The Pediatric Patient

Chief Complaint

This should be a brief statement of the presenting complaint (no matter the clinical setting). The chief complaint is usually best presented as a direct quote from the patient or informant explaining why the child was brought to medical attention.

Informant

Identify the person (usually a parent) who is providing the history, state whether an interpreter was used and make an assessment of the reliability of the informant.

History of Present Illness

Start with identifying data (i.e., age and sex) and then relate history chronologically. Be as complete as possible by including the seven dimensions of a symptom (i.e., timing, location, quality, quantity, setting, aggravating/alleviating factors, and associated manifestations). The History of Present Illness (HPI) should include information about the effect of an acute illness on the child's oral intake, activity level, hydration status, and ability to sleep. If the illness is chronic, include information about initial presentation, course, response to medications, impact on the child's growth and development, etc. For inpatient cases, a brief summary of the emergency department course can be provided after the HPI, including a clear statement as to the reason for admission.

Past Medical History

Include information about all significant illnesses, operations, accidents, common childhood diseases, and hospitalizations. Ask about chronic health problems, such as asthma, eczema, recurrent ear infections, or developmental delays. Verify if the child is receiving routine health care and, if so, the name of the provider.

Medications

List all medicines that the child is taking, including over-the-counter medications and herbal remedies/complementary medicines. Be sure to include medication names, dosages, route of administration, frequency, and indications.

Allergies

Include allergies to medications, foods, and environmental allergens. Ask about specific reactions. If it was a rash, try to clarify if it was urticarial, which is likely to be a true allergy, rather than a nonspecific eruption that may have occurred coincidentally.

Birth History

Note birth weight, gestational age, type of delivery, and place of delivery. Include age and parity ³

3 Parity, or “para,” indicates the number of pregnancies reaching viable gestational age (including live births and stillbirths).

of the mother, maternal medications or substance use, prenatal complications (e.g., gestational diabetes, hypertension, abnormal maternal labs or studies). Record duration of ruptured membranes, Apgar scores (as described in the newborn physical exam section), and resuscitation measures, if performed. Comment on nursery or neonatal intensive care unit (NICU) course/complications and baby's age at discharge. Include information on common nursery screening tests. Note the order of these questions: they begin with the prenatal course, then focus on the actual birth, and then turn to the postnatal course. In general, little detail is needed here for teens unless there were complications. In contrast, more detail is needed for infants less than 2 months of age or born prematurely, as the birth history has more relevance.

Box A contains a list of maternal/prenatal tests, screens, and procedures. Some of these are universal; others are selective. Box B demonstrates the shorthand notation for maternal pregnancy history. Box C lists the tests, screens, and procedures performed on newborns before discharge from the nursery.

Diet History

Nutrition is central to the child's well-being. Obesity in childhood is considered to be an epidemic in this country. Getting a complete nutritional history not only helps in monitoring the child's nutritional health, but may also help you make the diagnosis of an acute problem. For newborns and young infants, ask about the methods of feeding (i.e., breast or formula), as well as amount and frequency of feedings. For older infants and toddlers, document when and which solids were started and describe the child's present diet, including what the child is drinking. In school-aged children and older find out what the child eats in and out of the home, including during and between meals. Specify what the child drinks, including water, juice, milk, and sweetened beverages. For more details, see individual sections below for each age group.

Growth and Development

Describe the child's general pattern of growth, weight gain, and any concerns or abnormalities. Inquire if parent is worried about poor weight gain, overweight or obesity, unexpected change in growth, short stature, and abnormal head growth.

If meeting a patient for the first time beyond the neonatal period, obtain a developmental history. Note when the child first smiled, rolled over, reached for objects, sat up, walked with and without support, spoke his or her first words and sentences, was toilet trained, etc. Often parents will not remember exact age at time of these milestones but will be able to state if milestones were met on time of if they or their physicians ever had concerns about the child's development. Ask if there was ever an evaluation or services provided by Early Intervention.

For children under the age of 6, assess current achievement of age-appropriate developmental milestones in four domains; gross motor, fine motor, language, and social. This can be done through a combination of provider observations, parental report, and a wide array of developmental surveillance and screening questionnaires. There are many tools available for identifying developmental milestones. ⁴

4 For example, the “CDC Milestones” App is a milestone tracker for parents which also has age-based checklists with videos demonstrating each milestone.

Tailor this to the child's age. Adolescents do not need in-depth developmental histories.

See Table 24.1 which summarizes developmental milestones for developmental surveillance at preventive care visits.

TABLE 24.1

Developmental Milestones for Developmental Surveillance at Preventive Care Visits ^a

From Lipkin P, Macias M. Developmental milestones for developmental surveillance at preventive care visits. In Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics, 2017.

