Breast Development

Tanner stage I - prepubertal

Tanner stage II - breast bud

Tanner stage III - increased size of breast tissue

Tanner stage IV - separation of areola above breast tissue

Tanner stage V - adult breast

Pubic Development

Tanner stage I - prepubertal

Tanner stage II - light, straight, sparse hair

Tanner stage III - darker, coarser hair

Tanner stage IV - adult type pubic hair, limited to pubic area

Tanner stage V - adult pubic hair, with extension onto medial thighs, and in males up toward the umbilicus

Male Genitourinary development

Tanner I - prepubertal child

Tanner II - enlargement of testes and scrotum

Tanner III - increase in penile length and testes growth

Tanner IV - increased penile breadth and length, glans development, darkening of scrotal skin, larger testes

Tanner V - adult

Girls:

Peak height velocity: Tanner II-III

Menarche: Tanner stage IV (look for the mound, age 12)

Scoliosis screening: Tanner II-III

Boys:

Peak height velocity: Tanner IV

Scoliosis screening: Tanner II-III

Lethargic or listless babies appear to have little or no energy, are drowsy or sluggish, and may sleep longer than usual. They may be hard to wake for feedings and even when awake, are not alert or attentive to sounds and visual stimulation. Sometimes, this can develop slowly and a parent may not notice the gradual change.

Lethargy may be a sign of infection or other conditions such as low blood glucose (sugar). Consult your baby's physician if your baby's becomes lethargic or has a change in activity level.

Down's syndrome

Upward-slanting palpebral fissures, epicanthal folds, and a flat nasal bridge. Other features include Brushfield spots, simian crease, wide space bet. the first and second toes, short 5th finges, small ears and a flat occiput.

Fetal Alcohol syndrome

narrow and widespread eyes, long single philtrum, thin upper lip, short nose and hypoplasia of the nails and distal phalanges. Also it is assoc. with microcephaly, growth deficiency, and congenital heart disease. IQ is usually 50-80. These children often are hyperactive, and have problems with fine motor skills.

Children's temperatures flucutate more and tend to be higher than adult temperatures by one degree F.

Children 2-6 y/o may have significance dirurnal variation temperature, with a pm temperature as much as 1.6 degrees F higher than in the morning.

Infants are affected by environmental temperature (e.g. wrapping a blanket around it)

definition of fever in newborn: greater than 37.8 degrees Celcius (100.04);

older children: 38.4 is normal

Supraventricular tachycardia (SVT) - sudden onset and sudden termination; HR > 200; infants may present with irritability, decreased feeding, and increased respirations

sinus tachycardia  - gradual onset; HR variable by 10-15 BPM

sinus arrhythmia - common in younger children; pulse rate increases during inspiration, and decreases during expiration; normal finding in children

upon inspiration, stroke volume decreases, and to maintain constant cardiac output, HR increases

upon expiration, SV increases, and to maintain constant cardiac output, HR decreases

HR -

birth - 140/min

1 y/o - 110/min

< 6 y/o -  100/min

respiratory rate -

birth - 30-80 minute

infant - 20-60/min

6 y/o - 16-25/min

15 y/o - adult levels - 8-20/min

BP

systolic

birth - 70

1 mo - 85

6 mo - 90

5 y/o - 95

8 y/o - 100

13 y/o - 110

18 y/o - 120

diastolic

1 y/o - 55 mm Hg

8 y/o - 60 mm Hg

11 y/o - 65 mm Hg

18 y/o - 70 mm Hg

hypertension - blood pressure greater than the 95% for age and sex determined on three different occasions

significance: higher incidence of secondary hypertension in children with elevated blood pressure than in adults; seek cause of HTN

failure to thrive - either a low rate at child's current age or a low rate of increase

presentation: the (1) weight decreases first, (2) then height decreases, then head circumcerfence

etiology: psychosocial deprivation

growth plotted over time (aka growth curve) can tell you whether a child is falling across percentiles (e.g. from 90% originally to 25%), further eval neccessary

Failure to thrive disease progression: the (1) weight decreases first, (2) then height decreases, then head circumcerfence

skin turgor - a good indicator of nutrition and hydration; estimated by grasping the subcutaneous tissue over the abdominal wall between the thumb and index finger, and then releasing it

decreased turgor - skin fails to snap back to original position; implies intravascular volume depletion and poor nutrition

macrocephaly - head circumference greater than 2 standard deviations above the mean for a child of similar age and sex;+2 cm/mo is abnormal growth (during first 6 mo of life)

significance: hydrocephalus is most probable etiology (others include subdural hematoma, dubdural effusions, tumor, thickening of skull, benign familial megalocephaly), and transilluminates (+2 cm) on exam,

microcephaly - more than two standard deviations below the mean; less than the 5th percentile for age and sex

signifiance: mental retardation, caused by congential infections (cytomegalovirus, toxoplasmosis) or syphilis, trauma, and craniosynostosis.

