Physiologic anatomical features of the skin, the subcutaneous fat and lymph nodes. The technique of their research. Semiotics of the skin disorders and subcutaneous fat. Physiologic anatomical features of the bone and muscular system. Methodic of investigation Semiotics of the bones and muscular disorders
The skin is a complex and important part of the body which plays a large role in the life and health of a child. It has a close physiological connection with the activity of some organs and the organism as a whole. Therefore the skin is the original screen that displays the pathological changes in the organism. A careful examination and an adequate estimation of the condition of the skin has an important role in making a diagnosis of a child’s disease.
As you remember the skin consists of 3 layers:
I. Epidermis which consists of
a) corneal layer,
b) glassy layer,
c) grantilar layer,
d) spinous layer,
e) basal layer.
Basal membrane separates epidermis from the dermis.
II. Dermis.
III. Subcutaneous tissue.
Physiologicoanatomical features of the skin in children
The skin in a newborn is velvety smooth, puffy and friable, especially around the eyes, the legs, the dorsal aspect of the hands and feet, and the scrotum or labia.
There are some peculiarities of the epidermis in the newborn and young children:
In the newborn the epidermis is thinner than in adults.
The basal layer is well developed and has 2 kinds of cells – basal and melenocytes. The last ones do not produce melanin until the infant is 6 month. That is why the skin in the newborn is lighter in the first days of life.
The grantilar layer is thinner, consists of 2-3 lines of cells It is poorly developed except soles and palms. The absence of keratogliadin protein makes the skin transparent considerably, because keratogliadin protein gives the skin a white hue.
The glassy layer is absent.
The corneal layer is poorly developed, thin, it has only 2-3 lines of flattened corneal cells. The structure of the corneal layer is friable and puffy.
The clinical significance. Iewborn and younger children the skin is susceptible to superficial bacterial infection, candidosis (oral moniliasis) and intertrigo with maceration, weeping and erosion.
The dermis comprises the major portion of the skin. It is firm, fibrous, and elastic connective tissue network containing an elaborate system of blood and lymphatics vessels, nerves. It varies throughout the body from 1 to 4 mm in thickness. It is invaded by the epidermal downgrowth of hair follicles, sweat and sebaceous glands. The dermis consists of papillary and reticular layers.
There are some peculiarities of the dermis in the newborn and young (little) children:
In the newborn the papillary layer is poorly developed. In the premature infant it is absent.
The dermis has an embryonic structure – it has a lot of cellular elements and a little amount of fibrous structures. Elastic fibres are absent. They first appear in 5-6 months of life.
Labrocytes (mast cells) have a high biological activity.
In the newborn the quantity of water is higher than in an adult (80 % and 6-8 % respectively) in the dermis.
The basal membrane is poorly developed. It leads to easy separation of the epidermis from the dermis, it results in epidermolysis.
Morphological maturity of the derma occurs by 6 years.
The clinical significance. A newborn and an infant more often show blistering (bullous) reactions caused by the poor adherence between the epidermis and the dermis and frequently affected by chronic atopic dermatitis (eczema).
Basic physiological functions of the skin
The protective function is an immature function, it occurs because of thin epidermis and dermis, immature basal membrane, a little amount of fibrous structures and a good developing of blood vessels network.
The bactericidal function is an immature function, it is due to pH of the newborn skin (6.1-6.7) in an adult pH is acidic (4.2-5.6)). This pH medium is favourable for developing microbes.
The thermoregulation is immature function as the result of high emission heat process and immature heat production. The high emission heat processes occur because of a thin skin, a later beginning of sweat glands functioning, a well developed superficial vessel network, the vessels are in physiological vasodilatation. Muscles of the hair bulbs are poor developed, so gooseflesh does not appear.
The respiratory function is well developed. It helps immature lungs to perform the respiratory function. The intensity of the respiratory function is more intensive by 8 times in a newborn than in an adult. Well developed respiratory functions are caused by puffy and thin skin, a well developed superficial vessel network, physiological vasodilatation of vessels.
The deposition function is well developed. The skin is the depot of blood and water.
The reception (receptor) function is well developed. There are a lot of nerves in the skin, so the skin is a peripheral analyzer that grasps endo- and exogenous stimuli.
The excretion function is provided by sweat glands. The skin excretes some products of metabolism of fat and carbohydrate and different medicaments. The excretion function of the skin begins with the beginning of functioning sweat and sebaceous glands (3-4 months).
The resorption is well developed. It is caused by puffy and thin skin, well developed superficial vessel network, a great number of sebaceous glands and hair follicles. But resorption depends on the chemical structure of the substance: liposoluble substances are well absorbed, water-soluble substances are nonabsorptive.
The buffer function is poor developed, because iewborn and young children pH of the skin is nearly neutral (pH 6.1-6.7) therefore the skin can’t neutralize acids and alkaline.
The pigmentation function is immature.
The synthesis of vitamins. The skin synthesizes vitamin D and other biologically active substances.