Age	Social Language and Self-Help	Verbal Language (Expressive and Receptive)	Gross Motor	Fine Motor
Newborn to 1 week	Makes brief eye contact with adult when held	Cries with discomfort Calms to adult voice	Reflexively moves arms and legs Turns head to side when on stomach	Holds fingers closed Grasps reflexively
1 month	Calms when picked up or spoken to Looks briefly at objects	Alerts to unexpected sound Makes brief short vowel sounds	Holds chin up in prone	Holds fingers more open at rest
2 months	Smiles responsively (i.e., social smile)	Vocalizes with simple cooing	Lifts head and chest in prone	Opens and shuts hands
4 months	Laughs aloud	Turns to voice Vocalizes with extended cooing	Rolls over prone to supine Supports on elbows and wrists in prone	Keeps hands unfisted Plays with fingers in midline Grasps object
6 months	Pats or smiles at reflection Begins to turn when name called	Babbles	Rolls over supine to prone Sits briefly without support	Reaches for objects and transfers Takes small object with 4 fingers Bangs small object on surface
9 months	Uses basic gestures (holds arms out to be picked up, waves “bye-bye”) Looks for dropped objects Picks up food with fingers and eats it Turns when name called	Says “Dada” or “Mama” nonspecifically	Sits well without support Pulls to stand Transitions well between sitting and lying Balances on hands and knees Crawls	Picks up small object with 3 fingers and thumb Releases objects intentionally Bangs objects together
12 months	Looks for hidden objects Imitates new gestures	Says “Dada” or “Mama” specifically Uses 1 word other than Mama, Dada, or personal names Follows a verbal command that includes a gesture	Takes first independent steps Stands without support	Drops object in a cup Picks up small object with 2-finger pincer grasp
15 months	Imitates scribbling Drinks from cup with little spilling Points to ask for something or to get help	Uses 3 words other than names Speaks in jargon Follows a verbal command without a gesture	Squats to pick up objects Climbs onto furniture Begins to run	Makes mark with crayon Drops object in and takes object out of a container
18 months b , c	Engages with others for play Helps dress and undress self Points to pictures in book Points to object of interest to draw attention to it Turns and looks at adult if something new happens Begins to scoop with spoon	Uses 6–10 words other than names Identifies at least 2 body parts	Walks up with 2 feet per step with hand held Sits in small chair Carries toy while walking	Scribbles spontaneously Throws small ball a few feet while standing
2 years c	Plays alongside other children (parallel) Takes off some clothing Scoops well with spoon	Uses 50 words Combines 2 words into short phrase or sentence Follows 2-step command Uses words that are 50% intelligible to strangers	Kicks ball Jumps off ground with 2 feet Runs with coordination	Stacks objects Turns book pages Uses hands to turn objects (e.g., knobs, toys, and lids)
years b	Urinates in a potty or toilet Engages in pretend or imitative play Spears food with fork	Uses pronouns correctly	Begins to walk up steps alternating feet Runs well without falling	Grasps crayon with thumb and fingers instead of fist Catches large balls
3 years	Enters bathroom and urinates by self Plays in cooperation and shares Puts on coat, jacket, or shirt by self Engages in beginning imaginative play Eats independently	Uses 3-word sentences Uses words that are 75% intelligible to strangers Understands simple prepositions (e.g., on, under)	Pedals tricycle Climbs on and off couch or chair Jumps forward	Draws a single circle Draws a person with head and 1 other body part Cuts with child scissors
4 years	Enters bathroom and has bowel movement by self Brushes teeth Dresses and undresses without much help Engages in well-developed imaginative play	Uses 4-word sentences Uses words that are 100% intelligible to strangers	Climbs stairs alternating feet without support Skips on 1 foot	Draws a person with at least 3 body parts Draws simple cross Unbuttons and buttons medium-sized buttons Grasps pencil with thumb and fingers instead of fist

a Developmental milestones are intended for discussion with parents for the purposes of surveillance of a child's developmental progress and for developmental promotion for the child. They are not intended or validated for use as a developmental screening test in the pediatric medical home or in early childhood day care or educational settings. Milestones are also commonly used for instructional purposes on early child development for pediatric and child development professional trainees. These milestones generally represent the mean or average age of performance of these skills when available. When not available, the milestones offered are based on review and consensus from multiple measures as noted.

b It is recommended that a standardized developmental test be performed at these visits.

c It is recommended that a standardized autism screening test be performed at these visits.

School History

Progress and achievement in school is a key component of a child's well-being. Unsatisfactory school performance can be indicative of learning disabilities, psychosocial problems, or medical conditions. Identify what school the child attends and if he or she is in the appropriate grade. If behind a grade level, has the child been evaluated or receiving special education services (e.g., small class, speech, occupational or physical therapy, counseling)? Ask about the child's performance both academically and behaviorally. It is important to find out if the child likes school, has friends, or is the victim of bullying.

Immunization History

Vaccines are one of the major successes of twentieth-century medicine; clinicians are unlikely to see many of the vaccine-preventable diseases such as polio, measles, rubella, chickenpox, or diphtheria. It is essential to review the child's immunization history from birth through adolescence as there are recommended vaccines for all age groups. Ask to see the child's vaccine record if the parent has one. State registries are also a good resource to determine immunization status. Compare the child's vaccines with the most up-to-date CDC recommended immunization schedule. ⁵

5 https://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html (Reviewed February 5, 2019. Accessed February 26, 2019) or see the “CDC Vaccine Schedules” App.

If immunizations have been delayed, state the reason. If parents have refused vaccines, address their concerns, explain the rationale, and continue to encourage catch-up immunizations. If the child is missing one or more vaccines, consider the possibility the child is suffering from a vaccine-preventable illness. Note that the immunization schedule offers instructions for providing “catch-up” vaccinations for children who have fallen behind.

Menstrual History (if Appropriate)

Note age at menarche, regularity, length, associated symptoms, and character of menses.

Social History/Social Determinants of Health

It is essential to obtain a thorough social history for pediatric patients, as many social factors in their life, beyond what is apparent at the point of a medical visit, can affect their health and have a large influence on their overall well-being. It has become increasingly clear that the environment in which a child grows up has tremendous impact on their physical and mental health, in potentially positive and negative ways. These family and community strengths and deficits make up social determinants of health. Assessing social determinants will provide context for the child's surroundings and help identify protective factors as well as potentially harmful factors, which can then be addressed.

