KIMBERLY TACORDA, SN / REVIEWER
2. Caput Succedaneum - is the edema of the scalp
Cephalocaudal Examination and Deviation from Normal
The Head
A. Structures
1. Coronal Sutures - located in between parietal
and frontal bone.
2. Frontal Sutures - located in between two frontal
bones.
3. Sagittal Sutures - located in between two
parietal bones.
4. Lambdoidal suture - located in between the
parietal and occipital bones.
A. Fontanels
● Should feel flat and firm inside the bony edges
● A tense, bulging fontanelle is an indication of
increased intracranial pressure
● A soft, sunken fontanelle is associated with
dehydration
➔ Types:
(a) Anterior fontanel- closes at 12 to 18 months.
Located between the frontal and parietal bones.
(b) Posterior fontanel- closes at 8 to 12 weeks. Located
in between the parietal and occipital bones.
due to prolonged pressure.
➔ Complications:
➔ Characteristics:
● Craniosynostosis or Craniostenosis- is the
premature closure of Anterior Fontanel. ● Present at birth
● Microcephaly- is defined as a small, slow growing ● Crosses the suture line.
brain. ● Disappears after 2-3 days without
● Anencephaly- is the absence of the cerebral treatment.
hemisphere.
● Dandy Walker syndrome - ventricles dilate due to 3. Cephalhematoma- is the collection of blood due to
obstruction of the foramen of Luschka and rupture of periosteal capillaries.
Magendie.
➔ Characteristics:
● Present after 24 hours.
➔ Noticeable Features of the Head ● Never crosses the suture lines.
● Disappears after 4-6 weeks without
1. Craniotabes (Congenital Cranial Osteoporosis)- is treatment.
the localized softening of cranial bones.
4. Seborrheic Dermatitis/"cradle cap" - are scaly,
● Common to 1st born children due to early lightning greasy appearing salmon-colored patches usually
In Primi, lightning happens 2 weeks prior to the seen in the scalp behind the ears and in the
expected date of delivery. umbilicus caused by improper hygiene.
● Soft areas of the skull, especially along the suture
line, which pop in and out like a squeezed ➔ Management: application of oil the night before
Ping-Pong ball. shampooing the child.
● Bones may feel soft and thin along the suture lines
and flex very easily. 5. Hydrocephalus- is the excessive accumulation of
● Craniotabes is a harmless finding in the newborn, CSF in the ventricles of the brain.
unless it is associated with other problems, such as
rickets and osteogenesis imperfecta (brittle bones). ➔ Types of Hydrocephalus:
● In older children, this is a sign of Rickets or Vitamin
D deficiency.
 KIMBERLY TACORDA, SN / REVIEWER

