(18) Peds Flashcards

Question

``` Although obtaining accurate blood pressure readings in infants is challenging (Fig. 18-17), this measurement is nevertheless important for ```

Answer 1

some high-risk infants and should | be routinely performed after age 3 years.

Answer 2

140 (90-190) 130 (80-180) 115 (75-155)

Answer 3

30-60 The respiratory rate may vary considerably from moment to moment in the newborn, with alternating periods of rapid and slow breathing (called “periodic breathing”)

Answer 4

Commonly accepted cutoffs for defining tachypnea are >60/min from birth to 2 months, and >50/min from 2 to 12 months

Answer 5

Because fever is so common in infants and children, obtain an accurate body temperature when you suspect infection. Axillary and thermal-tape skin temperature recordings in infants and children are inaccurate. Auditory canal temperatures are accurate. Rectal temperatures are the most accurate for infants Body temperature in infants and children is less constant than in adults. The average rectal temperature is higher in infancy and early childhood, usually above 99°F (37.2°C) until after age 3 years. Body temperature may fluctuate as much as 3°F during a single day, approaching 101°F (38.3°C) in normal children, particularly in late afternoon and after vigorous activity

Answer 6

Examine the skin of the newborn or infant carefully to identify both normal markings and potentially abnormal ones. The photos on pp. 818–820 demonstrate normal markings. The newborn’s skin has a unique characteristic texture and appearance. The texture is soft and smooth because it is thinner than the skin of older children. Within the first 10 minutes after birth a normal newborn progresses from generalized cyanosis to pinkness. In lighter-skinned infants, an erythematous flush, giving the skin the appearance of a “boiled lobster,” is common during the first 8 to 24 hours after which the normal pale pink coloring predominates. Vasomotor changes in the dermis and subcutaneous tissue—a response to cooling or chronic exposure to radiant heat—can produce a lattice-like, bluish mottled appearance (cutis marmorata), particularly on the trunk, arms, and legs. This response to cold may last for months in normal infants. Acrocyanosis, a blue cast to the hands and feet when exposed to cold (see p. 818), is very common in newborns for the first few days and may recur throughout early infancy. Occasionally in newborns, a remarkable color change (harlequin dyschromia) appears with transient cyanosis of one half of the body or one extremity, presumably from temporary vascular instability. The amount of melanin in the skin of newborns varies, affecting pigmentation. Black newborns may have a lighter skin color initially, except in the nail beds, genitalia, and ear folds which are dark at birth. A dark or bluish pigmentation over the buttocks and lower lumbar regions is common in newborns of African, Asian, and Mediterranean descent. These areas, called slate blue patches, result from pigmented cells in the deep layers of the skin; they become less noticeable with age and usually disappear during childhood. Document these pigmented areas to avoid later concern about bruising. At birth, there is a fine, downy growth of hair called lanugo over the entire body, especially the shoulders and back. This hair is shed within the first few weeks. Lanugo is prominent in premature infants. Hair thickness on the head varies considerably among newborns and is not predictive of later hair growth. All of the original hair is shed within months and is replaced with a new crop, sometimes of a different color. Inspect the newborn closely for a series of common skin conditions. At birth, a cheesy white material called vernix caseosa, composed of sebum and desquamated epithelial cells, covers the body. Some newborns have edema over their hands, feet, lower legs, pubis, and sacrum; this disappears within a few days. Superficial desquamation of the skin is often noticeable 24 to 36 hours after birth, particularly in postterm babies (>40 weeks gestation), and it can last for 7 to 10 days. You should be able to identify four common dermatologic conditions in newborns— miliaria rubra, erythema toxicum, pustular melanosis, and milia—which are shown on p. 819. None of these is clinically significant. Note any signs of trauma from the birth process and the use of forceps or suction; these signs disappear but should prompt a careful neurologic examination.

Answer 7

Carefully examine and touch the newborn’s skin to assess the level of jaundice. Normal “physiologic” jaundice, which occurs in half of all newborns, appears on the second or third day, peaks at about the fifth day, and usually disappears within a week (although it may persist longer in breast-fed infants). Jaundice is best seen in natural daylight rather than artificial light. Newborn jaundice appears to progress from head to toe, with more intense jaundice on the upper body and less intense yellow color in the lower extremities. To detect jaundice, apply pressure to the skin (Fig. 18-19) to press out the normal pink or brown color. A yellowish “blanching” indicates jaundice

Answer 8

A common vascular marking is the “salmon patch” (also known as nevus simplex, “flame nevi,” telangiectatic nevus, or capillary hemangioma). These flat, irregular, light pink patches (see p. 819) are most often seen on the nape of the neck (“stork bite”), upper eyelids, forehead, or upper lip (“angel kisses”). They are not true nevi, but result from distended capillaries. They often disappear by 1 year of age and are covered by the hairline

Answer 9

Palpate the newborn or infant’s skin to assess the degree of hydration, or turgor. Roll a fold of loosely adherent skin on the abdominal wall between your thumb and forefinger to determine its consistency. The skin in well-hydrated infants returns to its normal position immediately upon release. Delay in return is a phenomenon called “tenting” and usually occurs in children with significant dehydration

Answer 10

This bluish discoloration usually appears in the palms and soles. Cyanotic congenital heart disease can present with severe acrocyanosis

Answer 11

Physiologic jaundice occurs during days 2 to 5 of life and progresses from head to toe as it peaks. Extreme jaundice may signify a hemolytic process or biliary or liver disease.

Answer 12

Scattered vesicles on an erythematous base, usually on the face and trunk, result from obstruction of the sweat gland ducts; this condition disappears spontaneously within weeks

Answer 13

Usually appearing on days 2 to 3 of life, this rash consists of erythematous macules with central pinpoint vesicles scattered diffusely over the entire body. They appear similar to flea bites. These lesions are of unknown etiology but disappear within 1 week of birth

Answer 14

Seen more commonly in black infants, the rash presents at birth as small vesiculopustules over a brown macular base; these can last for several months

Answer 15

Pinhead-sized smooth white raised areas without surrounding erythema on the nose (seen here), chin, and forehead result from retention of sebum in the openings of the sebaceous glands. Although occasionally present at birth, milia usually appear within the first few weeks and disappears over several weeks

Answer 16

This birthmark fades, usually within the first year of life

Answer 17

Also called the “stork bite,” or “angel kiss,” this splotchy pink mark fades with age

Answer 18

These light-brown pigmented lesions usually have borders and are uniform. They are noted in more than 10% of black infants. If more than five café-au-lait spots exist, consider the diagnosis of neurofibromatosis

Answer 19

These are more common among dark-skinned babies. It is important to note them so that they are not mistaken for bruises

Answer 20

Membranous tissue spaces called sutures separate the bones of the skull from one another. The areas where the major sutures intersect in the anterior and posterior portions of the skull are known as fontanelles. Examine the sutures and fontanelles carefully On palpation, the sutures feel like ridges and the fontanelles like soft concavities. The anterior fontanelle at birth measures 4 to 6 cm in diameter and usually closes between 2 and 26 months of age (90% between 7 and 19 months). The posterior fontanelle measures 1 to 2 cm at birth and usually closes by 2 months Carefully examine the fontanelle, because its fullness reflects intracranial pressure. Palpate the fontanelle while the baby is sitting quietly or being held upright. Clinicians often palpate the fontanelles at the beginning of the examination. In normal infants, the anterior fontanelle is soft and flat. A full anterior fontanelle with increased intracranial pressure is seen when a baby cries or vomits. Pulsations of the fontanelle reflect the peripheral pulse and are normal (and parents often inquire about them). Learn to palpate the fontanelle because a bulging fontanelle is concerning for increased intracranial pressure and a depressed fontanelle may suggest dehydration. Inspect the scalp veins carefully to assess for dilatation

Answer 21

Carefully assess skull symmetry (Fig. 18-21). Various conditions can cause asymmetry; some are benign, while others reflect underlying pathology. Look for asymmetric head swelling. A newborn’s scalp may be swollen over the occipitoparietal region. This is called caput succedaneum and results from capillary distention and extravasation of blood and fluid resulting from the vacuum effect of rupture of the amniotic sac. This swelling typically crosses suture lines and resolves in 1 to 2 days. The premature infant’s head at birth is relatively long in the occipitofrontal diameter and narrow in the bitemporal diameter (dolichocephaly). Usually, the skull shape normalizes within 1 to 2 years Pick up the infant and examine the skull shape from behind. Asymmetry of the cranial vault (positional plagiocephaly) occurs when an infant lies mostly on one side, resulting in a flattening of the parieto-occipital region on the dependent side and a prominence of the frontal region on the ipsilateral side. It disappears as the baby becomes more active and spends less time in one position, and symmetry is almost always restored. Interestingly, the current trend to have newborns sleep on their backs to reduce the risk for sudden infant death syndrome (SIDS) has resulted in more cases of positional plagiocephaly (Fig. 18-22). This condition can be prevented by frequent repositioning (providing “tummy time” when the infant is awake). Measure the head circumference (p. 814) to detect abnormally large head size (macrocephaly) or small head size (microcephaly), both of which may signify an underlying disorder affecting the brain. Palpate along the suture lines. A raised, bony ridge at a suture line suggests craniosynostosis. Palpate the infant’s skull with care. The cranial bones generally appear “soft” or pliable; they will normally become firmer with increasing gestational age

Answer 22

Check the face of infants for symmetry. In utero positioning may result in transient facial asymmetries. If the head is flexed on the sternum, a shortened chin (micrognathia) may result. Pressure of the shoulder on the jaw may create a temporary lateral displacement of the mandible. Examine the face for an overall impression of the facies; it is helpful to compare with the face of the parents. A systematic assessment of a child with abnormalappearing facies can identify specific syndromes.18 The box on the next page describes steps for evaluating fa

Answer 23

Carefully review the history, especially: ● Family history ● Pregnancy ● Perinatal history Note abnormalities on other parts of the physical examination, especially: ● Growth ● Development ● Other dysmorphic somatic features Perform measurements (and plot percentiles), especially: ● Head circumference ● Height ● Weight Consider the three mechanisms of facial dysmorphogenesis: ● Deformations from intrauterine constraint ● Disruptions from amniotic bands or fetal tissue ● Malformations from intrinsic abnormality in face/head or brain Examine the parents and siblings: ● Similarity to a parent may be reassuring (e.g., large head) but may also be an indication of a familial disorder Try to determine whether the facial features fit a recognizable syndrome, comparing with: ● References (including measurements) and pictures of syndromes ● Tables/databases of combinations of features

Answer 24

Percuss the cheek to check for Chvostek sign, which is present in some metabolic disturbances and occasionally in normal infants. Percuss at the top of the cheek just below the zygomatic bone in front of the ear, using the tip of your index or middle finger

Answer 25

Newborns keep their eyes closed except during brief awake periods. If you attempt to separate their eyelids, they will tighten them even more. Bright light causes infants to blink, so use subdued lighting. Awaken the baby gently and support the baby in a sitting position; often the eyes open. To examine the eyes of infants and young children, use some tricks to encourage cooperation. Small colorful toys are useful as fixation devices in examining the eyes. Newborns may look at your face and follow a bright light if you catch them during an alert period. Some newborns can follow your face and turn their heads 90° to each side. Examine infants for eye movements. Hold the baby upright, supporting the head. Rotate yourself with the baby slowly in one direction. This usually causes the baby’s eyes to open, allowing you to examine the sclerae, pupils, irises, and extraocular movements (Fig. 18-23). The baby’s eyes gaze in the direction you are turning. When the rotation stops, the eyes look in the opposite direction, after a few nystagmoid movements. During the first 10 days of life, the eyes may stare in one direction if just the head is turned without moving the body (doll’s eye reflex). During the first few months of life, some infants have intermittent crossed eyes (intermittent alternating convergent strabismus, or esotropia) or laterally deviated eyes (intermittent alternating divergent strabismus, or exotropia). Look for abnormalities or congenital problems in the sclera and pupils. Subconjunctival hemorrhages are common in newborns and resolve within a couple of weeks. The eyes of many newborns are edematous from the birth process. Observe pupillary reactions by response to light or by covering each eye with your hand and then uncovering it. Although there may be initial asymmetry in the size of the pupils, over time they should be equal in size and reaction to light. Inspect the irises carefully for abnormalities Examine the conjunctiva for swelling or redness. Most newborn nurseries use an antibiotic eye ointment to help prevent gonococcal eye infection. You will not be able to measure the visual acuity of newborns or infants. You can use visual reflexes to indirectly assess vision: direct and consensual pupillaryconstriction in response to light, blinking in response to bright light (optic blink reflex), and blinking in response to quick movement of an object toward the eyes.

Answer 26

