History
Birth History (eSlide 2.1)
Birth history should include any issues during pregnancy or during labor and delivery. Maternal complications during pregnancy, such as seizures, febrile illnesses, hypertension, or hyperglycemia, should be evaluated. Any medications or drugs that the mother took during pregnancy and any substances the infants were exposed to should be reviewed. The duration of gestation, presence of multiple fetuses, fetal movements, and presentation at birth are also important factors.
The child’s birth weight and length, as well as the Apgar score, should be noted. The Apgar score consists of five components: activity, pulse, grimace, appearance, and respiration. Postnatal complications, such as hyperbilirubinemia, retinopathy of prematurity, respiratory difficulties, feeding difficulties, and duration of respiratory support, may provide clues to underlying disease and functional impact. Complications during the mother’s previous pregnancies, such as stillbirths, miscarriages, or fetal anomalies, should be recorded.
History of Presenting Problem (eSlide 2.2)
The physician should determine the onset, progression, and associated factors of the current problem. It is important to determine which diagnostic tests have been performed, as well as any treatments that have been initiated. The child’s medical history, including any significant illnesses, hospitalizations, surgeries, procedures, previous trauma, medications taken, allergies, and immunization status, should be reviewed.
Developmental History
Developmental history is one of the most important aspects of pediatric history. Illnesses, injuries, and different disease processes can have a profound impact on the attainment of developmental milestones. Delays may be noted in gross motor, fine motor, speech and language, and/or psychosocial areas. A thorough understanding of developmental milestones (eSlides 2.3, 2.4, 2.5, and 2.6) and the age at which the child attained them can assist with diagnosis and treatment protocols. If delays are noted in motor skills, a neuromuscular disorder is more likely, and if delays are primarily noted in speech and language skills, assessment of the child’s hearing is warranted. A discussion of the developmental milestones is helpful in educating the family regarding what the child should be doing and what skills he or she should be working on. It should be emphasized that there is a wide range of normal for attaining certain skills, and the family may notice that the child progresses at different rates in different areas.
Family History
The family history should include any history of early stroke, early myocardial infarction, peripheral neuropathy, joint or tissue abnormalities, myopathies, bony abnormalities, gait abnormalities, or developmental delays; a history of these conditions should be ascertained through multiple generations. If a genetic disorder is suspected, the child and family should be referred for genetic testing, which can help with planning future pregnancies and provide counseling to the extended family.
Social and Educational History
The examiner should inquire about the child’s environment, including who lives with the child, who the caregivers are, and the layout and accessibility of the home. The child’s peer interactions, extracurricular activities, current educational history, and history of receiving early intervention services can give insight into the child’s social skills, personality, and learning abilities.
Physical Examination (eSlide 2.7)
There is no standardized approach to the physical examination of the pediatric patient. It should be tailored to the age and developmental level of the child. Developing a rapport by playing or talking with the child can be helpful. Very young children are typically most comfortable on their parent’s lap during the examination.
Growth
Height and weight should be monitored as the child grows. The average full-term newborn measures 50 cm in length and weighs 3400 g. Height increases 50% by the first year and doubles by the fourth year. Children’s adult height can be estimated by doubling their height at age 2 years. Body weight doubles by 5 months and triples by 1 year. Growth may be arrested early as a result of precocious puberty, with premature closure of the growth plate. Precocious puberty is defined as the onset of puberty in girls younger than 8 years and boys younger than 9 years. Decreases in the velocity of height or weight growth, as well as actual weight loss, may be associated with poor nutrition or malabsorption. Significant increases may indicate a pituitary tumor, metabolic disorder, or poor diet. The average head circumference at birth is 35 cm and increases to 47 cm by 1 year. Macrocephaly and microcephaly are defined as a head circumference greater than 2 standard deviations above and below the mean, respectively. With institution of the “Back to Sleep” program, there has been an increase in the presence of flattening of the occiput, brachycephaly, and plagiocephaly; these conditions resolve spontaneously.
Inspection
The child’s general appearance, movements, degree of engagement, skin, cranial deformities, facial dysmorphisms, joint abnormalities, and asymmetry of stature should be examined. The presence of certain physical abnormalities is linked with some common syndromes (eSlide 2.8) .
Musculoskeletal Assessment
Inspect and palpate the bones, joints, and muscles, and perform passive and active range of movement (ROM) of all joints. Loss of ROM may be attributable to joint contracture, and hypermobility may be due to connective tissue disorders. The back and spine examination should focus on any bony abnormalities, as well as any muscular asymmetries. The most common form of scoliosis is a right thoracic curve in adolescent girls.
It is not unusual for the child’s foot to be flat until 3 to 5 years of age. However, if the foot is rigid or painful, it may be the result of a tarsal coalition (eSlide 2.9) . If the child has pes cavus (eSlide 2.9) , the presence of a neuromuscular disease, such as Charcot-Marie-Tooth disease, should be investigated. The most common causes of intoeing are metatarsus adductus in infancy, tibial torsion in the toddler, and femoral anteversion in the older child. Children have normal, physiologic bow legs up to age 2 years, but rickets or Blount disease could account for pathologic genu varus position. If there is significantly reduced ROM at the hip or a leg length discrepancy, the hip may be subluxed or dislocated. An anteroposterior pelvis film will delineate the degree of subluxation.
Neurologic Assessment
Neurologic assessment evaluates cranial nerve function, sensory function, strength, movement, reflexes, coordination, balance, gait (eSlide 2.10) , and cognitive function. Infants will track an object to the midline at 1 month of age and from side to side at 3 months. Auditory evaluation should be reassessed in any child who demonstrates speech and language delays, articulation errors, inattentiveness to sound, a history of recurrent ear infections, or a history of brain injury.
Evaluations of primitive reflexes (eSlide 2.11) and postural responses (eSlide 2.12) are helpful tools in assessing an infant’s motor responses. Any asymmetry in responses may reflect an underlying stroke or peripheral nerve disorder, such as a brachial plexus injury. A true manual muscle examination is not very accurate before the age of 5 years. A child’s muscle tone will change during development. Hypotonia with associated areflexia in a newborn is consistent with spinal muscular atrophy. Hypertonia may be subdivided into spasticity, dystonia, and rigidity. Hypertonia indicates a central nervous system disorder. A child’s gait pattern changes and progresses from the age of 1 year to approximately 7 years: the base of support narrows, the stride length increases, and the cadence decreases.
Functional Assessment
Developmental skills can be formally assessed with a variety of tools, such as the Denver Developmental Screening Test II (DDST-II), Bayley Scales of Infant Development, and Gesell Developmental Schedule (eSlide 2.13) . A children’s version of the Functional Independence Measure (WeeFIM) was developed to evaluate a child’s functional progression. Cognition and potential for academic achievement can be assessed in the preschooler and school-age child with several tests (eSlide 2.14) . It is also important to evaluate a child’s social and adaptive skills and his or her perceived quality of life (eSlide 2.15) . Disability-specific assessment tools include the Gross Motor Function Measure (GMFM) and the Manual Abilities Classification Scale (MACS), which measure motor function in patients with cerebral palsy.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