(a) Communicating/extraventricular hydrocephalus - 6. Reye's Syndrome - An acquired encephalopathy of ● Congenital cataract whiteness and opacity
Failure to absorb CSF in the arachnoid space). young children that follows an acute febrile illness, of the lens of the newborn.
(b) Noncommunicating/intraventricular/obstructive usually influenza or varicella infection;
hydrocephalus-caused by tumor obstruction or fetal characterized by recurrent vomiting, agitation, and ➔ Test for Visual Acuity:
bone malformation. lethargy, which may lead to coma with intracranial
hypertension, ammonia and serum transaminases (a) 3 year old and school age
are elevated, death may result from edema of the ● General appearance
➔ Signs and Symptoms: brain and resulting cerebral herniation. ● Random Dot E Test for stereopsis or depth
perception (3 dimensional spaces)
(a) Signs of increased ICP ● Pre-school E Chart: for stereopsis or depth
● Abnormally large head perception (3 dimensional spaces)
The Senses
● Bulging and tensed fontanels ● Ishihara's Test: test for color blindness
● Projectile vomiting ● Allen Cards: test to visual acuity
● High pitched shrill cry Sense of Sight (Eyes)
● Cushing's Triad (b) School age – adult
➢ Hypertension with widening pulse ● Snellen’s test
pressure 1. Hypertelorism- widely spaced eyes can be a ➢ Retinoblastoma - is a malignant
➢ Bradycardia normal deviation in children. tumor of the retina of the eye
➢ Bradypnea 2. Sclera: Normal is light blue then later becomes dirty (a) Outstanding Sign: Cat's
white. eye reflex-whitish glow of
(b) Frontal bossing – prominent forehead. 3. Conjunctiva: pink and glossy. the pupil.
(c) Prominent scalp vein 4. Observe for eye bulging which may be associated (b) Red painful eye usually
(d) Sunset eyes with a tumor, and a sunken appearance which may accompanied with
(e) Diplopia or eye deviation is common after 6 months reflect dehydration. glaucoma
old. 5. Ptosis drooping of the lid over the pupil, is often (c) Blindness
associated with injury to the oculomotor nerve, ● Surgery:
➔ Therapeutic Management: cranial nerve III. Enucleation:
6. Sunset sign in which the sclera is seen between the removal of the
(a) Position: low semi-fowler. upper lid and the iris, may indicate retracted eyelids eyeball.
(b) Hyperventilate the child to facilitate CO₂ loss or hydrocephalus. ● Irradiation
(c) Surgery: 7. Cornea: rounded and adult sized. If larger than ● Chemotherapy
● AV shunt-Atrioventricular shunt. normal size suspect congenital glaucoma.
● VP shunt -Ventriculo-Peritoneal Shunt. 8. Pupils: Normally rounded and adult-sized. (c) Eye deviation is normal: 4-6 months old. After 6
● Coloboma: part of the iris is missing months signifies increased ICP or lazy eye.
"keyhole pupil“
 KIMBERLY TACORDA, SN / REVIEWER
➔ Nasal discharge characteristics and associated
➔ Management: Eye patch on the normal eye to
exercise the affected eye.
(d) Visual Acuity
● 3 years-20/40
● 4 years - 20/40
● 5 years – 20/30
● 6 years – 20/20
Sense of Smell (Nose)
➔ Normal color of nasal membrane: pinkish ➔ Conditions Associated with the nose:
● The nose should be proportional in size and 1.
be at the center of the face.
● Nasolabial folds are normally symmetrical.
A saddle-shaped nose is associated with
congenital defects such as cleft palate. 2.
● The child's airway must be patent to ensure
proper oxygenation 3.
● Nasal flaring is a sign of respiratory
distress
● Infants under 6 months of age will not
automatically open their mouths to breathe
when their nose is occluded, such as by
mucus.
● The mucus membranes should be dark pink 4.
and glistening.
● The nasal septum should be straight
without perforations, bleeding or crusting.
Sense of Hearing (Ears)
conditions:
1. Watery ➔ The first sense to develop and last to disappear.
● Clear, bilateral – allergy
● Serous, unilateral - spinal fluid from a. Hearing is essential for normal speech
cribriform plate development and learning.
2. Mucoid or Purulent b. The ears must be properly aligned to the
● Bilateral- upper respiratory outer canthus of the eyes
infection c. The tympanic membrane is normally
● Unilateral - foreign body, or pearly gray and translucent. It also
obstruction reflects light and the ossicles are
3. Bloody - nose bleed or trauma normally visible on inspection with an
otoscope
d. Causes of hearing loss during early
childhood:
Choanal Atresia- the posterior nares are obstructed 1. Birth trauma
with a bone or membrane characterized by 2. Frequent otitis media
resistance during catheter insertion. 3. Meningitis
➔ Management: Surgery within 24 hours. 4. Antibiotics
Chronic rhinitis- is characterized by pale 5. Congenital Abnormalities
membranes with nasal creases. 6. Genetic Syndrome
Epistaxis - nose bleeding caused by decreased
humidity, trauma, strenuous exercise and blood e. Indicators of hearing loss in an infant:
dyscrasias. 1. No startle reflex.
➔ Management: 2. Does not turn to sound by 4 months
(a) Sitting with the head slightly filled forward old.
(b) Apply cold compress. 3. Babbles as a young infant but
(c) Last resort: Epinephrine administration. stops babbling or develops speech
Cocaine user- absence of nasal hair with ulceration sounds after 6 months old.
of nasal mucosa and perforation of the nasal
septum. f. Indicators of hearing loss in a young
child:
1. No speech by 2 years old.
 KIMBERLY TACORDA, SN / REVIEWER