``` Birth - Blinks, may regard face 1 month - Fixes on objects 1½–2 months - Coordinated eye movements 3 months - Eyes converge, baby reaches toward a visual stimulus 12 months - Acuity around 20/60–20/80 ```

Answer 27

For the ophthalmoscopic examination, with the newborn awake and eyes open, examine the red retinal (fundus) reflex by setting the ophthalmoscope at 0 diopters and viewing the pupil from about 10 inches. Normally, a red or orange color is reflected from the fundus through the pupil. A thorough ophthalmoscopic examination is difficult in young infants but may be needed if ocular or neurologic abnormalities are noted. The cornea can ordinarily be seen at +20 diopters, the lens at +15 diopters, and the fundus at 0 diopters. Examine the optic disc area as you would for an adult. In infants, the optic disc is difficult to visualize but is lighter in color, with less macular pigmentation. The foveal light reflection may not be visible. Papilledema is rare in infants because the fontanelles and open sutures accommodate any increased intracranial pressure, sparing the optic discs.

Answer 28

The physical examination of the ears of infants is important because many abnormalities can be detected, including structural problems, otitis media, and hearing loss. The goals are to determine the position, shape, and features of the ear and to detect abnormalities. Note ear position in relation to the eyes. An imaginary line drawn across the inner and outer canthi of the eyes should cross the pinna or auricle; if the pinna is below this line the infant has low-set ears. Draw this imaginary line across the face of the baby on p. 821; note that it crosses the pinna. Otoscopic examination of the newborn’s ear can detect only patency of the ear canal because accumulated vernix caseosa obscures the tympanic membrane for the first few days of life A small skin tab, cleft, or pit found just forward of the tragus represents a remnant of the first branchial cleft and usually has no significance. However, occasionally it may also be associated with renal disease and acquired hearing loss if there is a family history of hearing loss. The infant’s ear canal is directed downward from the outside; therefore, pull the auricle gently downward, not upward, for the best view of the eardrum. Once the tympanic membrane is visible, note that the light reflex is diffuse; it does not become cone-shaped for several months. The acoustic blink reflex is a blinking of the infant’s eyes in response to a sudden sharp sound. You can produce it by snapping your fingers or using a bell, beeper, or other noisemaking device approximately 1 foot from the infant’s ear. Be sure you are not producing an airstream that may cause the infant to blink. This reflex may be difficult to elicit during the first 2 to 3 days of life. After it is elicited several times within a brief period, the reflex disappears, a phenomenon known as habituation. This crude test of hearing certainly is not diagnostic. Most newborns in the United States undergo hearing screenings, which are mandatory in the majority of states

Answer 29

0–2 mo: Startle response and blink to a sudden noise Calming down with soothing voice or music 2–3 mo: Change in body movements in response to sound Change in facial expression to familiar sounds Turning eyes and head to sound 3–4 mo: Turning to listen to voices and conversation 6–7 mo: Appropriate language development

Answer 30

The most important component of the examination of the infant nose is to test for patency of the nasal passages. You can do this by gently occluding each nostril alternately while holding the infant’s mouth closed. This usually will not cause stress because most infants are nasal breathers. Some infants are obligate nasal breathers and have difficulty breathing through their mouths. Do not occlude both nares simultaneously, as this will cause considerable distress. Inspect the nose to ensure that the nasal septum is midline. At birth, the maxillary and the ethmoid sinuses are present. Palpation of the sinuses of newborns is not helpful.

Answer 31

Use both inspection with a tongue depressor and flashlight and palpation to inspect the mouth and pharynx (Fig. 18-24). One method employs the parent to hold theinfant’s head and arms. The newborn’s mouth is edentulous and the alveolar mucosa is smooth with finely serrated borders. Occasionally, pearl-like retention cysts are seen along the alveolar ridges and are easily mistaken for teeth; these disappear within 1 or 2 months. Petechiae are commonly found on the soft palate after birth. Palpate the upper hard palate to make sure it is intact. Epstein pearls, tiny white or yellow, rounded mucous retention cysts, are located along the posterior midline of the hard palate. They disappear within months. Cysts may be noted on the tongue or mouth. Thyroglossal duct cysts may open under the tongue. Infants produce little saliva during the first 3 months. Older infants produce a lot of saliva and drool frequently. Inspect the tongue. The frenulum varies in tightness; sometimes it extends almost to the tip and other times it is short, limiting protrusion of the tongue (ankyloglossia or tongue tie). You will often see a whitish covering on the tongue. If this coating is from milk, it can be easily removed by scraping or wiping it away. Use a tongue depressor or your gloved finger to wipe away the coating. While there is a predictable pattern of tooth eruption, there is wide variation in the age at which teeth appear. A rule of thumb is that a child will have 1 tooth for each month of age between 6 and 26 months, up to a maximum of 20 primary teeth. The pharynx of the infant is best seen while the baby is crying. You will likely have difficulty using a tongue depressor because it produces a strong gag reflex. Infants do not have prominent lymphoid tissue so you will probably not visualize the tonsils which increase in size as children grow. Listen to the quality of the infant’s cry. Normal infants have a lusty, strong cry. The following box lists some unusual types of infant cries

Answer 32

Shrill or high pitched: Increased intracranial pressure. Also in newborns born to narcotic-addicted mothers. Hoarse: Hypocalcemic tetany or congenital hypothyroidism Continuous inspiratory and expiratory stridor: Upper airway obstruction from various lesions (e.g., a polyp or hemangioma), a relatively small larynx (infantile laryngeal stridor), or a delay in the development of the cartilage in the tracheal rings (tracheomalacia) Absence of cry: Severe illness, vocal cord paralysis, or profound brain damage

Answer 33

Palpate the lymph nodes of the neck and assess for any additional masses such as congenital cysts (Fig. 18-25). Because the necks of infants are short, it is best to palpate the neck while infants are lying supine, whereas older children are best examined while sitting. Check the position of the thyroid cartilage and trachea. In newborns, palpate the clavicles and look for evidence of a fracture. If present, you may feel a break in the contour of the bone, tenderness, crepitus at the fracture site, and may notice limited movement of the arm on the affected side.