Ask about family makeup (i.e., family members, caregivers, their relationships and dynamics); living situation (e.g., type of home, household members); living conditions (e.g., presence of heat, hot water, peeling paint, window guards); childcare arrangements (e.g., primary caretakers, home care, day care, after school care); parent's occupations, etc. Find out about play habits, friends, hobbies, activities (e.g., sports, digital media use), and family life. The presence of environmental exposures in the home such as cigarette smoke, allergens (e.g., mold, roaches, dust, pets) and lead should be elicited. Find out about potential safety risks in or near the home (e.g., stairs, animals, machinery, firearms, violence).

Other important social determinants of health to ask about include legal problems, (e.g., housing, immigration status, child support) and food insecurity. Find out about health insurance status and access to entitlements such as Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), Supplemental Nutrition Assistance Program (SNAP) or food stamps, and Supplemental Security Income for patients with disabilities (SSI).

The IHELLP questionnaire in Box D is a good framework to approach the assessment of social determinants in the pediatric population.

Constant reassessment of the social history at every health maintenance visit is essential as it can change often and have potentially positive or negative effects on the child. Reviewing areas such as child care arrangements, changes in the household, the physical and mental health of caregivers, social determinants of health and their impact, environmental exposures, and access to needed services must not be overlooked.

Furthermore, questions about culture and spirituality need to be explored to understand the unique contexts in which children and families view their health and illness. Kleinman's explanatory model ⁶

6 Kleinman A. Culture, illness, and care. Annals of Internal Medicine. 1978;88(2):251–258. doi:10.7326/0003-4819-88-2-251.

frames questions to elicit responses from children and families about their illnesses that are influenced by their beliefs. See also Chapter 5 , Mitigating Racism and Bias in Clinical Medicine.

For adolescents, a special format is utilized to obtain a detailed social history, called the HEEADSSS exam. This is an acronym for H ome, E ducation, E ating, A ctivities, D rugs, S exuality, S uicide/Depression, and S afety. The history is obtained directly from the teenager in a private setting and is confidential. Details of the HEEADSSS exam are provided in the adolescence section of this chapter.

Family History

The pediatric family history is basically the same as in the adult history but may play a more significant role in identifying genetic disorders and inborn errors of metabolism. Information about three generations should be obtained: that is, the child and his or her siblings; the parents and their siblings; and the grandparents. For each individual, the following information should be obtained:

• If alive, name and current age; if deceased, age at and cause of death

• Presence of any illnesses, such as asthma, coronary artery disease, diabetes, hypertension, stroke, cancer, or mental health disorders

• Presence of congenital malformations, developmental problems or genetic disorders

Updating the family medical history should be done routinely as this too may change with time and can be influential on the evolution of the child's medical conditions.

Review of Systems

The review of systems (ROS) needs to be age-appropriate, so while for the school-aged child and adolescent it may be similar to that of the adult, for younger children it will vary. Be complete but tailor your questions to the age of the child. For example, to elicit a history of congestive heart failure in an infant, it is useless to ask about two flight dyspnea or exertion. Instead, ask whether the child appears short of breath or sweaty when he or she drinks from a bottle. Also think about which symptoms can and cannot be reported based on the child's age or developmental level (i.e., realize that infants and young children cannot report dizziness, nausea, headache, or cold intolerance). Age-appropriate ROSs will be elaborated in each respective section below.

Anthropometrics

A crucial and unique component of the pediatric examination is assessment of growth, also known as anthropometrics. This is accomplished through careful measurements of growth parameters, then plotting of values on a standardized, gender-specific growth chart. For children under the age of 2 years, measurement of weight, length, and head circumference is a routine part of the well child examination. Weight alone is usually measured for sick visits. Weight should be obtained on either an infant scale (lying down or sitting) or adult scale when willing and able to stand alone, which is first zeroed and measured without clothes or diaper. Length should be measured with the child lying down, using a special measuring stick with the upper extension arm flush with the top of the head and the lower one flush with the bottom of the feet. Head circumference is measured with a measuring tape wrapped around the head like a crown, just above the attachment of the ears, around the occiput and forehead. For children above the age of 2 years, weight is measured standing up without outer clothes. Height is measured standing up using a stadiometer. ¹⁰

10 A stadiometer is used for measuring height. It is commonly constructed out of a ruler and a sliding horizontal headpiece which is adjusted to rest on the top of the patient's head.

Body mass index (BMI) should then be calculated and plotted.

To monitor growth of children in the United States, the Centers for Disease Control and Prevention (CDC) recommends using the World Health Organization (WHO) growth charts for children under 2 years of age, ¹¹

11 https://www.cdc.gov/growthcharts/who_charts.htm#The%20WHO%20Growth%20Charts Updated September 9, 2010. Accessed February 26, 2019.

and the CDC growth charts for children above the age of 2 years. ¹²

12 https://www.cdc.gov/growthcharts/clinical_charts.htm Updated June16, 2017. Accessed February 26, 2019.

After the measurements are plotted, the charts should be assessed for changes over time. This should be done at every well child visit. Growth in children should ideally follow along an expected trajectory, along a percentile line for that patient. This reflects varying degrees of expected growth and weight gain at different ages. Growth charts can reveal problems such as obesity (BMI >95 percentile), overweight (BMI >85 percentile), short stature, microcephaly, or macrocephaly. Looking at trends is important as crossing percentile lines may indicate too rapid or inadequate weight gain or growth, or lack of or excessive growth of the head, all of which can be cause for concern.