2. Speech sounds are not distinct at ● Monitor for tachycardia, as the child is ➔ Signs and Symptoms
appropriate ages. prone to CHD ● During puberty has poorly developed
● Educable and trainable sexual Characteristics (signs can be seen
g. If there are low set ears, suspect the ● Related to advanced paternal age during puberty)
following. ● Sterile
➔ Signs and Symptoms:
1. Kidney Malformations ● Low set ears ➔ Management: Estrogen administration to develop
● Mongolian Slant / Epicanthal fold secondary Sexual characteristics
Renal Agenesis-absence of kidney. ● Broad flat nose
● Protruding tongue (e) Klinefelter's Syndrome
Types: ● Puppy’s neck ● Trisomy of X chromosome
● Simian crease: single transverse line of the ● 47 XXY
(a) Unilateral palm
(b) Bilateral ● Mental retardation ➔ Signs and Symptoms
● Brushfield’s spots ● During puberty has poorly developed
secondary sexual characteristics such as
Signs: (b) Trisomy 18 (Edward’s Syndrome) small testes and penis.
● Extra chromosome 18 ● Sterile
(a) Oligohydramnios: earliest sign in - ● 47 XX+18/47xy+18
utero. ➔ Deletion Abnormalities
(b) 2 vessel cord ➔ Signs and Symptoms 1. Cri-du-chat
(c) Failure to void within 24 hours. ● sole of the foot is rounded, rocker’s bottom ● short arm chromosome 5
foot
➔ Management: kidney transplant (c) Trisomy 13 (Patau Syndrome) ➔ Signs and symptoms: meow – like cry
● Extra chromosome 13 2. Fragile X Syndrome
● 47 XX+13/47 xy+18 ● Weakened X chromosome
2. Chromosomal Aberration ● The most common form of mental
● Nondisjunction - uneven division of ➔ Signs and Symptoms retardation in boys.
chromosomes. ● Eye Agenesis(absence of eyes)
● Microphthalmia (small eyes) ➔ Signs and symptoms: During puberty typically
(a) Trisomy 21 (Down Syndrome) develops a maladaptive behavior such as head
● Extra chromosome 21 (d) Turner’s Syndrome (Gonadal Dysgenesis) banging, autism, and anti-social behavior.
● 47XX + 21/ 47 xy+21 ● Monosomy of X chromosome
➔ Translocation Abnormalities

1. Balanced Translocation Carrier
● a situation wherein for example
chromosome 14 instead of pairing with
chromosome14 it pairs with chromosome 18
resulting in 46 chromosomes, hence, no
abnormalities will be observed.
2. Unbalanced Translocation Syndrome
● is the resulting offspring of the balanced
translocation carrier containing 47
chromosomes and abnormalities are
evident.
➔ Others:
1. Mosaicism
● a situation wherein the uneven division of
chromosomes occurs during the mitotic cell
division after fertilization resulting in
different cells containing different numbers
of chromosomes.
2. Isochromosomes
● a situation of mismatching of chromosomes
due to vertical division instead of horizontal
division.
h. Otitis Media- middle ear infection common in children
due to wider & shorter eustachian tubes.
➔ Causes:
(a) Bottle propping
(b) Cleft lip/palate
KIMBERLY TACORDA, SN / REVIEWER
(c) URTI
➔ Signs and symptoms:
● Otoscopic exam reveals absence of light
reflex and a bulging tympanic membrane.
● Observe for passage of milky purulent, foul
smelling discharge.
● Observe for URTI.
➔ Complication: bacterial meningitis
➔ Management:
● Massive dosage of antibiotics to prevent
bacterial meningitis. (eg. Amoxicillin,
ampicillin)
● Mucolytic to liquefy secretions
● Ear ointment.
● TSB- if there is fever.
● Increased Oral Fluid intake and Vitamin
● Side lying on affected side
➔ Technique in Instilling Ear drops
● Below 3 years old: down and back.
● Above 3 years old: up and back.
i. Surgery:
● Myringotomy with tympanostomy tube insertion:
slight incision of tympanic membrane.
The Mouth, Tongue and Throat
a. Lips are normally symmetric without drying,
cracking or other lesions. Lip color is normally
pink in white children and more bluish in
darker-skinned children.
● Pale, cyanotic, or cherry-red lips indicate
poor tissue perfusion.
● Note for any clefts or edema.
b. Teeth are normally white, without a flattened,
mottled or pitted appearance.
● Discolorations on the crown of the tooth
may indicate dental caries.
● Discolorations on the tooth surface may be
associated with fluorosis or other medical
conditions.
c. Gums are normally pink, with a stippled or
dotted appearance.
● Gums should not be receding or raised.
● Inflammation and tenderness are
associated with infection and poor nutrition
d. The mucus membrane of the buccal mucosa is
usually pink.
e. The tongue is normally pink and moist, without a
coating, and it fits easily into the mouth.
● Tongue of a child is large relative to small
nasal and oral airway passages.
● Tremors are abnormal.
● White patches may be caused by Candida
infection.
f. The palate is usually pink with a dome-shaped
arch and no cleft. The uvula is at the center and
hangs freely from the soft palate.
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● Vitamin therapy (Vit B complex)