Answer 34

The infant’s thorax is more rounded than that of adults. The thin chest wall has little musculature; thus, lung and heart sounds are transmitted quite clearly. The bony and cartilaginous rib cage is soft and pliant. The tip of the xiphoid process often protrudes anteriorly, immediately beneath the skin

Answer 35

Carefully assess respirations and breathing patterns. Newborns, especially those born prematurely, show periods of normal rate (30 to 40 per minute) alternating respirations that may even cease for 5 to 10 seconds. This alternating pattern of rapid and slow breathing is called “periodic respiration” or “periodic breathing.” Do not rush to the stethoscope. Instead, observe the infant carefully as demonstrated in Figure 18-26, which demonstrates locations for retractions among infants. Inspection is easiest when infants are not crying; thus, work with the parents to settle the child. Observe for 30 to 60 seconds, note general appearance, respiratory rate, color, nasal component of breathing, audible breath sounds, and work of breathing, as described below. Because infants are obligate nasal breathers, observe their nose as they breathe. Look for nasal flaring. Observe breathing with the infant’s mouth closed or during nursing or sucking on a bottle to assess for nasal patency. Listen to the sounds of breathing; note any grunting, audible wheezing, or lack of breath sounds (obstruction). Nasal flaring, grunting, retractions, and wheezing are all signs of respiratory distress. Observe two aspects of the infant’s breathing: audible breath sounds and work of breathing. These are particularly relevant in assessing both upper and lower respiratory illness. Studies in countries with poor access to chest radiographs have found these signs at least as useful as auscultation. Any of the abnormalities listed below should raise concern about underlying respiratory pathology. In healthy infants, the ribs do not move much during quiet breathing. Any outward movement is produced by descent of the diaphragm which compresses the abdominal contents and in turn shifts the lower ribs outward. Pulmonary disease causes increased abdominal breathing and can result in retractions (chest indrawing), an indicator of pulmonary disease before 2 years of age. Chest indrawing is inward movement of the skin between the ribs during inspiration. Movement of the diaphragm primarily affects breathing with little assistance from the thoracic muscles. As mentioned in the preceding table, four types of retractions can be noted in infants: suprasternal, intercostal, substernal, and subcostal. Thoracoabdominal paradox, inward movement of the chest and outward movement of the abdomen during inspiration (abdominal breathing), is a normal finding in newborns (but not older infants). It persists during active, or rapid eye movement (REM), sleep even when it is no longer seen during wakefulness or quiet sleep because of the decreased muscle tone of active sleep. As muscle strength increases and chest wall compliance decreases with age, abdominal breathing should no longer be noted. If observed, it may signify respiratory disease

Answer 36

Inability to feed or smile | Lack of consolability

Answer 37

Tachypnea (see p. 815), apnea

Answer 38

Pallor or cyanosis

Answer 39

``` Nasal flaring (enlargement of both nasal openings during inspiration) ```

Answer 40

Grunting (repetitive, short expiratory sound) Wheezing (musical expiratory sound) Stridor (high-pitched, inspiratory noise) Obstruction (lack of breath sounds)

Answer 41

Nasal flaring (excessive movement of nares) Grunting (expiratory noises) Retractions (chest indrawing): Supraclavicular (soft tissue above clavicles) Intercostal (indrawing of the skin between ribs) Substernal (at xiphoid process) Subcostal (just below the costal margin)

Answer 42

Assess tactile fremitus by palpation. Place your hand on the chest when the infant cries or makes noise. Place your hand or fingertips over each side of the chest and feel for symmetry in the transmitted vibrations. Percussion is not helpful in infants except in extreme instances. The infant’s chest is hyperresonant throughout, and it is difficult to detect abnormalities on percussion.

Answer 43

After performing these maneuvers, you are ready for auscultation. Infant breath sounds are louder and harsher than those of adults because the stethoscope is closer to the origin of the sounds. It is often difficult to distinguish transmitted upper airway sounds from sounds originating in the chest. Upper airway sounds tend to be loud, transmitted symmetrically throughout the chest, and loudest as you move your stethoscope toward the neck. They are usually coarse inspiratory sounds. Lower airway sounds are loudest over the site of pathology, are often asymmetric, and often occur during expiration Expiratory sounds usually arise from an intrathoracic source, whereas inspiratory sounds can arise from an extrathoracic airway such as the trachea or from an intrathoracic source. During expiration, the diameter of the intrathoracic airways decreases because radial forces from the surrounding lung do not “tether” the airways open as occurs during inspiration. Higher flow rates during inspiration produce turbulent flow, resulting in appreciable sounds. Expiratory sounds usually arise from an intrathoracic source, whereas inspiratory sounds can arise from an extrathoracic airway such as the trachea or from an intrathoracic source. During expiration, the diameter of the intrathoracic airways decreases because radial forces from the surrounding lung do not “tether” the airways open as occurs during inspiration. Higher flow rates during inspiration produce turbulent flow, resulting in appreciable sounds.

Answer 44

Before examining the heart itself, observe the infant carefully for any cyanosis. Acrocyanosis in the newborn is discussed on pages 816 and 918. It is important to detect central cyanosis because it is always abnormal and because many congenital cardiac abnormalities, as well as respiratory diseases, present with cyanosis.20 Recognizing minimal degrees of cyanosis requires care. Look inside the body (i.e., the inside of the mouth, the tongue, or the conjunctivae) in addition to assessing skin color. A true strawberry pink is normal, whereas any hint of raspberry red suggests desaturation and requires urgent evaluation. The distribution of the cyanosis should be evaluated. An oximetry reading will confirm desaturation. Observe the infant for general signs of health. The infant’s nutritional status, responsiveness, irritability, and fatigue are all clues that may be useful in evaluating cardiac disease. Note that noncardiac findings (see box on the next page) are often present in infants with cardiac disease. Observe the respiratory rate and pattern to help distinguish the degree of illness and cardiac versus pulmonary diseases. An increase in respiratory effort is expected from pulmonary diseases, whereas in cardiac disease there may be tachypnea without increased work of breathing (called “peaceful tachypnea”) until heart failure becomes significant.

Answer 45

Immediately at birth Transposition of the great arteries Pulmonary valve atresia Severe pulmonary valve stenosis Possibly Ebstein malformation ``` Within a few days after birth All of the above plus: Total anomalous pulmonary venous return Hypoplastic left heart syndrome Truncus arteriosus (sometimes) Single ventricle variants ``` Weeks, months, or years of life All of the above plus: Pulmonary vascular disease with atrial, ventricular, or great vessel shunting (right-to-left shunting)

Answer 46

``` Poor feeding Tachypnea Poor overall appearance Failure to thrive Hepatomegaly Weakness Irritability Clubbing Fatigue ```

Answer 47

Palpation of the chest wall will allow you to assess volume changes within the heart. For example, a hyperdynamic precordium reflects a big volume change. The point of maximal cardiac impulse, or PMI, is not always palpable in infants and is affected by respiratory patterns, a full stomach, and the infant’s positioning. It is usually an interspace higher than in adults during the first few years of life because the heart lies more horizontally within the chest. Thrills are palpable when turbulence within the heart or great vessels is transmitted to the surface. Knowledge of the structures of the precordium helps pinpoint the origin of the thrill. Thrills are easiest to feel with your palm or the base of your fingers rather than your fingertips. Thrills have a somewhat rough, vibrating quality. Figure 18-27 shows locations of thrills that occur in infants and children from various cardiac abnormalities

Answer 48

The major branches of the aorta can be assessed by evaluation of the peripheral pulses. All neonates should have an evaluation of all pulses at the time of their newborn examination. In neonates and infants, the brachial artery pulse in the antecubital fossa is easier to feel than the radial artery pulse at the wrist. Both temporal arteries should be felt just in front of the ear. Palpate the femoral pulses. They lie in the midline just below the inguinal crease, between the iliac crest and the symphysis pubis. Take your time to search for femoral pulses; they are difficult to detect in chubby, squirming infants. If you first flex the infant’s thighs on the abdomen, this may overcome the reflex flexion that occurs when you then extend the legs. Palpate the pulses in the lower extremities using your index or middle finger. The dorsalis pedis and posterior tibial pulses (Fig. 18-28) may be difficult to feel unless there is an abnormality involving aortic run-off. Normal pulses should have a sharp rise and should be firm and well localized. As discussed on p. 814, carefully measure the blood pressure of infants and children (using an appropriate-sized infant blood pressure cuff) as part of the cardiac examination.

