Infants and children

Chapter 12 Infants and children


For convenience, we will consider five age bands:


• 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


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.


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.


After the presenting complaint has been defined, information about the child’s previous well-being and that of the family and their circumstances needs 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. Previous illnesses, hospital or doctor attendances as well as recent and previous medications are required in any child’s history.


Include details about parents’ and siblings’ medical histories and make direct queries in line with the presenting problems. If an autosomally recessive condition is being considered, it may be necessary to ask if the parents are consanguineously related.


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. Include details about the parent’s occupations and whoever else is helping with child care.


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.



THE EXAMINATION


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.


Try not to allow your eye level to be higher than that of your patient. Always remember what it is like from the child’s perspective, especially when surrounded by a group of unfamiliar adults.


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. 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). It is better to have a limited but tolerable examination than to try and complete a full examination that results in an inconsolable child.



GROWTH AND DEVELOPMENT



Growth


The continuum of growth from baby to adult has been described in three main phases (Fig. 12.1):


• The infant phase: a continuation of the exponential fetal growth rate that slows down into the second year of life. The critical factors in this phase are nutrition and hormones controlling metabolism, such as insulin-like growth factors (IGF) such as IGF1.

• The childhood phase: this extends from the second to beyond the 10th year. The critical factors in this phase are the pituitary hormones (especially growth hormone).

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

image

Fig. 12.1 Three phases of growth in childhood (after Professor J. Karlberg). The growth velocity varies at different ages, as the result of many variable influences. Karlberg summarised the continuum into three phases, each with its own principal factors.


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. 12.2) and head circumference in infants (under 2 years), and standing height (Fig. 12.3) in older children. Growth charts are used to help to determine the expected range at any given age.


image

Fig 12.2 and 12.3 Measurement of supine length and standing height. The measurement of length or height can be misleading and inaccurate unless done correctly, especially in infants.



Development


The evaluation of a child’s development is more complicated than an assessment of growth. For convenience, development is usually considered under eight main headings, which can be easily remembered as four sets of pairs








• Gross motor

• Fine motor

• Vision

• Hearing

• Expressive language

• Comprehension

• Social skills

• Behaviour
Motor skills

Motor skills

Special senses

Special senses

Communication

Communication

Psychosocial

Psychosocial


THE NEWBORN AND VERY YOUNG BABY


Newborns and young babies are examined routinely at birth, at approximately 6 weeks of age and when receiving immunisations.




imageReview: Gestation and weight of gestation



• Term
– born before 37 and 42 completed weeks gestation from last menstrual period (LMP)

• Preterm
– born before 37 completed weeks (259 days) gestation from LMP

– note that a preterm baby’s age can be expressed as either a chronological (uncorrected) age or an age postconception (corrected); the latter is important when considering growth and development in the first 2 years

• Post-term
– born after 42 completed weeks (294 days) gestation from LMP

• Small for gestational age or ‘small for dates’
– birth weight below 10th centile for gestational age

• Large for gestational age or ‘large for dates’
– birth weight greater than 90th centile for gestational age

Doctors need to know the most important signs and symptoms of serious ill health in the very young.


Newborns and young babies can become very sick quickly. Infections should be included in the differential diagnosis of any sick baby.



Growth


Newborns tend to lose from 5 to 10% of their birth weight in the first week but then steadily gain an average of 35–30 g per day over the next 6 months. The head circumference is a valuable measurement during this period.



Development


At birth, the newborn can hear, smell, taste, feel and see (but only up to approximately 30 cm). The social smile is a very important milestone of higher cortical function. Most behaviour observed in newborns even before this 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. 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. 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.



Examination


You should plot the progress of weight and head circumference on a centile chart. The baby must be undressed to be fully examined.



CIRCULATION AND CARDIOVASCULAR


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. 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 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.


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% of 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.



BREATHING AND RESPIRATION


Respiratory distress is the most important observation to be made. Auscultatory signs are usually far less significant.


All babies are obligate nose-breathers during feeding and nasal obstruction may manifest as a feeding problem. Audible inspiratory stridor or a hoarse cry warrants further evaluation.



ABDOMEN


Vomiting or ‘posseting’ of small quantities of milk is common but bile-stained vomiting warrants urgent assessment.




imageDifferential diagnosis: Respiratory distress


The combination of some or all of the following:


• Tachypnoea (normal upper limit varies with age)

• Recession (includes subcostal, intercostals or tracheal tug)

• Grunting (an end-expiratory groaning noise, breathing out against partially adducted vocal cords and providing self-positive and expiratory pressure)

• Flaring of nostrils (the alae nasi are accessory muscles of respiration)

• Cyanosis (may be subclinical, so check oxygen saturation with pulse oximeter)

• Apnoea (may be how a very young baby presents with a respiratory disorder, associated with a colour change (pallor or cyanosis)

• A periodic breathing pattern may be noted in preterm or very young babies and is physiological, often with pauses of 3–5 seconds being observed (especially during sleep) without a change in colour being seen

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, when prolonged, 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.


The palate must be inspected and palpated for clefts. The position and patency of the anus need to be checked. While viewing the perineum, the external genitalia should be inspected. In boys, both testes should be in the scrotum. Small hydroceles are common and need no action. The penis should have a normally sited urethral orifice with a foreskin adherent to the glans. 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.


The abdomen should not be distended. Divarication of the rectus abdominis muscles is common, as are umbilical hernias. The umbilical stump has usually separated by the 10th day.


A liver edge is usually palpable (approximately 1 cm below the costal margin).


Examine the hips while the nappy is off. The Ortolani and Barlow manoeuvres are used to detect abnormalities in the hip joint.




image Questions to ask: Jaundice in young babies



• Was the baby jaundiced in the first 24 hours of life?

• Was the baby still jaundiced during the third week of life?

• Is the baby well, thriving and gaining weight?

• What is the colour of the stools and the urine?

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Apr 20, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Infants and children

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