There are specialized growth charts for certain populations of children. Specific growth charts exist for patients with trisomy 21, Turner, Williams, and Marfan syndromes along with some other genetic syndromes. There are also growth charts for premature low birth weight (1500 to 2500 g) and very low birth weight (<1500 g) babies. ¹³

13 https://www.ucalgary.ca/fenton/2013chart . Accessed February 26, 2019.

Babies born preterm should have their measurements plotted at their corrected age (adjusted by subtracting gestational age in weeks from 40 weeks) until 2 years of age for most, and 3 years for those with birth weight <1000 g. However, if the child's growth catches up to the chronologic age-appropriate growth before 24 to 36 months of age, chronologic age is subsequently used.

Vital Signs

Vital signs, like in adults, include temperature, heart rate, respiratory rate, and BP. Which vital signs are measured may depend on the type of visit and the age of the patient. Temperature is measured with a digital rectal thermometer in infants and is most important to measure in young infants with suspicion of an infection. Temperature above 100.4°F, or 38°C, will warrant further investigation for source of the fever. While often measured for older children at sick visits, the actual number may not be as significant as the presence or absence of fever or how the child appears clinically. Rectal temperatures will be the closest approximation of core body temperature. Other means of measuring temperature include oral or axillary thermometer or tympanic membrane device.

Heart rate in infants is most easily counted with a stethoscope on the chest at the apex. For older children, it can be measured at the radial pulse. The rate can be counted for 15 seconds and multiplied by 4. Respiratory rate in infants should be counted for a full minute as young infants have periodic breathing which means it speeds up and slows down in waves. It can be measured by watching the chest rise and fall or auscultating with a stethoscope on the chest. The respiratory rate in older children can similarly be counted by observation or auscultation but for a shorter period of time. It is important to know that normal ranges for heart rate and respiratory rate vary by age. They start very high and decrease as the child gets older, until they reach adult norms. See Table 24.2 for normal pulse and respiratory rates by age.

Routine measurement of BP starts at age 3, but it is done earlier for children with high risk conditions such as history of prematurity <32 weeks gestation, small for gestational age, very low birth weight, other neonatal complications requiring intensive care, or umbilical artery line.

BP measurement must be done with proper cuff size and technique to obtain an accurate measurement. The child should be quietly seated with feet uncrossed and BP should be measured in the right arm, supported at heart level. The bladder length within the cuff should be 80% to 100% of the arm circumference and the width at least 40% of the arm circumference. Initial measurements can be done with a calibrated oscillometric machine or by auscultation. To measure BP in the legs, use an appropriately sized cuff at mid-thigh with the patient in the prone position. If the initial BP is >90th percentile, perform two more oscillometric or auscultatory measurements at the same visit and average them.

BP norms vary by age, sex, and height and are based on measurements from over 50,000 children. Percentile should be noted according to the current BP tables. ¹⁴

14 Flynn JT, Kaelber DC, Baker-Smith CM, et. al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics . 2017;140(3):e2017. doi:10.1542/peds.2017-1904.

An online BP calculator will be of assistance in obtaining appropriate percentiles and subsequent course of action, if indicated. ¹⁵

15 https://www.mdcalc.com/aap-pediatric-hypertension-guidelines . Accessed February 26, 2019.

Classification of normal and elevated BPs is found in Table 24.3 .

Maternal/Prenatal History

• Age

• Medical problems before the pregnancy (e.g., asthma, obesity, diabetes, epilepsy, hypertension, mental health issues, surgeries)

• Number and outcome of prior pregnancies (i.e., term vs. preterm births, miscarriage or termination, delivery complications)

• Use of assisted reproductive technology (e.g., in vitro fertilization, donor egg or sperm, surrogate)

• Location and duration of prenatal care

• Complications during the pregnancy (e.g., gestational diabetes or hypertension, bleeding, infections, treatment for preterm labor)

• Medications taken during the pregnancy

• Lab results (e.g., serologies, genetic testing, blood type, other labs) (see Box A )

• Ultrasound results

• Use of cigarettes, alcohol, recreational drugs, herbal products

Birth History

• Gestational age at time of delivery (<37 weeks = preterm; 34 to 37 weeks = late preterm; 37 to 42 weeks = term; >42 weeks = postterm)

• Induced or natural labor and duration of labor

• Duration of rupture of membranes (i.e., less than or greater than 18 hours)

• Intrapartum complications (e.g., fever, bleeding, high BP, pre-eclampsia)

• Medications administered to mother (e.g., antibiotics, magnesium sulfate, anesthesia)

• Type of delivery (i.e., normal spontaneous vaginal delivery [NSVD], cesarean section [C/S], vacuum assisted, forceps assisted)

• Position of the baby at delivery

• Complications of delivery (e.g., meconium, shoulder dystocia, placental abruption, birth trauma)

• Complications in the postpartum period (e.g., infection, bleeding)

Postnatal History

• Birth weight

• Birth length and head circumference

• Resuscitation maneuvers administered (e.g., suction, oxygen, respiratory support)

• Evidence of birth trauma

• Apgar score

• Skin-to-skin ¹⁶

  16 Skin-to-skin is a term used to describe the placement of the naked newborn on the mother's bare chest immediately after delivery. This procedure helps stabilize the baby's breathing, temperature, and heart rate; promotes breastfeeding; and is routine in uncomplicated deliveries.

  done?