Answer 49

You can evaluate the heart rhythm more easily in infants by listening to the heart than by feeling the peripheral pulses; in older children assess the rhythm either way. Infants and children commonly have a normal sinus dysrhythmia, with the heart rate increasing on inspiration and decreasing on expiration, sometimes quite abruptly. This normal finding can be identified by its repetitive nature and its correlation with respiration. Many neonates and some older children have premature atrial or ventricular beats that are often described as “skipped” beats. You can usually eradicate them by increasing their intrinsic sinus rate through exercise such as crying in an infant or jumping in an older child, although they may also be more frequent in the postexercise period. In a completely healthy child, they are usually benign and rarely persist. In addition to trying to detect splitting of the S2, listen for the intensity of A2 and P2. The aortic, or first component of the second sound at the base, is normally louder than the pulmonic, or second component (Fig. 18-29). You may detect third heart sounds which are low-pitched, early diastolic sounds best heard at the lower left sternal border, or apex; they reflect rapid ventricular filling. These are frequently heard in children and are normal. Fourth heart sounds represent decreased ventricular compliance, suggesting heart failure. You may also detect an apparent gallop (widely split S2 that varies), in the presence of a normal heart rate and rhythm. This is frequently found in normal children and does not represent pathology

Answer 50

One of the most challenging aspects of the cardiac examination in children is the evaluation of heart murmurs. In addition to listening to a squirming, perhaps uncooperative child, a major challenge is distinguishing common benign murmurs from unusual or pathologic ones. Characterize heart murmurs in infants and children by noting their specific location (e.g., left upper sternal border, not just left sternal border), timing, intensity, and quality. If each murmur is delineated completely, the diagnosis is usually made clinically, and laboratory tools such as ECG, chest x-ray, and echocardiography are needed for confirmation and better characterization. An important rule of thumb is that, by definition, benign murmurs in children have no associated abnormal findings. Many (but not all) children with serious cardiac malformations have signs and symptoms other than a heart murmur obtainable on careful history or examination. Many have noncardiac signs and symptoms, including evidence of genetic defects that may offer helpful diagnostic clues. Most children, if not all, will have one or more functional, or benign, heart murmurs before reaching adulthood.21–23 It is important to identify functional murmurs by their specific qualities rather than by their intensity. You will learn to recognize the common functional murmurs of infancy and childhood, which under most circumstances do not require evaluation. The box on the next page characterizes two benign heart murmurs in infants according to their locations and key characteristics In some infants, you will detect a soft, somewhat ejectile murmur, not over the precordium but over the lung fields, particularly in the axillae. This represents peripheral pulmonary artery flow and is partly the result of inadequate pulmonary artery growth in utero (when there is little pulmonary blood flow) and the sharp angle at which the pulmonary artery curves backward. In the absence of any physical findings to suggest additional underlying diseases, this peripheral pulmonary flow murmur (which is common) can be considered benign and usually disappears by 1 year. When you detect a murmur in a child, note all of the qualities as described in Chapter 9, The Cardiovascular System, to help you distinguish pathologic murmurs from benign murmurs. Heart murmurs that reflect underlying structural heart disease are easier to evaluate if you have a good knowledge of intrathoracic anatomy and the functional cardiac changes following birth and if you understand the physiologic basis for heart murmurs. Understanding these physiologic changes can help you distinguish pathologic murmurs from benign heart murmurs in children.

Answer 51

1. Closing ductus (newborns) - Transient, soft, ejection, systolic Upper left sternal border 2. Peripheral pulmonary flow murmur (newborn - 1 year) - Soft, slightly ejectile, systolic Upper left sternal border, radiating to lung fields and axillae

Answer 52

Change in Pulmonary Vascular Resistance Heart murmurs that are dependent on a postnatal drop in pulmonary vascular resistance, allowing turbulent flow from the high-pressure systemic circuit to the lowerpressure pulmonary circuit, are not audible until such a drop has occurred. Except in premature infants, murmurs of a ventricular septal defect or PDA are not heard in the first few days of life and usually become audible after a week to 10 days. Obstructive Lesions Obstructive lesions, such as pulmonic and aortic stenosis, are caused by normal blood flow through two small valves. They are not dependent on a drop in pulmonary vascular resistance. They are audible at birth. Pressure Gradient Differences Murmurs of atrioventricular valve regurgitation are audible at birth because of the high-pressure gradient between the ventricle and its atrium. Changes Associated with Growth of Children Some murmurs do not follow the patterns above, but become audible because of alterations in normal blood flow that occur with growth. For example, even though it is an obstructive defect, aortic stenosis may not be audible until considerable growth has occurred and is frequently not heard until adulthood, although a congenitally abnormal valve is responsible. Similarly, the pulmonary flow murmur of an atrial septal defect may not be heard for a year or more because right ventricular compliance gradually increases and the shunt becomes larger, eventually producing a murmur caused by too much blood flow across a normal pulmonic valve.

Answer 53

The breasts of the newborn in both males and females are often enlarged from maternal estrogen effect; this may last several months. The breasts may also be engorged with a white liquid, sometimes colloquially called “witch’s milk,” which may last 1 or 2 weeks

Answer 54

Inspect the abdomen with the infant lying supine (and, optimally, asleep). The infant’s abdomen is protuberant as a result of poorly developed abdominal musculature. You will easily notice abdominal wall blood vessels and intestinal peristalsis. Inspect the newborn’s umbilical cord to detect abnormalities. Normally, there are two thick-walled umbilical arteries and one larger but thin-walled umbilical vein which is usually located at the 12 o’clock position. The umbilicus in the newborn may have a long cutaneous portion (umbilicus cutis) which is covered with skin, and an amniotic portion (umbilicus amnioticus) which is covered by a firm gelatinous substance. The amniotic portion dries up and falls off within 2 weeks, whereas the cutaneous portion retracts to be flush with the abdominal wall. Inspect the area around the umbilicus for redness or swelling. Umbilical hernias are detectable by a few weeks of age. Most disappear by 1 year, nearly all by 5 years. In some normal infants, you will notice a diastasis recti. This involves separation of the two rectus abdominis muscles, causing a midline ridge most apparent when the infant contracts the abdominal muscles. A benign condition in most cases, it resolves during early childhood

Answer 55

Auscultation of a quiet infant’s abdomen is easy. You may hear an orchestra of musical tinkling bowel sounds upon placement of your stethoscope on the infant’s abdomen

Answer 56

You can percuss an infant’s abdomen as you would an adult’s, but may note greater tympanitic sounds because of the infant’s propensity to swallow air. Percussion is useful for determining the size of organs and abdominal masses. It is easy to palpate an infant’s abdomen because infants like being touched. A useful technique to relax the infant is to hold the legs flexed at the knees and hips with one hand and palpate the abdomen with the other. A pacifier may quiet the infant in this position. When palpating the liver, start gently low in the abdomen, moving upward with your fingers. This technique helps to identify an extremely enlarged liver that extends down into the pelvis. With a careful examination, you can feel the liver edge in most infants, 1 to 3 cm below the right costal margin. One technique for assessing liver size in infants is simultaneous percussion and auscultation.24 Percuss and simultaneously auscultate, noting a change in sound as you percuss over the liver or beyond it. Of note, a scratch test (described on page 880 for older children) can be attempted in infants. The spleen, like the liver, is felt easily in most infants. It is soft with a sharp edge and it projects downward like a tongue from under the left costal margin. The spleen is moveable and rarely extends more than 1 to 2 cm below the left costal margin. Palpate the other abdominal structures. You will commonly note pulsations in the epigastrium caused by the aorta. This is felt on deep palpation to the left of the midline. You may be able to palpate the kidneys of infants by carefully placing the fingers of one hand in front of and those of the other behind each kidney. The descending colon is a sausage-like mass in the left lower quadrant. Once you have identified the normal structures in the infant’s abdomen, use palpation to identify abnormal masses.

Answer 57

Inspect the male genitalia with the infant supine noting the appearance of the penis, testes, and scrotum. The foreskin completely covers the glans penis. It is nonretractable at birth though you may be able to retract it enough to visualize the external urethral meatus. The foreskin gradually loosens over months to years and becomes retractable. The rate of circumcision had declined over several decades in North America and varies worldwide, depending on cultural practices, but is now recommended by the AAP and by experts in many parts of the world due to reduced rates of HIV and other infections among circumcised males. Inspect the shaft of the penis, noting any abnormalities on the ventral surface. Make sure the penis appears straight. Inspect the scrotum noting rugae which should be present by 40 weeks gestation. Scrotal edema may be present for several days following birth because of the effect of maternal estrogen. Palpate the testes in the scrotal sacs, proceeding downward from the external inguinal ring to the scrotum. If you feel a testis up in the inguinal canal, gently milk it downward into the scrotum. The newborn’s testes should be about 10 mm in width and 15 mm in length and should lie in the scrotal sacs most of the time. In about 3% of neonates, one or both testes cannot be felt in the scrotum or inguinal canal. This raises concern of cryptorchidism. In two thirds of these cases, both testes are descended by 1 year of age. Examine the testes for swelling within the scrotal sac and over the inguinal ring. If you detect swelling in the scrotal sac try to differentiate it from the testis. Note whether the size changes when the infant increases abdominal pressure by crying. See if your fingers can get above the mass, trapping it in the scrotal sac. Apply gentle pressure to try to reduce the size of the mass and note any tenderness. Note whether it transilluminates (Fig. 18-30).

Answer 58

In the newborn female, the genitalia will be prominent due to the effects of maternal estrogen. The labia majora and minora have a dull pink color in lightskinned infants and may be hyperpigmented in dark-skinned infants. During the first few weeks of life there is often a milky white vaginal discharge that may be blood tinged and is not a cause for concern. This estrogenized appearance of the genitalia decreases during the first year of life. Examine the different structures systematically, including the size of the clitoris, the color and size of the labia majora, and any rashes, bruises, or external lesions (Fig. 18-31). Next, separate the labia majora at their midpoint with the thumb of each hand, or as shown in Figs. 18-83 and 18-84 below. Inspect the urethral orifice and the labia minora. Assess the hymen, which in newborns and infants is a thickened, avascular structure with a central orifice, covering the vaginal opening. You should note a vaginal opening, although the hymen will be thickened and redundant. Note any discharge.

Answer 59

The rectal examination generally is not performed for infants or children unless there is question of patency of the anus or an abdominal mass. In such cases, flex the infant’s hips and fold the legs to the head. Use your lubricated and gloved pinky to perform the examination.

