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Infant/Toddler Examination
You
should be able to conduct a complete examination
of all organ systems in all infants/toddlers using
an age appropriate approach. Specific maneuvers that
are a part of the infant/toddler examination include:
Ear examination
Ask about hearing concerns
•
Inquire about infant’s response to
•
Observe an older infant’s/toddlers speech
pattern
• Assess
the shape of the ears
Determine if both ears are well formed
Examine the child from the front, with the
child’s head held erect and
the eyes facing forward.
Draw an imaginary line between the inner
canthi and extend it around the head.
This line should be at or above the
top of the pinnae
Palpate the tragus and posterior auricular area
Otoscopic exam including insufflation
•Position
the child for an ear examination
This
part of the exam can be examined either on
the examination table or in the caregiver’s
lap.
The head should be stabilized to prevent
movement
during
otoscopy.
A parent or
assistant
can assist with
the
examination
by
folding the child’s
wrists and arms over the child’s abdomen with one hand and then holding
the child’s head against the parent’s/assistant’s
chest
with
the
other.
•Visualize
the external canal
Gently hold the tragus and insert the otoscope
while visualizing the canal.
In contrast to adults, gentle posterior traction may help you visualize the
canal and eventually
the
tympanic membrane.
•Visualize
the tympanic membrane
Identify
the landmarks starting with long handle of
the malleus then moving
to the “cone of light” in
the pars tensa
Carefully
visualize the pars
flaccida
courtesy
of M. Whipple, MD |
•Perform pneumatic otoscopy
Hold
the otoscope and bulb with one hand and retract
the pinna with the other
Gently apply a small “puff” of
air to
the tympanic membrane
Normal movement: medially
(away from you) with the application
of air and laterally
(toward you) when the bulb is released
Any delay
in language
acquisition or
loss
of language
milestones
should prompt
a referral for
formal hearing
testing
Hearing
impairment
is estimated
to occur in 1-2/1000
live births
Some
etiology
of
hearing
loss in
childhood
Sensory
neural: cochlear
malformation, damage
to hair cells
(due to noise,
disease,
ototoxic
agents)
or 8th nerve
damage
Conductive:
(most
common)—ear
canal atresia,
cerumen
impaction,
otitis media with
effusion
Position/Shape
of the
ears
Malformed
external
and
middle
ears
may
be
associated
with
serious
renal
or
other
craniofacial
malformations
Tenderness
to palpation
of
the
tragus
is indicative
of
otitis
externa.
You
will
also
typically
see
white
cheesy
material
in
the
external
auditory
canal.
Treatment
is
aural
toilet
and
topical
antibiotics
Tenderness
to palpation and/or redness in the posterior
auricular area may suggest mastoiditis.
Otoscopy:
Areas of retraction in the pars flaccida may represent
a cholesteatoma and should be further evaluated.
A cholesteatoma acts as a benign tumor causing local
bone destruction and is a nidus for bacteria to grow
and cause chronic infections.
The most common reason for an immobile tympanic membrane
(TM) with pneumatic otoscopy is a poor seal between
the otoscope and ear canal
You must assess the movement of the TM to determine
if a patient has otitis media. In addition to pneumatic
otoscopy; acoustic tympanometry can be used.
Changes in the appearance of the TM that are highly
suggestive of acute infection include: bulging or purulent
material visualized behind the tympanic membrane. Guidelines
for the diagnosis and treatment of otitis media: www.aap.org
Removal of cerumen is difficult but sometimes necessary
to adequately see the TMs. The external auditory
canal bleeds easily with minor trauma so ask for
help if you need to clear out cerumen. It can be
done by gentle irrigation with warm water, H2O2 or
with direct visualization and use of a wire/plastic
loop.
Save the mouth exam for the very last in young
children
Ask child to open their mouth and
show you their teeth (appropriate
for an older toddler/child).
If this doesn’t
work, be prepared to
be fast with your tongue
blade.
An alternative is to be flexible and
look in the mouth when the child is
crying for some other reason!!!
Count
the number
of teeth and note
position
Note
any
defects
or
discolorations
Inspect
gums, mucosal
surfaces
and
posterior
pharynx
Inspect
the
buccal
mucosal
and
gums
looking
for
ulcers,
candida
or
trauma
To
see
the
posterior
pharynx,
you
may
have
to
use
the
tongue
blade
and
gag
the
child.