Nursery History

• Feeding (e.g., breast, formula, any problems); see Box G for breastfeeding recommendations

  Box G

  Importance of Breastfeeding

  When it comes to neonatal and infant nutrition, the adage “breast is best” is grounded in evidence that shows both short- and long-term health benefits for both the mother and child. For the breastfed baby, they include reduced incidence of respiratory tract infections and otitis media, gastrointestinal tract infections, necrotizing enterocolitis, sudden infant death syndrome and infant mortality, allergic disease, celiac disease, inflammatory bowel disease, obesity, childhood leukemia, and lymphoma. “The American Academy of Pediatrics recommends exclusive breastfeeding for about 6 months, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant. ^a

  a Eidelman AI, Schanler RJ, Johnston M, et. al. Breastfeeding and the use of human milk. Pediatrics . 2012;129(3):e827–841.

  ” Therefore, it is critical for pediatricians and newborn nurseries to create an environment that promotes and supports the practice of breastfeeding. Fortunately many hospitals and birthing facilities are striving to be designated Baby-Friendly by adhering to the Ten Steps to Successful Breastfeeding, ^b

  b https://www.babyfriendlyusa.org/for-facilities/practice-guidelines/10-steps-and-international-code/ . Accessed February 26, 2019.

  which addresses systems, staff, and mother and child to increase breastfeeding initiation and duration.

• Weight change, weight at discharge (i.e., infants can lose up to 10% of birth weight in first few days)

• Abnormal physical exam findings (and treatment if indicated)

• Results of screenings (hearing, critical congenital heart defects) ¹⁷

  17 Universal newborn hearing screening is performed in the nursery through either evoked otoacoustic emissions (EOAE) or auditory brainstem response (ABR) testing. These are noninvasive, easily performed evaluations of physiologic activity which underlie normal auditory function.

  ^{, 18}

  18 Critical congenital heart defect (CCHD) screening is part of the recommended newborn universal screening panel. It is performed in the nursery after 24 hours of age using pulse oximetry to measure oxygen saturation in the right hand and one foot. Readings of ≥95% in right hand and foot and ≤3% difference between the two is considered passing.

  ; see Table 24.2

• Blood type and Coombs test

• Bilirubin result (and risk level, need for phototherapy based on AAP guidelines ¹⁹

  19 American Academy of Pediatrics. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics . 2004;114(1):297. doi:10.1542/peds.114.1.297.

  )

• Complications in the nursery (e.g., respiratory distress, concern for sepsis, neonatal abstinence syndrome, hypoglycemia)

• Receipt of routine medications (e.g., vitamin K, erythromycin, hepatitis B vaccine)

• Administration of other medications (antibiotics, morphine)

• Was the state-specific newborn screening performed and are results available? ²⁰

  20 Universal newborn screening tests performed on newborn blood samples for early identification of treatable congenital conditions before symptoms begin. These conditions include a variety of inborn errors of metabolism, endocrine disorders, hemoglobinopathies, immunodeficiencies, and genetic disorders. There are a core set of recommended tests and others that are U.S. state-specific.

• Was a circumcision performed?

• Age at discharge

• Pediatrician follow-up

If the baby spent time in the NICU, the history will be more expansive. Get a detailed history of the NICU course by systems. Infants in the NICU have a unique set of conditions which are beyond the scope of this chapter. Review complications, studies, treatments, and length of stay.

It is also important to obtain a family history to be alerted to inheritable medical conditions that may affect the baby. One must also obtain a full social history for the neonate early on. What is the family makeup and how are the living conditions in the home to which this baby will go? Who will be the primary caretaker, and is there a support system?

During the first month of life, the main focus is on appropriate feeding and physical growth as well as the bonding of the parent-infant dyad. Furthermore, bringing home a newborn is an exciting yet intimidating experience for new parents and providing thorough anticipatory guidance and answering all their questions about newborn care, no matter how trivial, is essential. For well child visits during this neonatal period, obtain an interval history, asking about parental concerns and well-being, the infant's diet, elimination and sleep habits. Inquire about or observe developmental milestones.

• Diet: What is the infant drinking?

  • If breastfeeding:

    • How is breastfeeding going?

    • How many times does the baby feed in a day? (expect 8 to 12 feeds/day)

    • How is the baby's latch? Is it painful?

    • Is the baby receiving vitamin D supplementation?

    • Is the baby taking any formula?

  • If formula feeding:

    • How much is the baby taking each feed?

    • How often is the baby feeding? (expect 6 to 8 feeds/day)

    • How is the formula being prepared (i.e., is it ready to feed, concentrated liquid, or powder)?

• Elimination

  • How many wet diapers per day? (expect 1 per day of age until 1 week then 6 to 8 per day)

  • What is the consistency of the stool? (expect transition from the dark green-black tarry meconium stools to seedy soft yellow or green stools by a few days of age)

• Sleep

  • Where is the infant sleeping? (i.e., crib or bassinet; co-sleeping not recommended) Is the infant in the parent's room?

  • Is the baby sleeping supine?

  • Is there anything in the crib? There should be no pillows, blankets, toys, stuffed animals, bumpers, positioners.

• Development/Behavior

  • Gross motor (e.g., lifts head briefly when prone, moves all extremities)

  • Fine motor (e.g., hands in a fist)

  • Language (e.g., responds to sounds, calms to voice)

  • Social (e.g., fixates on face, follows with eyes)

  • Is the baby fussy?

• Social

  • How has the family adapted to the newborn?

  • How is the mother's mood? Does she have a support system?

  • Do they have provisions and services in place for the baby? (WIC, baby care supplies)

• Screenings: Check state newborn screen results

• Anticipatory guidance (here are some examples)

  • Wash hands often, avoid sick contacts

  • Keep cord dry until it falls off

  • Use rear-facing car seat in back seat of car

  • Don't shake or hit the baby

  • Avoid exposure to second- or third-hand smoke

Vital Signs and Anthropometrics

The respiratory rate and degree of respiratory effort are carefully assessed while the infant is undressed. The respiratory rate of a newborn usually averages from 30 to 60 breaths/min. Observe the respiratory rate for 1 minute because periods of apnea and periodic breathing are common, especially among preterm infants. Look for grunting respirations and for chest retractions, each of which is evidence of respiratory distress.