Answer 60

Enormous changes in the musculoskeletal system occur during infancy. Much of the examination of the infant focuses on detection of congenital abnormalities, particularly in the hands, spine, hips, legs, and feet. Combine the musculoskeletal examination with the neurologic and developmental examination. The newborn’s hands are clenched. Because of the palmar grasp reflex (see the discussion on the nervous system, p. 849) you will need to help the infant extend the fingers. Inspect the fingers carefully, noting any defects. Palpate along the clavicle noting any lumps, tenderness, or crepitus; these may indicate a fracture. Inspect the spine carefully. Although major defects of the spine such as meningomyelocele are obvious and often detected by ultrasound before birth, subtle abnormalities may include pigmented spots, hairy patches, or deep pits. These abnormalities, if present within 1 cm or so of the midline, may overlie external openings of sinus tracts that extend to the spinal canal. Do not probe sinus tracts because of the potential risk for introducing infection. Palpate the spine in the lumbosacral region, noting any deformities of the vertebraeExamine the newborn and infant’s hips carefully at each examination for signs of dislocation.26,27 Figures 18-32 to 18-36 and discussion cover the two major techniques, one to test for the presence of a posteriorly dislocated hip (Ortolani test) (Fig. 18-32), and another to test for the ability to sublux or dislocate an intact but unstable hip (Barlow test) Make sure the baby is relaxed for these techniques. For the Ortolani test, place the baby supine with the legs pointing toward you. Flex the legs to form right angles at the hips and knees, placing your index fingers over the greater trochanter of each femur and your thumbs over the lesser trochanters (Fig. 18-34). Abduct both hips simultaneously until the lateral aspect of each knee touches the examining table For the Barlow test, place your hands in the same position as for the Ortolani test. Pull the leg forward and adduct with posterior force; that is, press in the opposite direction with your thumbs moving down toward the table and outward (Fig. 18-36). Feel for any movement of the head of the femur laterally. Normally, there is no movement and the hip feels “stable.” Test for femoral shortening using the Galeazzi or Allis sign. Place the feet (with knee flexed and sacrum flat on the table) together and note any difference in knee heights. Examine a newborn or infant’s legs and feet to detect developmental abnormalities. Assess symmetry, bowing, and torsion of the legs. There should be no discrepancy in leg length. It is common for normal infants to have asymmetric thigh skin folds, but if you do detect asymmetry, make sure you perform the instability tests because dislocated hips are commonly associated with this finding. Most newborns are bowlegged, reflecting their curled-up intrauterine position Some normal infants exhibit twisting or torsion of the tibia inwardly or outwardly on its longitudinal axis. Parents may be concerned about a toeing in or toeing out of the foot and an awkward gait, all of which are usually normal. Tibial torsion usually corrects itself during the second year of life after months of weight bearing Examine the feet of newborns and infants. At birth, the feet may appear deformed from retaining their intrauterine positioning, often turned inward (Fig. 18-37). You should be able to correct the feet to the neutral and even to an overcorrected position (Fig. 18-38). Scratch or stroke along the outer edge to see if the foot assumes a normal position. The normal newborn’s foot has several benign features that may initially cause concern. The newborn’s foot appears flat because of a plantar fat pad. There is often inversion of the foot, elevating the outer margin (see p. 922). Other babies will have adduction of the forefoot without inversion, called metatarsus adductus which requires close follow-up. Still others will have adduction of the entire foot. Finally, most toddlers have some pronation during early stages of weight-bearing with eversion of the foot. In all of these normal variants the abnormal position can be easily overcorrected past midline. They all tend to resolve within 1 or 2 years

Answer 61

The examination of the nervous system in infants includes techniques that are highly specific to this particular age. Unlike many neurologic abnormalities in adults that produce asymmetric localized findings, neurologic abnormalities in infants often present as developmental abnormalities such as failure to do ageappropriate tasks. Therefore, the neurologic and developmental examinations need to proceed together. A developmental abnormality should prompt you to pay particular attention to the neurologic examination. The neurologic screening examination of all newborns should include assessment of mental status, gross and fine motor function, tone, cry, deep tendon reflexes, and primitive reflexes. More detailed examination of cranial nerve function and sensory function are indicated if you suspect any abnormalities from the history or screening The neurologic examination can reveal extensive disease but will not pinpoint specific functional deficits or minute lesions

Answer 62

Assess the motor tone of newborns and infants, first by carefully observing their position at rest and testing their resistance to passive movement. Further, assess tone as you move each major joint through its range of motion, noting any spasticity or flaccidity. Hold the baby in your hands to determine whether the tone is normal, increased, or decreased (Fig. 18-39). Either increased or decreased tone may indicate intracranial disease although such disease is usually accompanied by a number of other signs.

Answer 63

You can test for sensory function of the newborn in only a limited way. Test for pain sensation by flicking the infant’s palm or sole with your finger. Observe for withdrawal, arousal, and change in facial expression. Do not use a pin to test for pain.

Answer 64

``` I Olfactory Very difficult to test II Visual acuity Have infant regard your face and look for facial response and tracking. II, III Response to light Darken room, raise infant to sitting position to open eyes. Use light and test for optic blink reflex (blink in response to light). Use the otoscope’s light (without speculum) to assess pupillary responses III, IV, VI Extraocular movements Observe how well the infant tracks your smiling face (or a bright light) and whether the eyes move together. V Motor Test rooting reflex. Test sucking reflex (watch infant suck breast, bottle, or pacifier) and strength of suck. VII Facial Observe infant crying and smiling; note symmetry of face. VIII Acoustic Test acoustic blink reflex (blinking of both eyes in response to a loud noise). Observe tracking in response to sound. IX, X Swallow Observe coordination during swallowing. Gag Test for gag reflex. XI Spinal accessory Observe symmetry of shoulders. XII Hypoglossal Observe coordination of sucking, swallowing, and tongue thrusting. Pinch nostrils; observe reflex opening of mouth with tip of tongue to midline. ```

Answer 65

The deep tendon reflexes are present in newborns but may be difficult to elicit and may vary in their intensity because the corticospinal pathways are immature. Their exaggerated presence or their absence has little diagnostic significance, unless this response is different from results of previous testing or extreme responses are observed or they are very asymmetric. Use the same techniques to elicit deep tendon reflexes as you would for an adult. You can substitute your index or middle finger for the reflex hammer as shown in Figure 18-40. The triceps, brachioradialis, and abdominal reflexes are difficult to elicit before 6 months of age. The anal reflex is present at birth and important to elicit if a spinal cord lesion is suspected. In newborns, a positive Babinski response to plantar stimulation (dorsiflexion of big toe and fanning of other toes) can be elicited and may persist for several months. In order to best elicit the ankle reflex of an infant, grasp the infant’s malleolus with one hand and abruptly dorsiflex the ankle (Fig. 18-41). You may note rapid, rhythmic plantar flexion of the newborn’s foot (ankle clonus) in response to this maneuver. Up to 10 beats are normal in newborns and young infants; this is unsustained ankle clonus.

Answer 66

Evaluate the newborn’s and infant’s developing central nervous system by assessing infantile automatisms, called primitive reflexes. These develop during gestation, are generally demonstrable at birth, and disappear at defined ages. Abnormalities in these primitive reflexes suggest neurologic disease and merit more intensive investigation.

Answer 67

Refer to the developmental milestones on p. 810 and to the items on a standardized developmental screening instrument to learn which agespecific developmental tasks to evaluate. By observation and play with the infant, you can do both a developmental screening examination and an assessment for gross and fine motor achievement. Specifically, look for weakness by observing sitting, standing, and transitions. Note station, or the posture of sitting or standing. Assess fine motor development in a similar way, combining the neurologic and developmental examination. Key milestones include the development of the pincer grasp, ability to manipulate objects with the hands, and more precise tasks, such as building a tower of cubes or scribbling. Fine and gross motor development progresses in a proximal to distal direction. Assess the infant’s cognitive and social–emotional development as you proceed with the comprehensive neurologic and developmental examination. Some neurologic abnormalities produce deficits or slowing in cognitive and social development. Infants who have developmental delay may have abnormalities on the neurologic examination because much of the examination is based on age-specific norms. A normative measure of development is the developmental quotient,30 shown here: Development quotient = × 1 00 Development age Chronologic age Assess the development of an infant or child using standard scales for each type of development. Assign to each child a gross motor developmental quotient, a fine motor developmental quotient, a cognitive developmental quotient, and so forth. Importantly, these estimates are never a perfect assessment of a child’s development or potential because both can change over time Developmental Quotients: >85% normal 70-85% possibly delayed <70% delayed

Answer 68

``` Place your fingers into the infant’s hands and press against the palmar surfaces. The infant will flex all fingers to grasp your fingers. Birth to 3–4 mo ```

Answer 69

``` Touch the sole at the base of the toes. The toes will curl. Birth to 6–8 mo ```

Answer 70

``` Stroke the perioral skin at the corners of the mouth. The mouth will open and the infant will turn the head toward the stimulated side and suck. Birth to 3–4 mo ```

Answer 71

``` Hold the infant supine, supporting the head, back, and legs. Abruptly lower the entire body about 2 feet. The arms will abduct and extend, hands will open, and legs will flex. The infant may cry. Birth to 4 mo ```

Answer 72

``` With the infant supine, turn head to one side, holding jaw over shoulder. The arms/legs on side to which head is turned will extend while the opposite arm/leg will flex. Repeat on other side. Birth to 2 mo ```

Answer 73

``` Support the infant prone with one hand and stroke one side of the back 1 cm from midline, from shoulder to buttocks. The spine will curve toward the stimulated side. Birth to 2 mo ```

Answer 74

``` Suspend the infant prone with one hand. The head will lift up, and the spine will straighten. Birth to 6 mo ```

