Today was an excellent day; excellent because I got to examine a bunch of babies. If you are a baby-lover like me, one of the best ways to lift your mood is to walk into a room and have a 6-month old give you a toothless grin.
I know, all of you adult doctors out there think of pediatrics as just screaming kids and smelly diapers. The fact is, my adult patients have an average smell worse than my pediatric ones (if you can average smells…I think my son\’s fancy calculator can do that). There is a deeper reason for these physicians\’ aversion to the micro-human: fear. It is not widely known, but the majority of doctors are actually terrified of babies. No, they don\’t fear baby commando squads or babies with poison darts; they are afraid to take care of babies. They just aren\’t like those bigger humans: you know, those things that babies turn in to.
So before exploring the abdomen and more southern reaches, I want to do a quick overview of the examination of an infant. While adult exams are usually done focusing on a problem or complaint, the exam of an infant is looking for normality. I want to find nothing but a normal baby when I do an infant exam. Yet my exam is also focused on what I don\’t want to find.
I will focus on the exam of the newborn, taking some diversions to more mature babies if the exam warrants. The newborn exam is important because it is the child\’s first exam ever. Nobody has examined the child before, so if there are problems you will be the one to diagnose them. I always keep this in mind when I do my first exam on an infant.
So here is my exam of the bun when it is fresh out of the oven…
General: First you have to assess the overall status of the child. Is it breathing well? Is it pink or blue (not boy or girl, oxygenated or sick)? How does it react when you examine it (normal babies cry)? Does it have tentacles, antlers, or skin made out of composite fiber able to deflect bullets? All of these are important things to decide before examining the child; both for the child\’s sake (so you can treat problems) and yours (so you don\’t get stuck with antlers).
Head: Heads of newborns are not normal. The bones are not fused, so they can get bent out of shape easily through the process of being born. This results in a condition called molding, where the infant\’s head gets squashed as it passes through mom\’s pelvis and so comes out elongated (looking somewhat like Jane Curtin). It is worse in firstborn children, as mom\’s pelvis has not been stretched. Pediatric nurses hide molding by putting a hat on the child (the hat also warms the head). This keeps parents from thinking they have brought a mutant into the world. Molding resolves in the first few days.
The heads can also have large squishy areas at the back of the top of the head. This is from trying to fit a big head through a little exit. It is called a cephalohematoma. While these feel funny, they don\’t cause any problems (except maybe for extra jaundice if the squishy area is big enough).
Finally, the head is examined for a normal fontanel. This is the \”soft\” spot (there are actually two) where more than two bones in the head come together. When examining the fontanels and the sutures where two skull bones come together, the bones should move freely of each other. If they are prematurely fused, it results in a condition called crainosynostosis. This makes the head grow into a funny shape and needs to be fixed surgically (although it is usually not picked up until 4-6 months of age).
Eyes: People often ask of their newborn: \”Can they see? What is their vision like?\” Unfortunately, in the fourteen years I have practiced, not one infant has answered this question for me. It must be classified information.
The main goal of the eye exam is to rule out a cancer that happens in infants called retinoblastoma. This happens in the first six months of life, and not only can cause the eye to go blind, but it actually can spread all over the body – so it is important to find it quickly. Retinoblastoma is ruled out by looking for the red reflex, which is the redness to the eyes that is photoshopped out of digital photos.
The other thing that can happen with the eye is a blocked tear duct. This causes the eye to be really goopy. It is no big deal, but parents don\’t like the goop.
Nose: The main problem that can happen with the nose is for it to get blocked up. Since babies are obligate nose breathers, blocked nasal passages can cause significant distress (and can make the baby snort loudly). A membrane sometimes covers the nose as it enters the mouth cavity; this is called choanal atresia. This has to be fixed right away.
Mouth: The main problem in the mouth of the newborn is a problem with the palate. Cleft palate happens when the two sides of the palate (top of the mouth) don\’t join together properly. Sometimes this causes a significant deformity, but sometimes it is only the soft palate that is cleft. (which can interfere with feeding).
Neck: Babies don\’t have much in the way of necks, although they do have more than an offensive lineman has.
This picture illustrates the neck-less nature of the offensive lineman, which is similar to that of some babies. Babies, however, don\’t usually wear a tux or hold a helmet.
Chest: The chest exam of a newborn is also generally boring. More important is the assessment of the child\’s breathing. You generally know there is a problem before you listen to the chest.
This is a good stopping point for this post. Stay tuned for more infantile hijinx.
Hmm….I suppose \”infantile hijinx\” sums up this blog, doesn\’t it?