to tell the child and family that you are going to ask a number of routine questions about the child’s background after hearing about the presenting complaints. The initial history-taking is the most ‘natural’ opportunity to collect this information, as having to go back and ask more questions out of the context of history-taking is more awkward.

The social history is separate from but allied to the family history. It is important to understand the composition of the household in which the child lives. The two-generation family tree can be further annotated with names, occupations and other details, helping to fill in details of the child’s social history. It should include details about the parents’ occupations and whoever else is helping with child care. Children old enough to be attending nursery or school should be asked the name of the establishment as well as how they are getting on.

Child abuse is a common problem. Children can be harmed by adults in a number of different ways: emotionally, physically, neglected, sexually or, rarely, by induced illnesses and poisoning. The nature of any injury or illness in any child, from any background, must be explained satisfactorily in the history and be a plausible cause of the findings seen on examination. If you have any such concerns about a child or family you must share them with colleagues and social services.

The examination

Inspection and observation are the most important skills to be developed if you are going to arrive at the right diagnosis. The younger the child, the more important it is to be able to observe the child’s well-being and any physical signs from a distance. This process should start from the moment the child and family appear in front of you. Do not wake up sleeping children to examine them until you have observed them carefully first (Fig. 12.3).

Figs 12.3 Swollen wrists (a) and rib ends (b) seen in rickets. Observation may be all that is needed to notice these signs of rickets. Sometimes these findings are coincidental to the presenting problem.

How one approaches a child to be examined is determined by the child’s age, level of development and understanding. The younger the child (except in the youngest of infants), the more imaginative one may have to be to ensure a satisfactory consultation but remember it is easy to make older children and adolescents feel patronised.

Whenever possible try not to allow your eye level to be higher than that of your patient. If necessary, get down on the floor; this may be very basic psychology but it works. If you are approaching a child seated on its parent’s lap or on a bed or couch, when you are within 1 metre of the patient the child should see you are coming down to eye level. This is especially important when several doctors congregate around a bed, for example, on ward rounds. Always remember what it is like from the child’s perspective, especially when being surrounded by a group of unfamiliar adults.

It may take some time to win the confidence of young children. Sometimes the pyrexial, irritable child may not allow you any physical contact without crying and, despite a friendly approach, it may also be impossible to observe the child at rest. Once a child starts crying it may be difficult to continue with the examination.

Palpation and auscultation may be important parts of the physical assessment. The order in which you perform them depends on where the problem is, what the problem is likely to be and how ill and how cooperative your young patient is. Whenever possible start peripherally with the hands or feet, making it clear to the child that you are a friendly doctor. Percussion is rarely a rewarding process in the very young.

Young patients should think the examination is fun. If you present yourself as playing a game, they will be relaxed and you will gain more information; if a child is frightened or in pain, then this can be impossible to achieve. Make the child comfortable first. Ensure your hands are clean and warm and that your stethoscope will not be too cold on the child’s skin.

Avoid unpleasant procedures if at all possible (e.g. rectal examinations). Think of what implications your actions may have in the future: if your examination and care of a child does not cause upset, and you relieve pain and discomfort effectively, that child is more likely to tolerate future examinations. It is better to have a limited but tolerable examination than to try and complete a full examination that results in an inconsolable child because the child is more likely to be uncooperative next time.

Growth and development

Growth involves an increase in size and concludes when an individual has acquired full size and reproductive capabilities. Development parallels growth and leads to individuals acquiring all the skills and attributes that enable them to achieve full independence from their parents and to raise their own children.

GROWTH

Compared with other mammals and primates, human offspring are very immature and dependent. A human newborn is completely dependent for most of its first year until weaned and walking. Our newborns have a head that is only just small enough to be delivered through the average woman’s pelvis. The cerebral neuronal network is almost complete at birth, but is more or less devoid of myelin, whereas most other species have completed this essential ‘wiring’ before the end of gestation, hence the more advanced abilities of their newborns. If the growth in head (or occipital frontal) circumference (Fig. 12.4) of a child in the first year of life is extrapolated into the volume of brain growth, it is clear why humans cannot have more developed newborns – this is the price Homo sapiens pays for being bipedal with a narrow pelvis and large brain.