Answer 75

``` Suspend the infant prone and slowly lower the head toward a surface. The arms and legs will extend in a protective fashion. 8 mo and does not disappear ```

Answer 76

``` Hold the infant around the trunk and lower until the feet touch a flat surface. The hips, knees, and ankles will extend, the infant will stand up, partially bearing weight, sagging after 20–30 seconds. Birth or 2 mo until 6 mo ```

Answer 77

``` Hold the infant upright as in positive support reflex. Have one sole touch the tabletop. The hip and knee of that foot will flex and the other foot will step forward. Alternate stepping will occur. Birth (best after 4 days; variable age to disappear) ```

Answer 78

After infancy, the rate of physical growth slows by approximately half. After 2 years, toddlers gain about 2 to 3 kg and grow 5 cm per year. Physical changes are impressive. Chubby, clumsy toddlers transform into leaner, more muscular preschoolers. Gross motor skills also develop quickly. Almost all children walk by 15 months, run well by 2 years, and pedal a tricycle and jump by 4 years. Fine motor skills develop through neurologic maturation and environmental manipulation (Fig. 18-42). The 18-month-old who scribbles becomes a 2-year-old who draws lines and then a 4-year-old who makes circles

Answer 79

Toddlers move from sensorimotor learning (through touching and looking) to symbolic thinking, solving simple problems, remembering songs, and engaging in imitative play. Language develops with extraordinary speed. An 18-month-old with 10 to 20 words becomes a 2-year-old with three-word sentences, and a 3-year-old who converses well. By 4 years, preschoolers form complex sentences. They remain preoperational, however, without sustained logical thought processes.

Answer 80

New intellectual pursuits are surpassed only by an emerging drive for independence (Fig. 18-43). Because toddlers are impulsive and have poor self-regulation, temper tantrums are common. Self-regulation is an important developmental task with a wide range of normal

Answer 81

Children grow steadily but more slowly. Strength and coordination improve dramatically with more participation in activities (Fig. 18-45). This is also when children with physical disabilities or chronic illnesses become more aware of their limitations

Answer 82

Children become “concrete operational”—capable of limited logic and more complex learning. They remain rooted in the present with little ability to understand consequences or abstractions. School, family, and environment greatly influence learning (Fig. 18-46). A major developmental task is self-efficacy, or the ability to thrive in different situations. Language becomes increasingly complex.

Answer 83

Children become progressively more independent, initiating activities and enjoying accomplishments. Achievements are critical for self-esteem and developing a “fit” within major social structures— family, school, and peer activity groups. Guilt and poor self-esteem also may emerge. Family and environment contribute enormously to the child’s selfimage. Moral development remains simple and concrete with a clear sense of “right and wrong.”

Answer 84

Middle childhood is an active period of growth and development. Goal-directed exploration, increased physical and cognitive abilities, and achievements by trial and error mark this stage. The physical examination is more straightforward during this age period, but always consider the developmental stages and tasks that school-aged children are facing.

Answer 85

characteristic: Enhanced strength and coordination Competence in various tasks and activities ``` health care needs: Screening for strengths, assessing problems Involving parents Support for disabilities Anticipatory guidance: safety, exercise, nutrition, sleep ```

Answer 86

``` characteristic: “Concrete operational:” focus on the present Emphasis on short-term consequences Achievement of knowledge and skills, self-efficacy ``` healthcare needs: Support; screening for skills and school performance

Answer 87

characteristic: Achieving good “fit” with family, friends, school healthcare needs: Assessment, support, advice about interactions including peer relationships Sustained self-esteem Support, emphasis on strengths Evolving self-identity Understanding, advice, support

Answer 88

An important aspect of examining children is that parents are usually watching and taking part in the interaction, providing you the opportunity to observe the parent–child interaction. Note whether the child displays age-appropriate behaviors. Assess the “goodness of fit” between parents and child. Although some abnormal interactions may result from the unnatural setting of the examination room, others may be a consequence of interactional problems. Careful observation of the child’s interactions with parents and the child’s unstructured play in the examination room can reveal abnormalities in physical, cognitive, and social development or issues with parent–child relationship. Normal toddlers are occasionally terrified or angry at the examiner. Often, they are completely uncooperative. Most eventually warm up to you. If this behavior continues or is not developmentally appropriate, there may be an underlying behavioral or developmental abnormality. Older, school-aged children have more self-control and prior experience with clinicians and are generally cooperative with the examination.

Answer 89

``` Behaviorala Poor parent–child interactions Sibling rivalry Inappropriate parental discipline “Difficult temperament” Developmental Gross motor delay Fine motor delay Language delay (expressive or receptive) Delay in social or emotional tasks Social or Environmental Parental stress, depression Risk for abuse or neglect Neurologic Weakness Abnormal posture Spasticity Clumsiness Attentional problems, hyperactivity Autistic features Musculoskeletal abnormalities ```

Answer 90

One challenge in examining children in this age group is avoiding a physical struggle, a crying child, or a distraught parent. Accomplishing this successfully is one aspect of the “art of medicine” in the practice of pediatrics. Gain the child’s confidence and allay the child’s fears from the start of the encounter. Your approach will vary with the circumstances of the visit. A health supervision visit allows greater rapport than a visit when the child is ill. The child should remain dressed during the interview to minimize the child’s apprehension. It also allows you to interact more naturally and observe the child playing, interacting with the parents, and undressing and dressing. Toddlers who are of 9 to 15 months may have stranger anxiety, a fear of strangers that is developmentally normal. It signals the toddler’s growing awareness that the stranger is new. You should not approach these toddlers quickly. Play can help the child warm up to you. Make sure they remain solidly in their parent’s lap throughout much of the examination and that the parent remains close when the child is on the examination table Engage children in age-appropriate conversation. Ask simple questions about their illness or toys. Compliment their appearance or behavior, tell a story, or play a simple game (Fig. 18-47). If a child is shy, turn your attention to the parent to allow the child to warm up gradually. Also, sometimes the parent is anxious. Helping the parent relax or asking them to help by reading to the child or playing with the child can help relax everyone in the examination room. With certain exceptions, physical examination does not require use of the examining table; it can be done on the floor or with the child in a parent’s lap. The key is to engage the child’s cooperation. For young children who resist undressing, expose only the body part being examined. When examining siblings, begin with the oldest child who is more likely to cooperate and set a good example. Approach the child pleasantly. Explain each step as you perform it. Continue conversing with the family to provide distraction Plan the examination to start with the least distressing procedures and end with the most distressing ones, usually involving the throat and ears. Begin with parts that can be done with the child sitting such as examining the eyes or palpating the neck. Lying down may make a child feel vulnerable, so change positions with care. Once a child is supine, begin with the abdomen, saving throat and ears or genitalia for last. You may need a parent’s help to restrain the child for examination of the ears or throat; however, use of formal restraints is inappropriate. Patience, distraction, play, flexibility in the order of the examination, and a caring but firm and gentle approach, are all key to successfully examining the young child (Fig. 18-48). Children are usually accompanied by a parent or caregiver. Even when alone, they are often seeking health care at the request of their parent; indeed, the parent is usually sitting in the waiting room. When interviewing a child, you need to consider the needs and perspectives of both the child and the caregivers

Answer 91

``` Examine a child sitting on parent’s lap. Try to be at the child’s eye level. First examine the child’s toy or teddy bear, then the child. Let the child do some of the examination (e.g., move the stethoscope). Then go back and “get the places we missed.” Ask the toddler who keeps pushing you away to “hold your hand.” Then have the toddler “help you” with the examination. Some toddlers believe that if they can’t see you, then you aren’t there. Perform the examination while the child stands on the parent’s lap, facing the parent. If 2-yr-olds are holding something in each hand (such as tongue depressors), it is more difficult for them to fight or resist. Hand the child an age-appropriate book and engage the child in reading. ```