Determine the pulse by auscultation of the heart. The average heart rate of a newborn ranges from 120 to 140 beats/min. There are wide fluctuations; the rate increases to as fast as 200 during crying and decreases to as low as 90 during sleep. A heart rate lower than 90 is of concern.

The temperature should be checked using a rectal thermometer. The infant's buttocks are spread, and a well-lubricated thermometer is inserted slowly through the anal sphincter to approximately 1 inch (2.5 cm). Note that this also establishes that the anus is patent, thereby ruling out the existence of imperforate anus. Newborn infants often have relative thermal instability, and for this reason the ambient temperature should also be determined. Achieving temperature stability is one of the early adaptational challenges for a term infant and takes much longer for preterm infants.

Basic measurements are taken next. The infant's length is measured from the top of the head to the bottom of the feet; the length is usually between 18.5 and 20.5 inches (47 and 52 cm). The head is measured at its greatest circumference around the occipitofrontal area. The head circumference is usually 13.5 to 14.5 inches (34 to 37 cm). These and all other measurements performed during the physical examination should be plotted on appropriate growth curves, correcting for the gestational age.

General Appearance

There is a lot to be learned by simple observation of the newborn. At first glance, the examiner can assess the infant's activity level, coloring, and respiratory status to help determine immediate next steps. If the newborn is limp, cyanotic, or in respiratory distress, urgent attention is needed as opposed to proceeding with routine care. In addition, the general appearance of the baby can reveal dysmorphic features or congenital anomalies, such as cleft lip, or orthopedic deformities, findings that will be addressed later but are still important to note.

Note the posture. A normal term newborn keeps the arms and legs symmetrically flexed. Relaxation of the limbs is suggestive of neurologic depression and necessitates further evaluation. The finding of one side flexed while the other side is relaxed is abnormal; such posture is suggestive of an injury, either neurologic or musculoskeletal, that occurred before or during the birthing process.

Note the movements. Normally, all four limbs should be moving in a random and asymmetric manner. Fine movements of the face and fingers are usually present. Abnormal movements include jerky, symmetric, coarse movements. All extremities should be moving, with full range of motion seen at some time.

Listen to the child's cry. Evaluate the cry for its nature, pitch, intensity, and effort. A healthy child has a strong cry, indicative of normally functioning airways. The cry varies in intensity with breathing. The cry is high-pitched and shrill in diseases associated with increased intracranial pressure. Children born to drug-addicted mothers often have high-pitched cries. A low-pitched, hoarse cry that is infrequent and low in intensity is often associated with hypothyroidism, hypocalcemic tetany, or Williams syndrome. A sound that resembles a cat mewing suggests a condition known as cri du chat syndrome . Absence of crying is suggestive of severe illness or central nervous system dysfunction.

Skin

Inspect the newborn's skin from head to toe looking for color changes, rashes, birthmarks, lesions, or signs of breakdown in the skin barrier. Are there any skin findings from birth trauma, manifested by petechiae, ecchymoses, or lacerations?

Skin color in newborns is related partially to the amount of fat present. Preterm infants generally appear redder because they have less subcutaneous fat than do term infants. In addition, the newborn has vasomotor instability, and the color of the skin may vary greatly from moment to moment and from one area of the body to another. It is often noted that when the infant is lying on one side for a time, a sharp color demarcation appears: The lower half of the body becomes red, and the upper half is pale. Seen more commonly in preterm than in term infants, this has been termed the harlequin color change and is benign. The episodes may persist from 30 seconds to 30 minutes.

Inspect for cyanosis or acrocyanosis. Acrocyanosis is a benign condition in which the hands and feet are cyanotic and cool, but the trunk is pink and warm. See Fig. 24.2 . This condition is common among newborns. In central cyanosis, the tongue and gums are also blue. Persistent central cyanosis can be suggestive of respiratory abnormalities or the presence of cyanotic congenital heart disease.

Is plethora present? Plethora is a condition marked by an excess of blood and a marked redness of the complexion. Plethora in the newborn usually indicates high levels of hemoglobin. Is pallor present? Pallor may be associated with anemia or, more commonly, with cold stress and peripheral vasoconstriction. Pallor may also reflect asphyxia, shock, sepsis, or edema. It should be recognized that the presence of pallor may mask cyanosis in a newborn with circulatory failure.

Physiologic jaundice is found in almost 50% of all term newborns by the third or fourth day after birth. This finding, which is even more prevalent among preterm infants, results from delay in the maturation of enzymatic processes in the liver. In most cases, jaundice is a self-limited condition, resolving after 96 hours of age. However, very high levels of bilirubin in the newborn's serum can lead to a condition known as kernicterus, in which permanent neurologic damage may occur. As such, it is important to monitor the serum bilirubin level and to treat elevated levels with phototherapy.

Icterus appearing before the third day may indicate a pathologic condition. Disorders that must be considered are hemolytic anemia, caused by blood group incompatibility or by bacterial or viral infections, and galactosemia, an inborn error of galactose metabolism. Visible jaundice in newborns does not appear until the serum bilirubin is approximately 5 mg/dL. When the level exceeds this threshold, the jaundice spreads in an orderly manner, from the top of the head to the soles of the feet. A transcutaneous bilirubinometer is used prior to discharge to facilitate recognizing potentially dangerous levels of jaundice.