Fig. 12.4 Head circumference chart. The phenomenal growth in head circumference seen during the first years of life is as a result of brain myelination, without which the infant’s development cannot advance.

The continuum of growth from baby to adult has been described by three main phases (Fig. 12.5):

• Infant phase: a continuation of the exponential fetal growth rate that slows down in the second year of life. Critical factors are nutrition and hormones controlling metabolism (e.g. insulin-like growth factors such as IGF₁).

• Childhood phase: this extends from the second to beyond the 10th year. Critical factors are the pituitary hormones (especially growth hormone).

• Adolescent (pubertal) phase: this extends from the onset of puberty until the achievement of final adult stature and fully mature reproductive capabilities. Critical factors are the sex steroids (androgens and oestrogens).

Fig. 12.5 Three phases of growth in childhood (after Professor J. Karlberg). The growth velocity varies at different ages – this is as result of many variable influences. Karlberg summarised the continuum into three phases, each with their own principal factors.

Each of the phases is interdependent on a large number of factors such as genetics, nutrition, hormones and the environment (including love and affection) (Fig. 12.6).

Fig. 12.6 Nonorganic failure to thrive. For some children who are not growing as well as expected, no organic cause can be identified. If they are removed from their home environment, their growth velocities may accelerate. The importance of an affectionate and loving environment for normal growth and development cannot be over estimated.

Any examination of a child is incomplete without an assessment of growth and development. It is usual to assess weight in all ages, supine length (Fig. 12.7) and head circumference in infants (<2 years), and standing height in older children (Fig. 12.8). The measurement of length or height can be misleading and inaccurate unless done correctly, especially in infants.

Fig. 12.7 Measurement of supine length.

Fig. 12.8 Measurement of standing height.

Growth charts are used to help determine the expected range at any given age; there are standards derived for most developed nations and by the World Health Organization. Either the standard deviation scores either side of the mean, or centiles are used to recognise the different normal variations in growth and growth velocity. The more serial measurements there are available to plot, the more certain one can be about whether the pattern of growth falls within an expected range (Figs 12.9, 12.10).

Fig. 12.9 Childhood Growth Foundation (UK) growth charts for girls. For pubertal stages see Figs 8.1, 8.3 and 12.44.

Fig. 12.10 Childhood Growth Foundation (UK) growth charts for boys. The charts for boys and girls are British standards derived from longitudinal data observed in cohorts of British children with cross-sectional observations used in updating them. For pubertal stages see Figs 9.4 and 12.44.

DEVELOPMENT

Evaluation of a child’s development is more complicated than assessment of growth because of the large variation in the normal patterns of development. Furthermore, an individual child’s rate of development can vary, and there are also confounding transcultural and transracial differences.

Although newborn babies are dependent, they can hear, smell, taste, feel and see. By the end of their development they will be able to think and solve problems, be mobile and agile, develop innumerable skills and be capable of rearing their own children.

For convenience, development is usually considered under eight main headings, which can be easily remembered as four sets of pairs:

• Expressive language

Various schemes have been elaborated to help health professionals determine whether a child is developing along an expected pattern of ‘normality’. Some of these schemes are merely screening devices; others are more elaborate and describe an infant or an infant’s abilities more thoroughly (Figs 12.11, 12.12).

Fig. 12.11 Child development. The eight areas are closely interdependent. To reflect this, some group hearing with speech and vision with fine motor.

Fig. 12.12 Outline of some important common developmental milestones. The bar represents the typical age of acquisition, the right-hand end representing when >90% of healthy normal children should have acquired these skills.