Alternative
tricks
you
can
use
include
asking
the
child
to “roar
like a lion”, “pant like a dog”,
have
their
parents
model
what
you
would
like
to
child
to
do
or
have
the
child
look
in
your
mouth.
The numbering system for primary teeth is different than the system used in
adults.
There are 20 primary teeth
Time for first tooth eruption is variable;
delayed eruption maybe familial or
associated with other syndromes/conditions
(like hypothyroidism)
There
may be developmental anomalies associated
with tooth development
Dental
caries
is
the
most
common
chronic
illness
in the
United
States.
More
than ½ of
children within
the U.S. have dental
caries. Steptococcus
mutans is associated
with the development
of dental caries.
Early childhood caries
may occur
on the smooth surfaces
if upper/lower
incisions
because of prolonged
exposure
to sugar
containing
substances.
Site
for caries
in
children
include
pits/fissues
of biting (occlusal)
surfaces
in
older
children
(> 3
yo)
Using
a tongue blade in this population is challenging.
Inserting it along the side of the mouth and
then gagging the child will allow for an unobstructed
view of the posterior pharynx in most children.
The
size of tonsils are described in the following
way
Grade
Appearance
0 Absent
1 Visible between the tonsillar pillars
2 Easily visible outside of the tonsillar fossae
3 Enlarged and occupying >75% of posterior pharynx
4 Touching in the midline occupying all of the posterior pharynx
The diagnosis is streptococcal pharyngitis is a laboratory,
not clinical diagnosis. Other infections that can cause
tonsillar exudates include EBV infections, CMV infections,
S. aureus infections, adenoviral infections.
The approach the pediatric heart examination is the
same as in an adult. Included here is a brief discussion
of MURMURS in children.
As the pulmonary vascular resistance decreases, flow
through the Patent Ductus Ateriosus or Patent Foramen
Ovale stops as these structures close. Some murmurs
heard shortly after birth will disappear.
However, as the pulmonary vascular resistance decreases,
this may allow left to right shunting and new murmurs
may appear (such as seen with a VSD)
Presence
of central
cyanosis
is an
important
clue
for congenital
heart
disease.
Those
lesions
associated
with
cyanotic
heart
disease
are the “Ts”:
Tetralogy of Fallot, Tricuspid Atresia, Transposition
of the Great Arteries, Total Anomalous venous return & Truncus
arteriosus
(there
are
others
but
these
are
easy
to
remember)
Beyond the newborn period
50% of children have innocent murmurs
Non-pathologic murmurs include:
Peripheral Pulmonary flow murmur:
Soft (1-2/6) systolic ejection murmur heard
in L upper sternal
border with radiation to the axilla and
back
Soft
(1-2/6) continuous
murmur heard in 1st or 2nd ICS)
Soft
(<3/6) early systolic murmur heard along
the L sternal border between the 2nd/3rd
or 4th/5th. Intensity varies with position & might
be heard with the bell. “Vibratory/blowing/musical” in
quality.
Hemic
murmur
(flow
murmur)
Heard
in
states
with
increased
physiologic
need
(fever,anemia).
Heard
at
base
of
the
heart,
soft
(<3/6)
and
often
associated
with
tachycardia
Musculoskeletal Examination
Do
Observe the child closely; noting in particular range of motion and limb use
An excellent time to get this information is
before the examination while the child
is playing or interacting with their parents.
Inspect
the joints for redness
or swelling
Start
with
the
hands
or
some
non-threatening
part
of
the
examination;
examine
the
affected
joint
last.
Palpate
methodically
and
in
a
systematic
manner
the
involved
area
and
all
other
areas
that
influence
the
involved
area.
Note
muscles,
bony
prominences,
other
important
landmarks,
and
joints
of
the
involved
body
part.
Be
observant
for
pain
or
warmth
Assess
Active
and
Passive
Range
of
motion
for
each
major
joint.
Young
children
may
not
cooperate
with
this
part
of
the
examination;
you
may
have
to
range
their
joints
and
gauge
how
much
they
resist
you
to
judge
function.
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