Answer 92

``` “Blow out” the otoscope light. “Beep” the stethoscope on your nose. Make tongue-depressor puppets. Use the child’s own toys for play. Jingle your keys to test for hearing. Shine the otoscope through the tip of your finger (or the child’s finger) to show it doesn’t hurt, “lighting it up,” and then examine the child’s ears with it. Use age-appropriate toys and books. ```

Answer 93

Begin the interview by greeting and establishing rapport with each person present (Fig. 18-50). Refer to the child by name rather than by “him” or “her.” Clarify the role or relationship of all of the adults and children. “Now, are you Jimmy’s grandmother?” “Please help me by telling me Jimmy’s relationship to everyone here.” Address the parents as “Mr. Smith” and “Ms. Smith” rather than by their first names or “Mom” or “Dad.” When the family structure is not immediately clear, you may avoid embarrassment by asking directly about other members. “Who else lives in the home?” “Who is Jimmy’s father?” “Do you live together?” Do not assume that just because parents are separated, only one parent is actively involved in the child’s life. Families come in many varieties—these include traditional families, single parents, separated/divorced parents, blended, same-sex parents, kinship families, foster families, and adoptive families. Use your personal experiences with children to guide how you interact in a health care setting. To establish rapport, meet children on their own level. Eye contact on their level, participating in playful engagement, and talking about what interests them are always good strategies. Ask children about their clothes, one of their toys, what book or TV show they like, or their adult companion in an enthusiastic but gentle style. Spending time at the beginning of the interview to calm and connect with an anxious child can put both the child and the caregiver at ease.

Answer 94

One challenge when several people are present is deciding to whom to direct your questions. While eventually you need to get information from both the child and the parent, it is useful to start with the child. Asking simple open-ended questions like “Are you sick? . . . Tell me about it,” followed by more specific questions, often provides much of the clinical data. The parents can then verify the information, add details that give you the larger context, and identify other issues you need to address. Sometimes children are embarrassed to begin, but once the parent has started the conversation, direct questions back to the child. Characterize symptom attributes the same way you do with adults. Your mom tells me that you get stomachaches. Tell me about them. Show me where you get the pain. What does it feel like? Is it sharp like a pinprick, or does it ache? Does it stay in the same spot, or does it move around? What helps make it go away? What makes it worse? What do you think causes it? The presence of family members allows you to observe how they interact with the child. A child may be able to sit still or may get restless and start fidgeting. Watch how the parents set, or fail to set, limits when needed.

Answer 95

Each individual in the room, including the clinician, may have a different idea about the nature of the problem and what needs to be done about it. Discover as many of these perspectives and agendas as possible. Family members who are not present (e.g., the absent parent or grandparent) may also have concerns. Ask about those concerns, too. “If Suzie’s father were here today, what questions or concerns would he have?” “Have you, Mrs. Jones, discussed this with your mother or anyone else?” “What does she think?” For example, Mrs. Jones brings Suzie in for abdominal pain because she is worried that Suzie may have an ulcer and is also worried about Suzie’s eating habits. Suzie is not worried about the belly pain, but is uneasy about the changes in her body and about getting fat. Mr. Jones thinks that Suzie’s schoolwork is not getting enough attention. You, as the clinician, need to balance these concerns with what you see as a healthy 12-year-old girl in early puberty with some mild functional abdominal pain and appropriate concern for possible emerging obesity. Your goals need to include uncovering the concerns of each person and helping the family to be realistic about the range of “normal.”

Answer 96

In general, family members provide most of the care and are your natural allies in promoting the child’s health. Being open to a wide range of parenting behaviors helps to make this alliance. Raising a child reflects cultural, socioeconomic, and family practices. It is important to respect the tremendous variation in these practices. A good strategy is to view the parents as experts in the care of their child and yourself as their consultant. This demonstrates respect for the parents’ care and minimizes their likelihood of discounting or ignoring your advice. Parents face many challenges raising children, so practitioners need to be supportive, not judgmental. Comments like, “Why didn’t you bring him in sooner?” or “What did you do that for?” do not improve your rapport with the parent. Statements acknowledging the hard work of parenting and praising successes are always appreciated. “Mr. Smith, you are doing such a wonderful job with Bobby. Being a parent takes so much work and Bobby’s behavior here today clearly shows your efforts. We might have some suggestions for you at the end of the visit.” Or to the child, “Bobby you are so lucky to have such a wonderful dad.”

Answer 97

As with adults, the chief complaint may not relate to the real reason the parent has brought the child to see you (Fig. 18-51). The complaint may be a bridge to concerns that may not seem like a legitimate reason to go to the clinician. Create a trusting atmosphere that allows parents to be open about all their concerns by asking facilitating questions such as: Do you have any other concerns about Randy? Was there anything else that you wanted to tell/ask me today?

Answer 98

12, 15, 18, and 24 months followed by annual visits when the child is 3 and 4 years old. An additional visit at 30 months is also recommended to assess the child’s development.

Answer 99

3 and 4 years

Answer 100

The AAP and Bright Futures periodicity schedules for children recommend annual health supervision visits during this period.8 As for earlier ages, these visits present opportunities to assess the child’s physical, mental, and developmental health and the parent– child relationship and the child’s relationships with peers and school performance (Fig. 18-52). Once again, health promotion should be incorporated into all interactions with children and families. Older children enjoy talking directly with the examiner. In addition to discussing health, safety, development, and anticipatory guidance with parents, include the child in these conversations using age-appropriate language and concepts. Discuss the child’s experience and perceptions of school, interactions with peers, and other cognitive and social activities. Focus on healthy habits such as good nutrition, exercise, reading, stimulating activities, health sleep hygiene, screen time, and safety. About 12% to 20% of children have some type of chronic physical, developmental, or mental condition.33 These children should be seen more frequently for monitoring, disease management, and preventive care (Fig. 18-53). Some behaviors that become established at this age can lead to or exacerbate chronic conditions such as obesity or eating disorders. Health promotion is critical to optimize healthy habits and minimize unhealthy ones. Helping families and children with chronic diseases deal most effectively with these disorders is a key part of health promotion. For all children, health promotion involves assessing and promoting the family’s overall health. The specific components of the health supervision visit for older children are the same as the components for younger children. Emphasize school performance and experiences as well as appropriate and safe sports and activities and healthy peer relationships.

Answer 101

5 cm per year. velocity increases

Answer 102

underweight: <5% healthy 5-85% overweight 85-95% obese >95%

Answer 103

1-2y/o: 110 (70-150) 2-6y/o: 103 (68-138) 6-10y/o: 95 (65-125)

Answer 104

20-40 early childhood 15-25 late childhood reach adult levels by 15 y/o

Answer 105

absence of tachypnea | tachypnea in kids >1y/o is RR>40

Answer 106

auditory canal b/c easy and no discomfort

Answer 107

to determine whether the gaze is conjugate or symmetric to test visual acuity in each eye

Answer 108

The corneal light reflex test and the cover–uncover test | are particularly useful in young children

Answer 109

<3 y/o: the simplest examination is to assess for fixation preference by alternately covering one eye; the child with normal vision will not object, but a child with poor vision in one eye will object to having the good eye covered >4y/o: eye charts (shapes, E)

Answer 110

3 months - eyes converge, baby reaches 12 months - 20/200 <4 y/o - 20/40 >4 y/o - 20/30

Answer 111

the auricle must be pulled upward, | outward, and backward to afford the best view.

Answer 112

● Use the best angle of the otoscope. ● Use the largest possible speculum. ● A larger speculum allows you to better visualize the tympanic membrane and is less painful since it is not inserted as far as a smaller speculum. ● A small speculum may not provide a seal for pneumatic otoscopy. ● Don’t apply too much pressure which will cause the child to cry and may cause false-positive results on pneumatic otoscopy. ● Insert the speculum ¼ to ½ inch into the canal. ● First find the landmarks. ● Careful—sometimes the ear canal resembles the tympanic membrane. ● Note whether the tympanic membrane is abnormal. ● Remove cerumen if it is blocking your view, using one of the following: ● Special plastic curettes ● A moistened microtipped cotton swab ● Flushing of ears for older children ● Special instruments that can also be purchased.

Answer 113

■ The first is the method generally used in adults, with the otoscope handle pointing upward or laterally while you pull up on the auricle. Hold the lateral aspect of your hand that has the otoscope against the child’s head to provide a buffer against sudden movements by the patient (Figs. 18-61 and 18-62). ■ The second position, with the handle of the otoscope pointing down toward the child’s feet, is preferred by many pediatricians because of the angle of the auditory canal in children. While holding the otoscope with the handle pointing down, pull up on the auricle. Steady your hand against the child’s head and pull up on the auricle with that hand, while you hold the otoscope with the other hand

Answer 114

Maxillary sinuses are noted on x-rays by age 4 years, sphenoid sinuses by age 6 years, and frontal sinuses by age 6 to 7 years. The sinuses of older children can be palpated as in adults, looking for tenderness.45 Transillumination of the paranasal sinuses of younger children has poor sensitivity and specificity for diagnosing sinusitis or fluid in the sinuses

Answer 115

Central incisor - 5-8 m - 6-8 y Lateral incisor - 5-11 m - 7-9 y Cuspids - 24-30 m - 11-12 y First bicuspids - 10-12 y Second bicuspids - 10-12 y First molars - 16-20 m - 6-7 y Second molars - 24-30 m - 11-13 y Third molars - 17-22 y

Answer 116

Note the size, position, symmetry, and appearance of the tonsils. The peak growth of tonsillar tissue is between 8 and 16 years (Fig. 18-54). The size of the tonsils varies considerably in children and is often categorized on a scale of 1+ to 4+, with 1+ being easy visibility of the gap between the tonsils, and 4+ being tonsils that touch in the midline with the mouth wide open. The tonsils in children often appear more obstructive than they really are. Tonsils in children usually have deep crypts on their surfaces, which often have white concretions or food particles protruding from their depths. This does not indicate disease

Answer 117

submucosal cleft palate

Answer 118

adenoidal hypertrophy

Answer 119

viral infection (croup)

Answer 120

tonsilitis

Answer 121

infections (mostly viral, but sometimes bacterial) and not due to malignant disease, even though the latter is a concern for many parents

Answer 122

In children, the presence of nuchal rigidity is a more reliable indicator of meningeal irritation than Brudzinski sign or Kernig sign. To detect nuchal rigidity in older children, ask the child to sit with legs extended on the examining table. Normally, children should be able to sit upright and touch their chins to their chests. Younger children can be persuaded to flex their necks by having them follow a small toy or light beam. You also can test for nuchal rigidity with the child lying on the examining table, as shown in Figure 18-72. Nearly all children with nuchal rigidity will be extremely sick, irritable, and difficult to examine. In many countries the incidence of bacterial meningitis has plummeted because of vaccinations.

Answer 123

The normal ratio is about 1:1. Prolonged inspirations or expirations are a clue to disease location. Degree of prolongation and effort or “work of breathing” are related to disease severity.

Answer 124

Preschool and school-aged children often have benign murmurs (see figure on p. 879). The most common (Still’s murmur) is a grade I–II/VI, musical, vibratory, early and midsystolic murmur with multiple overtones located over the mid or lower left sternal border; it may also be heard over the carotid arteries. Carotid artery compression will usually cause the precordial murmur to disappear. This murmur may be extremely variable and may be accentuated when cardiac output is increased, as occurs with fever or exercise. The murmur will diminish as the child goes from supine to sitting to standing. In preschool or school-aged children, you may detect a venous hum. This is a soft, hollow, continuous sound, louder in diastole, heard just below the right clavicle (Fig. 18-76). It can be completely eliminated by maneuvers that affect venous return, such as lying supine, changing head position, or jugular venous compression. It has the same quality as breath sounds and is therefore frequently overlooked. The murmur heard in the carotid area or just above the clavicles is known as a carotid bruit. It is early and midsystolic with a slightly harsh quality. It is usually louder on the left and may be heard alone or in combination with the Still’s murmur. It may be completely eradicated by carotid artery compression

Answer 125

benign preschool or early school age ``` Grade I–II/VI, musical, vibratory Multiple overtones Early and midsystolic Mid/lower left sternal border Frequently also a carotid bruit ```

Answer 126

benign preschool or early school age Soft, hollow, continuous Louder in diastole Under clavicle Can be eliminated by maneuvers

Answer 127

benign preschool or later Early and midsystolic Usually louder on left Eliminated by carotid compression

Answer 128

benign preschool or school age Grade 2–3 systolic ejection Loudest at pulmonary auscultation area Harsh, nonvibratory Intensity increases when in the supine

Answer 129

The spleen, like the liver, is felt easily in most children. It too is soft with a sharp edge, and it projects downward like a tongue from under the left costal margin. The spleen is moveable and rarely extends more than 1 to 2 cm below the costal margin

Answer 130

During early infancy, there is a common and normal progression from bowleggedness (Fig. 18-87) that begins to disappear at about 18 months of age, often followed by transition toward knock-knees. The knock-knee pattern (Fig. 18-88) is usually maximal by age 3 to 4 years and gradually corrects by age 9 or 10 years. Children may toe in when they begin to walk. This may increase up to 4 years of age and then gradually disappear by about 10 years of age

Answer 131

Testable in older children

Answer 132

Use Snellen chart after age 3 yrs. Test visual fields as for an adult. A parent may need to hold the child’s head

Answer 133

Have the child track a light or an object (a toy is preferable). A parent may need to hold the child’s head

Answer 134