Observe the pigmentation. Large, slate-blue, well-demarcated areas of pigmentation in the sacrogluteal area or elsewhere are called dermal melanocytosis, originally referred to as Mongolian spots, and are normal variants. Ninety percent of all dermal melanocytosis are in the buttock area, but they can also be found along the back, on the extremities, or even the face. These spots fade and disappear by 5 to 6 years of age in 98% of children who have them. Dermal melanocytosis is present in more than 90% of African American newborns and 70% of Asian-American newborns but in fewer than 10% of white newborns. Fig. 24.3 shows a classic dermal melanocytosis.

Telangiectasias in the dermis on the eyelids, glabella, or nape of the neck are common and known as nevus simplex or salmon patches as seen in Fig. 24.4 . They appear as pink patches with irregular, feathery borders. They are often referred to as “stork bites” or “angel kisses.” Since they are due to dilated blood vessels beneath thin skin, they can darken with crying or lighten with pressure. Those on the face tend to fade as the skin thickens and disappear while those on the back of the neck may become permanent.

Vascular lesions, which encompass vascular neoplasms and vascular malformations, are common, generally benign, and usually will involute. However, some may be more serious, resulting in serious complications, or may be associated with complex syndromes. Vascular lesions have undergone changes in terminology, originally featuring descriptive characteristics (such as port wine stain or strawberry birthmark). Now the nomenclature is based on clinical characteristics, such as cellular makeup and natural clinical progression. The International Society for the Study of Vascular Anomalies (ISSVA) classifies vascular lesions into broad categories: vascular tumors, simple malformations, combined vascular malformations, anomalies of major named vessels, and vascular malformations associated with other anomalies. For more information and on different types of vascular nevi, refer to the Clinicopathologic Correlations section at the end of this chapter.

Other birthmarks that may suggest the presence of an underlying genetic disorder include café-au-lait spots (see Fig. 8.46 ) and hypopigmented macules. One or two café-au-lait spots, the color of coffee with milk, are not uncommon in the newborn. In dark-skinned individuals, the macule is darker than the surrounding skin and should be described as “café sans lait” (coffee without milk). The presence of more than six of these spots, measuring greater than 0.5 cm, is the hallmark of neurofibromatosis type I, an autosomal dominantly inherited condition that combines café-au-lait spots, axillary or inguinal freckles (see Fig. 8.49 ), pigmented hamartomas in the iris (Lisch nodules), and bony abnormalities such as scoliosis and pseudarthrosis with benign tumors of the Schwann cells called neurofibromas. In this condition, multiple café-au-lait spots are frequently the presenting feature.

The presence of hypopigmented macules suggests a condition known as tuberous sclerosis complex. In this disorder, the hypomelanotic macules ( Fig. 24.5 ) are often described as ash-leaf shaped, with one side smooth and the other side jagged, and are associated with other dermatologic manifestations (e.g., facial angiofibromas known as adenoma sebaceum, and shagreen patches, ²²

22 An elevated cluster of closely set, skin-colored papules often present on the back and lumbosacral area.

as seen in Fig. 24.6 ), the presence of benign tumors in the brain (cortical “tubers,” subependymal nodules), kidney (angiomyolipomas and cysts), and heart (rhabdomyomas), seizures, and developmental delay. Because of the significance of some of these findings, the presence of multiple hypomelanotic ash-leaf spots noted during an initial evaluation should trigger a full evaluation for associated features.

Is a rash present? Erythema toxicum neonatorum is a common rash among newborns. The condition is seen in 40% of otherwise healthy term newborns; it is not seen in premature newborns. It is a self-limited, benign eruption of unknown cause, consisting of individual papules or pustules on an erythematous base. Sometimes they are clustered. The lesions may appear anywhere on the body except on the palms and soles and have the appearance of flea bites. It is most commonly seen during the first 1 to 3 days after birth but may be present at birth. The lesions tend to be transient, coming and going even up to a couple of weeks of life. Erythema toxicum is pictured in Fig. 24.7 .

Milia on the face are seen in almost 50% of all newborns. Milia appear as tiny whitish papules on the cheeks, nose, chin, and forehead and usually disappear by 3 weeks of age.

Bullous lesions may be present at birth. One or two blisters on the lips or hands may represent “sucking blisters.” Blisters that first appear at 3 to 4 days of life may be staphylococcal pustulosis, which manifests as pustular or bullous skin lesions found mainly around the groin and umbilicus. The vesicular lesions of herpes simplex also usually appear after the third day after birth, up to the third week and require immediate treatment due to the very serious nature of herpes infection in neonates.

Widespread small pustules, many of them ruptured and leaving a collarette of scale with underlying pigmentation, represent transient neonatal pustular melanosis, which is benign. This condition, present at birth, is of unknown origin and is most commonly found on the trunk and extremities. It is seen in 5% of African American newborns and in 0.5% of white newborns. Fig. 24.8 shows the stages of transient neonatal pustular melanosis in a newborn. Notice the intact pustule and the ruptured pustule with a collarette of scale. The pustules last 48 to 72 hours, and the pigmented macules may last 3 weeks to 3 months.