anterior fontanelle: closes bet. 4-26 mo (90% close between 7-19 months)

posterior fontanelle: closes to palpation within a few weeks after birth, should always close by two months of age

premature closure of the sutures - craniosynostosis, which can hamper normal enlargement of the head and lead to distortions (since cranial bones infancy grow predominantly at their borders, craniosynostosis)

10 to 20% of craniosynostosis is related to various syndromes

bulging fontanelle -inc. intracranial pressure

physiologic - crying (remains pulsatile)

pathologic - hydrocephalus, meningitis, subdural hematoma, shaken baby, and tumor (non-pulsatile, visibly)

depressed fontanelle - dec. intracranial pressure - volume depletion

craniosynostosis - premature closure of the sutures

presentation: assymetry of the head or a decrease in head growth

significance: (1) can hamper normal enlargment of the head and lead to distortions (since cranial bones in infancy grow predominantly at their borders), (2) 10-20%  related to various syndromes

caput succadaneum - diffuse boggy swelling of the scalp brought on by pressure that usually disappears by the first day or two of life; doesn't cross suture lines

cephalohematoma - caused by a subperiosteal collection of blood over one or more flat bones of the skull; swelling does not cross suture lines; decreases by 3-6 weeks, may persist

strabismus - commonly occurs in first few months of life; disappears by 6 months of age

exotrophia - constant turning outward

exophoria - turning outward (in dark)

esotropia - constant turning inward

esophoria - turning inward (in dark)

infantile esotropia - present at birth, tends to run in families, and almost always requires surgery

accomodative esotropia - related to hyperopia, children who are farsighted compensate by increased accommodation; if hyperopia is severe enough, the eye may not be able to diverge in order to compensate for the convergence; esotropia then develops that disappears with treatment of the hyperopia.

nonaccommodative esotropia - usually due to poor vision, trauma, or prematurity

tests - corneal light reflex test - tests for tropias and the alternate cover test - tests for phorias

strabismus - can lead to amblyopia. Visual information from the dysfunctional eye is suppressed. The most frequent cause of visual loss in children.

Age 4 or 5

is the age up until children may have 20/30 vision.

Ambloypia - most frequent cause of visual loss in children; visual image from dysfunctional eye is suppressed and amblyopia will occur

etiologies: strabismus, uncorrected hyperopia or myopia and cataracts;

significance: earlier the treatment, the better the outcome; if an affected child is over 8 years of age, treatment is rarely effective

Brainstem Auditory Evoked Potentials
Otoacoustic Emissions: Faint sounds produced by motion of outer hair cells of the cochlea – detected  by microphone sealed in the external auditory canal
2 1/2 y/o - Play audiometry
Office screening
Formal Screening

infants: acoustic blink reflex (loud noise => blink)

5-6 m/o: turn head toward sound

delayed speech development: parental suspicion of decreased hearing are important red flags

Pneumatic otoscopy - evaluates the mobility of the tympanic membrane;

decreased mobility of tympanic membrane - sensitive indicator of an effusion

choanal atresia: a bony (90%) or membranous (10%) obstruction that can be either unilateral or bilateral. Bilateral choanal atresia presents with severe respiratory distress at delivery. the affected infant's cyanosis is relived by crying (paradoxical cyanosis).

The diagnosis is made by the inability to pass a plastic suction catheter through the nares.

Location of apical impulse

Fourth IC space – age 7 5th IC space

Lateral to midclavicular line until age 7

Louder P2

Splitting of S2 at apex is normal

S3 may be normal
Innocent murmurs are common

Kernig’s Sign

Today, the maneuver is usually performed with the
patient supine with hips and knees in flexion. Exten-
sion of the knees is attempted: the inability to extend
the patient’s knees beyond 135 degrees without caus-
ing pain constitutes a positive test for Kernig’s sign.

Brudzinski’s neck sign.

With the patient supine, the physician places one
hand behind the patient’s head and places the other
hand on the patient’s chest. The physician then raises
the patient’s head (with the hand behind the head)
while the hand on the chest restrains the patient and
prevents the patient from rising. Flexion of the
patient’s lower extremities (hips and knees) constitutes
a positive sign. Brudzinski’s neck sign has more sensitivity than Kernig’s sign.

Both signs indicative for menigitis.