The newborn and very young baby

Only babies born at term are discussed here; preterm newborns have characteristics of their own. Newborns (called neonates when <4 weeks old) are extraordinary patients to be involved with. At birth they are ‘untried’ in terms of most homeostatic processes. They have recently completed the transition from the relatively hypoxic environment of the uterus, where they were dependent on the placental circulation (Fig. 12.13), and have had to cope with the stress of delivery, including huge adaptations in their cardiorespiratory physiology to enable them to breathe air.

Fig. 12.13 The fetoplacental circulation. The fetal cardiorespiratory blood flow is in parallel rather than in series after birth with the closure of the foramen ovale and the ductus arteriosus.

Newborns and young babies are examined routinely at birth, at approximately 6–8 weeks of age and when receiving immunisations. They are usually seen by doctors (e.g. general practitioners, paediatric resident staff or specially trained midwives) trained in their care. They are also seen if they are acutely ill by doctors unaccustomed to young babies (e.g. accident department staff).

Specific aspects about the ‘routine neonatal examination’ are discussed at the end of this section.

GROWTH

Newborns appear on the steepest part of the infant growth curve. They tend to lose 5–10% of their birth weight in the first week but then steadily gain an average of 25–30 g/day over the next 6 months. The length measurement of newborns and infants is likely to be unacceptably inaccurate unless a supine stadiometer is used (see Fig. 12.7). The head circumference is a valuable measurement during this period. Care needs to be taken when measuring the true head circumference: use a nonstretchable tape, applied closely around the scalp and take the largest circumference obtained around the occiput and forehead. With correct technique a reliable interobserver measurement to within ±0.1 cm can be obtained (Fig. 12.14).

Fig. 12.14 Measurement of head circumference. The simplest ‘investigation’ in paediatric neurology.

DEVELOPMENT

At birth, the newborn can hear, smell, taste, feel and see (but only up to approximately 30 cm). The social smile (smiling in response to smiling and cooing parents) is a very important milestone of higher cortical function. Most behaviour observed in newborns before this event is the result of responses initiated by the brainstem and spinal cord, for example, startling to sound and the primitive reflexes.

HISTORY

The feeding history is important because feeding is the most strenuous action the newborn has to do. Any compromise in cardiorespiratory function is revealed in difficulty in taking or completing feeds. In breastfed babies, it is difficult to be certain how well the feeding is progressing because the quantities of feed are unknown. Mothers breastfeeding for the first time may not be sure how well they (both) are doing. Ask the mother how often and for how long her baby breastfeeds, how she feels the feeds are progressing, and whether she has any subjective feelings of let down of milk. Documented weight gain in the baby and the mother feeling that her breasts empty are helpful indicators. With bottle-fed babies it should be easy to ask about quantities of infant formula taken.

Details about maternal health, the pregnancy and delivery, as well as the baby’s condition and birth weight, are important to record. Apart from any parental concerns, ask about vitamin K administration, jaundice, stools and how the baby responds to handling. Pay close attention to what an experienced mother’s observations have to say about her baby: she will have spent a great deal of time observing the baby closely; if she perceives something different about this baby then it may be an important diagnostic clue.

EXAMINATION

Newborns and young babies are examined when they are acutely ill or, more commonly, during routine checks. The observation and skills used are common to both the acute and routine situations. You should plot the progress of weight and head circumference on a centile chart. The baby must be undressed to be fully examined.

The very young (like the very old) often have nonspecific symptoms and signs even when they are seriously ill. Doctors in training need to know the most important signs and symptoms of serious ill health in the very young. To help less experienced carers of newborns, a scoring system for symptoms and signs was developed (see ‘symptoms and signs’ box).

Newborns and young babies can become very sick quickly. Infections should be included in the differential diagnosis of any sick baby. These infections can often be bacterial and serious. It is good practice to think of the likely infection and how it was acquired and to complete a full septic screen and give broad-spectrum parenteral antibiotics until the culture results are known.