``` Play a game with a soft cotton ball to test sensation. Have the child clench the teeth and chew or swallow some food ```

Answer 135

``` Have the child “make faces” or imitate you as you make faces (including moving your eyebrows) and observe symmetry and facial movements. ```

Answer 136

``` Perform auditory testing after age 4 yrs. Whisper a word or command behind the child’s back and have the child repeat it ```

Answer 137

``` Have the child stick the “whole tongue out” or “say ‘ah’.” Observe movement of the uvula and soft palate. Test the gag reflex ```

Answer 138

``` Have the child push your hand away with his head. Have the child shrug his shoulders while you push down with your hands to “see how strong you are.” ```

Answer 139

Ask the child to “stick out your | tongue all the way.”

Answer 140

Adolescence is the period of transition from childhood to adulthood. The physical transformation generally occurs over a period of years, beginning at an average age of 10 years in girls and 11 years in boys. On average, girls end pubertal development with a growth spurt by age 14 years and boys by age 16 years. The age of onset and duration of puberty vary widely, although the stages follow the same sequence in all adolescents. Early adolescents are preoccupied with these physical changes

Answer 141

Although less obvious, cognitive changes during adolescence are as dramatic as changes in physique. Most adolescents progress from concrete to formal operational thinking, acquiring an ability to reason logically and abstractly and to consider future implications of current actions (Fig. 18-95). Although the interview and examination resemble those of adults, keep in mind the wide variability in cognitive development of adolescents and their often erratic and still limited ability to see beyond simple solutions. Moral thinking becomes sophisticated with lots of time spent debating issues. Recent evidence shows that brain development (especially in the right prefrontal cortex) probably continues well into the twenties

Answer 142

Adolescence is a tumultuous time, marked by the transition from family-dominated influences to increasing autonomy and peer influence (Fig. 18-96). The struggle for identity, independence, and eventually intimacy leads to stress, health-related problems, and often, high-risk behaviors. This struggle also provides an important opportunity for health promotion.

Answer 143

a comfortable, confidential | environment

Answer 144

10-14 y/o: 85 (55-115) | >15 y/o: 60-100

Answer 145

The benign pulmonary flow murmur is a grade I–II/VI soft, nonharsh murmur with the timing characteristics of an ejection murmur, beginning after the first sound and ending before the second sound, but without the marked crescendo–decrescendo quality of an organic ejection murmur. If you hear this murmur, evaluate whether the pulmonary closure sound is of normal intensity and whether splitting of the second heart sound is eliminated during expiration. An adolescent with a benign pulmonary ejection murmur will have normal intensity and normally split second heart sounds. The pulmonary flow murmur may also be heard in the presence of volume overload from any cause such as chronic anemia, and following exercise. It may persist into adulthood

Answer 146

older child, adolescence and later benign Grade I–II/VI soft, nonharsh Ejection in timing Upper left sternal border Normal P2

Answer 147

The first easily detectable sign of puberty is usually the appearance of breast buds although pubic hair sometimes appears earlier. The average age of the appearance of pubic hair has decreased in recent years, and current consensus is that the appearance of pubic hair as early as 7 years can be normal, particularly in dark-skinned girls who develop secondary sexual characteristics at an earlier age

Answer 148

Stage 1: Preadolescent - elevation of nipple only Stage 2: Breast Bud Stage - elevation of breast and nipple as a small mound - enlargement of areolar diameter Stage 3: - Further enlargement of elevation of breast and areola - no separation of their contours Stage 4: - Projection of areola and nipple to form a secondary mound above the level of breast Stage 5: Mature Stage - projection of nipple only - areola has receded to general contour of the breast (although in some normal individuals the areola continues to form a secondary mound)

Answer 149

The first reliable sign of puberty starting between ages 9 and 13.5 years is an increase in the size of the testes. (Next, pubic hair appears, along with progressive enlargement of the penis. The complete change from preadolescent to adult anatomy requires about 3 years, with a range of 1.8 to 5 years)

Answer 150

``` Stage 1: Preadolescent Pubic hair - no pubic hair except for the fine body hair (vellus hair) similar to that on the abdomen Penis - same size and proportions as in childhood Testes & Scrotum - same size and proportions as in childhood ``` Stage 2: Pubic hair - Sparse growth of long, slightly pigmented, downy hair, straight or only slightly curled, chiefly at the base of the penis Penis - Slight or no enlargement Testes & Scrotum - Testes larger; scrotum larger, somewhat reddened, and altered in texture Stage 3: Pubic hair - Darker, coarser, curlier hair spreading sparsely over the pubic symphysis Penis - Larger, especially in length Testes & Scrotum - Further enlarged Stage 4: Pubic hair - Coarse and curly hair, as in the adult; area covered greater than in stage 3, but not as great as in the adult and not yet including the thighs Penis - Further enlarged in length and breadth, with development of the glans Testes & Scrotum - Further enlarged; scrotal skin darkened Stage 5: Adult Pubic hair - Hair adult in quantity and quality, spreads to the medial surfaces of the thighs but not up over the abdomen Penis - Adult in size and shape Testes & Scrotum - Adult in size and shape

Answer 151

Stage 1: Preadolescent - no pubic hair except for the fine body hair (vellus hair) similar to that on the abdomen Stage 2: Sparse growth of long, slightly pigmented, downy hair, straight or only slightly curled, chiefly along the labia Stage 3: Darker, coarser, curlier hair, spreading sparsely over the pubic symphysis Stage 4: Coarse and curly hair as in adults; area covered greater than in stage 3 but not as great as in the adult and not yet including the thighs Stage 5: Hair adult in quantity and quality, spreads on the medial surfaces of the thighs but not up over the abdomen

Answer 152

``` First, examine the patient standing assessing symmetry of shoulders, scapula, and hips. Then have the child bend forward with the knees straight and head hanging straight down between extended arms (Adams forward bend test). ``` If you detect scoliosis use a scoliometer to test for the degree of scoliosis. Have the teen bend forward again as described above. Place the scoliometer over the spine at a point of maximum prominence making sure that the spine is parallel to the floor at that point, as shown in Figure 18-102. If needed, move the scoliometer up and down the spine to find the point of maximal prominence. An angle greater than 7° on the scoliometer is a reason for concern and often used as a threshold for referral to a specialist. Of note, the sensitivity and specificity of both the Adams forward bend test and scoliometer vary greatly according to the skill and experience of the examiner. You can also use a plumb line, a string with a weight attached, to assess symmetry of the back (Fig. 18-103). Place the top of the plumb line at C7 and have the child stand straight. The plumb line should extend to the gluteal crease (not shown here).

Answer 153

neuro or musculoskeletal abnormalities

Answer 154

(1) Stand straight, facing forward (2) move neck in all directions (3) shrug shoulders (4) hold arms out to the side against resistance (5) hold arms out to side w/ elbows bent 90 degrees, raise and lower arms (6) hold arms out, completely bend, straighten elbows (7) hold arms down, bend elbows 90 degrees, pronate and supinate forearms (8) make a fist, clench, and then spread fingers (9) squat and suck walk for 4 steps forward (10) stand straight w/ arms at sides facing back (11) bend forward w knees straight and touch toes (12) stand on heels and rise to the toes