g. Bell's Palsy-7th cranial nerve injury or facial nerve ● Analgesics to relieve pain
paralysis usually related to forceps delivery in ● Physical therapy to stimulate facial nerve
newborns. and help maintain muscle ➔ Management:
● It occurs when the nerve that controls the ● Facial massage and exercises ● Never attempt to remove as this may cause
facial muscles is swollen, inflamed, or ● Moist hot packs to affected area bleeding.
compressed, resulting in facial weakness or ● Wash with cold boiled water.
paralysis. h. Tracheoesophageal Fistula (TEF) or ● DOC: Mycostatin, Nystatin
Tracheoesophageal Atresia (TEA) is the narrowed
➔ Signs and Symptoms: connection between esophagus and the m. Kawasaki Disease - is an acute, febrile, self-limited,
● Distorted facial appearance stomach(fistula) or a blind pouch between the infectious, multi-system vasculitis, which occurs in
● Inability to move muscle on affected side esophagus and stomach (atresia). young children. Fever is often prolonged and
of the face coronary aneurysms may lead to myocardial
● Twitching or weakness or paralysis of one ➔ Signs and Symptoms: - 4C’s infarction and death.
or both sides of the face ● Coughing
● Drooping of the eyelids ● Choking ● Also known as Kawasaki
● Continuous drooling of saliva ● Cyanosis syndrome/Mucocutaneous Lymph Node
● Excessive tearing in one eye ● Continuous drooling Syndrome or Infantile Polyarteritis
● Impairment of taste ● It was first described in 1967 by Dr.
● Inability to open 1 eye or close the other ➔ Management: Emergency Surgery Tomisaku Kawasaki in Japan.
eye ● The disease occurs most often in boys and
i. Epstein pearls (gingival cysts of the newborn) - among Asians.
➔ Diagnostic Procedure: are white, glistening cysts usually seen on the ● The cardiac complications are, by far, the
● Physical assessment palate or gums related to hypercalcemia. most important aspect of the disease since
● Electromyography - to confirm presence of it causes inflammation of blood vessels and
nerve damage j. Natal Tooth- is a tooth at the moment of birth aneurysms.
● Xray of the skull to rule out infections or related to hypervitaminosis froth w/in 28 day of life ● May lead to MI in children
tumors ● Usual cause of acquired heart disease in
● MRI or CT scan to eliminate other causes of k. Neonatal tooth- is the appearance of a tooth the USA.
pressure on the facial nerve. within 28 days of life.
➔ Management: ➔ Signs and Symptoms:
● Give artificial tears l. Oral trush or "Oral Moniliasis' - are white ● Fever lasting for more than 5 days which is
● Antivirals (acyclovir) cheese-like or curd-like patches that coat the unresponsive to acetaminophen or
● Steroids (prednisone) tongue and mouth. ibuprofen

