- good indicator of nutrition and hydration

- when decreased, intravascular volume depletion and poor nutrition probable

Skin turgor

- type of birthmark which may be confused with a bruise

Mongolian spots

- may be confused with neurofibromatosis

Cafe au lait spots

- tufts of hair overlying the spine, dimples, discolorations, cysts or masses may be a sign of this

Spina bifida occulta

- at this age, infant should steadily hold the head forward in the sitting position

4 months

- >95th percentile head size

- hydrocephalus is most frequent cause of this

- other causes include subdural hematoma, subdural effusions, intracranial tumor, thickening of the skull, benign familial megalocephaly

Macrocephaly

- can be done in a child <1 yr of age w/ macrocephaly

- w/ exam an area greater than 2 cm may be abnormal

Transillumination

- an ominous sign for mental development

- 25% -> 75% of adult brain size at birth -> 1 yr

- causes include congenital infections, cytomegalovirus, toxoplasmosis, syphilis, trauma, craniosynostosis

- associated with fetal alcohol syndrome

Microcephaly

- normally not palpable after the 6th month of life

- final closure does not occur until early adulthood

- intersect at anterior and posterior fontanelles

Sutures

- 4-6 cm at birth

- closes between 4 and 26 months of age

- condition reflects intracranial pressure

- volume depletion leads to depression

- increased intracranial pressure (hydrocephalus, meningitis, subdural hematoma, shaken baby, tumor) leads to bulging w/o pulsation

- bulges w/ crying but remains pulsatile

Anterior Fontanelle

- usually closes to palpation within a few weeks after birth

- should close by two months of age

Posterior Fontanelle

- premature closure of the sutures

- presents as asymmetry of the head or decrease in head growth

- can hamper normal enlargement of the head and lead to distortions

- 10-20% relate to various syndromes

- even w/o this, infants who sleep on their back can develop abnormal head shape

Craniosynostosis

- this overlapping of skull bones is commonly present at birth

- normal head shape should be regained by the 1st month of life

Molding

- thin, parchment-like, soft mushy area of the skull that can be indented like a ping pong ball

- commonly found along suture lines

- may be physiologic until 3 months of age

- associated with hydrocephalus, hypervitaminosis A, osteogenesis imperfecta, rickets, and syphilis

Craniotabes

- diffuse boggy swelling of the scalp brought on by pressure

- usually disappears by the 1st or 2nd day of life

- crosses suture lines

Caput succadaneum

- caused by a subperiosteal collection of blood over one or more flat bones of the skull

- swelling does not cross suture lienes

- decreases by 3-6 weeks, but may persist

Cephalohematoma

- sinuses develop in this order

- 6 months (x2), 3 years (x2), 3-7 yrs

Maxillary & Ethmoid, Sphenoid & Mastoid air cells, Frontal

- macular development is not complete until this age

- thus 20/30 vision may be considered normal til 4 or 5

6 to 7 yrs

- age group that when healthy maintain central and steady fixation

- indicates 20/200 or better vision

Infants

- a dime recognized at 5 ft is consistent with this level of vision

20/50

- in regards to vision, at 3 yrs of age this should be done utilizing Allen picture cards (20 ft = 20/30)

Formal vision screening

- when absent, this indicates cataracts or retinoblastoma

Red reflex

- small children have this AV ratio on their retina

- this ratio decreases as the child ages

1:1

- retinal hemorrhages in infants and small children almost always indicate this

- complete dilated eye exam is indicated in every case

Child Abuse (shaken baby syndrome)

- newborns pupils at rest are small and will contract and dilate at this speed relative to adults

More slowly

1/3 of term babies have this

- caused by thin membrane located across the lower end of the tear duct

- persistent watering of the eye is noted

- usually spontaneously clears in first few weeks

- potential complications include persistent conjunctivitis

Nasolacrimal duct obstruction

- speckled appearance of the iris (Brushfield spots) and nasal epicanthal folds are associated with this disorder

Down's Syndrome

- increased distance between the eyes

Hypertelorism

- may be present at birth or 1st several weeks

- symptoms include excessive tearing, photophobia, and blepharospasm (eyelid twitch)

- cloudy, big corneas, dilated pupil, red/irritated eye

Glaucoma

- common in 1st few months of life

- -tropia (constant), -phoria (latent)

- any of this after 6 months should refer to ophtho

- infantile esotropia (needs surgery, runs in families)

- accommodative esotropia (hyperopia)

- nonaccommodative esotropia (poor vision, trauma, prematurity)

Strabismus

- test for strabismus

- shine a penlight onto the eye

- light reflex should occur nearly in center or slightly nasal

- have child look at object 20 ft away

- if light reflex is seen laterally/medially, eso/exo-tropia present

Corneal light reflex test

- test for strabismus

- cover one of pt's eyes

- if eye movement occurs on removal of eye cover, eso/exo-phoria is present

Alternate cover test

- upper edge of pinna should aline with this facial structure

- low-set ears accompany renal & auditory abnormalities

Line drawn between canthi of eye

- in constrast to the adult, infants require you to pull the pinna this direction to straighten the auditory canal

Downward

- Pneumatic otoscopy evaluates this feature of the TM

- tympanograms may also be done on infants >6 months to test this

- Decrease in this is the most sensitive indicator of an effusion

TM mobility

- common in small children

- TM shows increased vascularity (bright red)

- may be retracted or bulging

- air fluid level may be present

Suppurative otitis media

- risk for this associated with premature infants, children who have had meningitis, cleft palates, family history of deafness

Hearing loss

- Hearing screening tests should be started at this age

3 yrs

- infants 1-3 months old are these type of breathers

Obligate nose breathers

- bony or membranous obstruction that can be either unilateral or bilateral

- presents with severe respiratory distress at delivery

- cyanosis is relieved by crying

- diagnosis made by inability to pass a plastic suction through the nares

Choanal atresia

- flaring of the nasal alae usually indicate this

Respiratory distress

- usually due to recurrent infections

- if found in <10 yrs think cystic fibrosis

- if they don't have CF, a CT should rule out glioma or encephalocele

Nasal polyp

- children do not localize pain to this location very well <6 yrs

Throat

- Clept Lip/Palate are repaired at these two ages

3/8 months of age