Circulation and cardiovascular

The order of examination will depend on the condition of the baby. Auscultation of the heart sounds and listening for murmurs may be the priority before the baby cries. Inspection of the newborn’s colour and perfusion is crucial. Peripheral cyanosis is common in the first days of the newborn period (acrocyanosis) because of vasoconstriction and relative polycythaemia (haemoglobin range 14.9–23.7 g/dl at birth): capillary refill time may therefore be more sluggish. Central cyanosis is best observed in the tongue and mucous membranes; these may be the only sites that are noticeably blue in cyanosed nonwhite babies. On inspection, the only signs of congenital heart disease may be respiratory distress at rest. A pale baby may be anaemic or even hypoxic.

The rate, rhythm and character of the brachial and femoral pulses (Fig. 12.15) need to be assessed. Weak or absent femoral pulses may suggest coarctation of the aorta, as would four-limb blood pressure measurements demonstrating an upper limb to lower limb gradient in blood pressure. Large volume pulses are found with a patent ductus arteriosus. The precordium should be palpated and the presence of an apex beat (usually on the left) and heaves or thrills noted (Fig. 12.16).

Fig. 12.15 Palpating femoral pulses. The femoral pulse can be difficult to feel; use a point halfway from pubic tubercle to anterior superior iliac spine as a guide and do not press so firmly as to occlude the pulsation.

Fig. 12.16 Palpating the apex beat. Palpate the whole precordium, left and right. The apex beat is usually palpated in the left fifth intercostal space in the midclavicular line.

The separation of the two components of the second heart sound on auscultation may be difficult because of the baby’s fast heart rate (Fig. 12.17). A single second heart sound may indicate pulmonary outflow obstruction. Innocent (non-pathological) systolic murmurs are common in the newborn and may be heard on day 1 in over 20% babies who have structurally normal hearts. Pansystolic and continuous murmurs are suspicious, as are ejection systolic murmurs that radiate to the back or neck. Many babies with structural congenital heart disease may not have a murmur, although they may have symptoms and other signs of cardiovascular disease.

Fig. 12.17 Auscultating the heart sounds and listening for murmurs. Even when the baby is asleep, it can be hard at first to differentiate the first and second heart sound; palpating a brachial or femoral pulse simultaneously may help you.

Symptoms and signs

The baby check

Baby check ^* is a system to help parents, health professionals and carers assess the seriousness of a baby’s illness. It uses 19 signs and symptoms with scores which, when added together, give a total score which correlates with the seriousness of the baby’s illness. The scoring system has been validated for use by parents, doctors and nurses in babies under 1 year old.

Breathing and respiration

The presence of respiratory distress is the most important observation to be made. Auscultatory signs are usually far less significant than the observation one makes as a baby is undressed.

Remember that all babies are obligate nose-breathers during feeding and nasal obstruction may manifest as a feeding problem. The presence of audible inspiratory stridor or a hoarse cry warrants further evaluation.

Abdomen

Observing a feed and inspection of stools can be important parts of the evaluation. The vomiting or ‘posseting’ of small quantities of milk is common but bile-stained vomiting warrants urgent assessment.

The presence of jaundice is very common. When seen in the first 24 hours of life it is usually due to a pathological haemolytic process. A physiological jaundice is extremely common after the second day, continuing into the second week. It is usually related to breastfeeding. If jaundice is in association with pale stools, dark urine or failure to thrive, then pathological hepatic or obstructive cause is much more likely. Bilirubin in the urine requires investigation.

The gastrointestinal tract starts at the mouth and ends at the anus. Both ends need to be looked at. The palate must be inspected for clefts and palpated for clefts (Fig. 12.18). The position and patency of the anus needs to be checked (Fig. 12.19). While viewing the perineum, the external genitalia should be inspected. In boys, both testes should be in the scrotum (Fig. 12.20). Small hydroceles are common and need no action. If hernias are suspected then make a prompt referral to a paediatric surgeon. The penis should have a normally sited urethral orifice with a foreskin adherent to the glans (this adherence is physiological and should not be interfered with). In girls there should be an introitus and a normally sized clitoris. Any ambiguity in the genitalia requires urgent assessment by a paediatric endocrinologist before sex is assigned.