● Bilateral Conjunctivitis
● Polymorphous rash (primarily on trunk)
● Changes of peripheral extremities -
Erythema of the palms and soles,
indurative edema of the hands and feet,
membranous desquamation from
fingertips.
● Changes of lips and oral cavity - Dry, red,
fissured lips, Strawberry tongue, diffuse
erythema of mucus membrane
● Arthralgia and symmetrical swelling of
joints
● Tachycardia
● Acute nonpurulent swelling of cervical
lymph node to >1.5 cm in diameter
➔ Diagnostics:
(a) Complete blood count may reveal anemia
and thrombocytosis
(b) Erythrocyte sedimentation rate (ESR)
elevation
(c) C-reactive protein (CRP) elevation
(d) Elevated liver function tests and low serum
(e) ECG may show coronary artery changes
and aneurysms
(f) 2-dimensional echocardiography may
reveal artery changes
(g) UTZ may show enlarged gallbladder
➔ Kawasaki Syndrome: Diagnostic Criteria
● Fever for 5 days
● At least four of five features:
a. Bilateral conjunctival injection
(bulbar, non-purulent
KIMBERLY TACORDA, SN / REVIEWER
b. Cervical adenitis (unilateral)
c. Rash (truncal, perineal
accentuation, polymorphous but
non-vesicular)
d. Inflamed oral mucosa (fissured
lips, strawberry tongue)
e. Hand and feet inflammation
(periungual peeling around 14-21
days)
● No alternate diagnosis
● Fever plus 3/5 criteria are diagnostic when
coronary abnormalities are present
➔ Management:
● DOC: ASA (Acetylsalicylic acid)
● Administer intravenous gamma globulin
which can decrease the risk of developing
coronary artery abnormalities when given
early in the disease.
● Corticosteroids
n. Cleft Lip- is the failure of the median maxillary nasal
processes to fuse by 5-8 weeks of pregnancy.
● Common in males
➔ Types:
● Unilateral Incomplete
● Unilateral Complete
● Bilateral Complete
● Bilateral Cleft Lip and Palate
● Medial Cleft Lip With a Partial Nasal Cleft
● If only skin tissue is affected one speaks of cleft lip.
Cleft lip formed in the top of the lip as either a small
gap or an indentation in the lip (partial or
incomplete cleft) or continues into the
nose(complete cleft). Lip cleft can occur as one
sided (unilateral or two sided (bilateral).
O. Cleft palate - is the failure of the palate to fuse by 9-12
weeks of pregnancy.
● Common in female
● Can be unilateral or bilateral
➔ Signs and Symptoms
● Evident at birth. If cleft lip is found, you
should check for probable cleft palate using
a padded tongue depressor
● Milk overflows through the nostrils
● Frequent colic
● Frequent otitis media
● URTI
➔ Surgery
● Cheiloplasty-surgery for Cleft , done as
early as 1-3 months to save the sucking
reflex.
● Uranoplasty-surgery for cleft palate done
as early as 4-6 months to save the speech.
➔ Pre-op Nursing Management
1. Give emotional support especially to the
parents.
2. Proper nutrition, if unable to suck, use
rubber tipped medicine dropper.
3. Prevention of colic:
 KIMBERLY TACORDA, SN / REVIEWER

● Breast feeding position: upright. 5. Protect and maintain integrity of suture

Burp frequently.
(a) At the middle and after
breastfeeding.
(b) At least 3-5 minutes after
bottle feeding, place the
baby in a prone position.
lines such as Logan Bar, wash with saline
and half strength hydrogen peroxide.
6. Prevent from crying - Give analgesic, check
for wet diaper, feed on time.

4. Orient parents to the feeding technique that will

be used post-op.
● Post-Cheiloplasty: rubber tipped syringe
● Post-Uranoplasty: paper cup or soup spoon

5. Apply Elbow restraints pre-op so that the baby

can easily adjust post-op. Colds or nasopharyngitis
is a condition that warrants suspension of surgery
as this can lead to septicemia or generalized
infection.

➔ Post-op Nursing Management:

1. Maintenance of airway by proper position

● Post-Cheiloplasty: side-lying
position
● Post-Uranoplasty: prone position.

2. Monitor for Respiratory Distress Syndrome.

3. Assess for signs of bleeding: frequent
swallowing.
4. Provide proper nutrition - begin with clear
liquid except red or brown color.