Prenatal or transplacental infections of the fetus may manifest with cutaneous symptoms. If a pregnant woman contracts rubella in the first trimester, there is a 20% chance that the infant may have the congenital rubella syndrome. A cutaneous sign of congenital rubella is the blueberry muffin lesion. Such lesions, which represent sites of extramedullary hematopoiesis, are bluish-red macular or papular lesions ranging in size from 2 to 8 mm. They are noted at birth or within the first 24 hours and appear on the face, neck, trunk, or extremities. Other features of the congenital rubella syndrome include eye defects (especially cataracts), cardiac defects (e.g., ventricular septal defects and valvular defects), deafness, bone lesions, hepatosplenomegaly, jaundice, thrombocytopenia, interstitial pneumonitis, and later, developmental delay. Fig. 24.9 shows a child with the classic blueberry muffin rash of congenital rubella.

Congenital syphilis may present as an erythematous maculopapular rash that later turns brown or becomes a hemorrhagic vesicular rash. This is a rash that commonly affects the palms and soles.

Is hair present? A newborn's skin may be covered with fine, soft, immature hair, known as lanugo hair. Lanugo hair frequently covers the scalp and brow in premature infants but is usually absent in term infants, except perhaps on the ears and shoulders. Inspect the lumbosacral area for tufts of hair. Tufts of hair (hypertrichosis) in this area are suggestive of the presence of an occult spina bifida or a sinus tract, anomalies that may be an external sign of tethering of the spinal cord. Fig. 24.10 shows sacral hypertrichosis in a child who had a tethered spinal cord. Examine the fingernails. In a post-term infant, the fingernails are long and may be stained yellow if meconium was present in the amniotic fluid. Hypoplastic fingernails may be a marker for fetal alcohol syndrome.

Head

Examination of the head involves a thorough assessment of its shape, symmetry, and fontanelles. The skull may be molded, especially if the labor was prolonged and the head was engaged for a long period. The head may appear elongated or egg- or cone-shaped. The head shape returns to normal in the ensuing days to weeks. The skull of a child born by primary cesarean section without preceding labor has a characteristic roundness.

In the newborn, the sutures are frequently felt as ridges as a result of the overriding of the cranial bones by molding as the skull passes through the vaginal canal. The sutures may also separate due to shifting of the bones, called split sutures, which feel like spaces between the bones. Palpate the fontanelles, or “soft spots.” The anterior fontanelle is located at the junction of the frontal (metopic), coronal, and sagittal sutures, is usually 1.5 to 2.5 inches (3 to 6 cm) in diameter, and is diamond-shaped. The triangular posterior fontanelle is located at the junction of the sagittal and lambdoid sutures and measures 0.4 to 0.8 inch (1 to 2 cm) in diameter. Normally, the fontanelles are flat. While the size may vary, they must be open, otherwise craniosynostosis ²³

23 Craniosynostosis is a condition in which one or more of the sutures close too early, causing problems with normal brain and skull growth. This premature closure of the sutures may cause increased intracranial pressure resulting in the skull or facial bones changing from a normal, symmetrical appearance.

may be suspected. A bulging fontanelle may be indicative of increased intracranial pressure; a depressed fontanelle may be seen in dehydration. Normally during crying, the fontanelles bulge. Pulsations of the fontanelles reflect the pulse. The anterior fontanelle normally closes by 18 months of age, but there is a wide range of normality between 10 and 24 months; the posterior fontanelle should be closed by 2 months of age and may already be closed in the neonatal period. The locations of the fontanelles and suture names are shown in Fig. 24.11 .

Caput succedaneum is edema of the soft tissues over the vertex of the skull that is related to the birth process during a vertex delivery. The normal movement of the fetal head through the birth canal produces a marked molding of the very soft fetal skull and scalp edema. This swelling, which is present at delivery, crosses the sutures and resolves in the first few days. In a face presentation, there can be discoloration, and swelling of the newborn's face.

Caput succedaneum should be differentiated from a cephalohematoma, which is a subperiosteal hemorrhage limited to one cranial bone, often the parietal. There is no discoloration of the overlying scalp, and the swelling does not cross the suture line. The swelling is usually not visible until several hours or days after birth, inasmuch as subperiosteal bleeding is generally a slow process. Approximately 15% of cephalohematomas are bilateral, and each is palpably distinct from the other side. No treatment is required for cephalohematomas, which are generally resorbed by 2 to 12 weeks, depending on the size, however, breakdown of the extravasated blood may contribute to jaundice. Fig. 24.12 shows a newborn with a caput succedaneum; Fig. 24.13 shows a child with a cephalohematoma. Note in Fig. 24.13 that the swelling stops in the midline at the sagittal suture; this is characteristic of a cephalohematoma.

Inspect the scalp for lesions from fetal scalp electrodes, used for monitoring fetal well-being during difficult labors, and for areas of alopecia. A 0.4- to 0.8-inch (1- to 2-cm) well-demarcated area of smooth shiny skin with no hair may represent aplasia cutis congenita, an abnormality of fetal development of unknown cause, which is usually an isolated finding in an otherwise well newborn. Nevus sebaceus, a benign hamartoma of the skin that is noted at birth or soon after, is most commonly found on the scalp or face. When on the scalp, the lesion has a clearly demarcated area of alopecia surrounding it. These lesions are caused by overgrowth of sebaceous and apocrine glands as well as the epidermis and immature hair follicles. They appear as well-defined yellow, pink, or tan plaques that vary in shape (round, oval, or linear) and ranging in size from one to several centimeters. In older children, they can appear thickened, verrucous, or nodular.

Inspect the face for symmetry. The eye creases should be equal. Observe the infant as he or she sucks or cries. The mouth should remain on a level plane. If it is asymmetric, suspect a facial paralysis or a congenital anomaly of one or more facial muscles, a condition known as asymmetric crying facies syndrome .

The face may reveal abnormal features such as epicanthal folds, widely spaced eyes, or low-set ears, each of which may be associated with congenital defects or genetic syndromes.