The secretation function. The skin secretes keratin, squalen, calcium and phosphorus. In a newborn the secretion of keratin and squalen is decreased, the secretion of calcium and phosphorus is increased.
The metabolic function is well developed, therefore newborns and young children have a high regeneration of the epidermis and d the ermis.
Physiologicoanatomical features of appendages of the skin in children
Appendages of the skin are sebaceous gland, sweat gland, hair.
Sebaceous glands are well developed, begin to function since 7-months of the intrauterine life. The quantity of sebaceous glands in 1 cm2 is relatively large in a newborn.
Millia is often seen in the newborn. That is the obstruction of the excretory duct of sebaceous glands. Millia localizes on the nose and cheeks, have yellow-roseate color, its size is 1×1 mm. Millia disappears by 2-3 month.
Sweat glands are poorly developed.
There are two types of sweat glands: eccrine and apocrine. In a newborn eccrine sweat glands are well formed, but their excretory ducts are feebly developed and obstructed. Eccrine sweat glands begin secretory function by 2 months.
Morphological and physiological maturity of eccrine sweat glands occurs by 5-7 years.
The formation of apocrine sweat glands finishes by one year but they begin to function only in the puberty period.
Hair. The hair covering the skin in a newborn falls gradually during the first year of life instead of permanent hair appearance. With age the hair becomes thicker.
Subcutaneous fat. In a newborn the thickness of subcutaneous fat is relatively larger than in an adult (12 % and 8 % in an adult). Distribution of the fat is not regular in a newborn. They have good subcutaneous fat all over the body except the abdomen where there is insensitive deposition during the first 6 months.
The subcutaneous fat has an embryonic structure; it gives the possibility to deposit fat and to perform the hemopoietic function.
If we look at the chemical structure of the subcutaneous fat we will see the predomination of saturated fatty acids. This gives a good turgor to the skin.
The next peculiarity of the subcutaneous fat in the newborn is the presence of a brown adipose tissue. It localizes in the back neck part, in the axillary area, around the thyroid gland and the kidneys, in the intrascupullar space and around great vessels. The main function of the brown fat is heat production without muscle contraction. In 5-6 months the brown fat disappears. The subcutaneous fat is absent in the abdomen, peritoneal and thoracic cavities, therefore the inner organs are movable.
The peculiarity of the skin iewborn
At birth the skin is covered with grayish-white, cheese-like substance called vernix caseosa. If it is not removed during the first bath, it will dry and disappear in 24 or 48 hours. It is thought to have insulating and bacteriostatic properties. A fine, downy hair called lanugo is present on the skin, especially on the forehead, cheeks, shoulders and back. It usually disappears spontaneously in a few weeks.
The technique of the examining of the skin
The skin is assessed for color, texture, temperature, moisture, and turgor. Hair is also inspected for color, texture, quality, distribution, and elasticity. The examination of the skin and its accessory organs primarily involves inspection and palpation.
Physical factors influencing assessment. The doctor examines the child in a well-illuminated room, with nonglare lighting. Ideally, the room should be neutral in color. Colors such as pink, blue, yellow, or orange cast deceiving glows on the skin. The room should also be comfortably warm, since air-conditioning can cause a cold-induced cyanosis and excessive heat can produce flushing. Poor hygiene and artificial paint oails or lips also mask the true determination of color. Sometimes it is necessary to clean the skin with soap and water and to remove cosmetics before beginning the inspection. Although not a common situation in pediatrics, the doctor should remembers that such factors can hide the signs of ecchymoses, petechiae, pallor, or cyanosis.
Texture, temperature, moisture, and turgor can be subjectively inspected, but palpation must be done for a greater accuracy. Clothing always interferes with palpation, thereby necessitating that the doctor examines each area of the body nude either as the part of the general overall examination or combined with the assessment of each body system. Since texture is affected by climatic exposure, such as cold, sun, wind, and so on, the doctor should compare the texture of the areas of the body that are usually clothed with those that are generally exposed.
Genetic factors influencing the assessment of color. The normal color in light-skinned children varies from a milky-white and rosy color to a more deep-hued pink color. In general bluish discoloration or cyanosis is not normal, except in a newborn. Dark-skinned children, such as American Indians, Hispanic, black, Latin, Mediterranean, or Oriental descents, have inherited various brown, red, yellow, olive-green and bluish tones in their skin, which can falsely alter the assessment. For example, some children of Mediterranean origiormally have bluish-tinged lips, suggestive of cyanosis. Oriental persons, whose skin is normally of a yellow tone, may appear to be jaundiced. Full-blooded black individuals often have normal bluish pigmentation of the gums, buccal cavity, borders of the tongue, and nail beds. The visible portion of their sclera may contain speckled deposits of brown melanin that resemble petechiae.
Physiologic factors influencing the assessment of color. Edema of the skin affects color in all individuals because it increases the amount of interstitial fluid, thereby increasing the distance between the outermost layers of the epidermis and the pigmented and vascular layers. Edema decreases the intensity of the skin color, sometimes producing a false pallor.
Exposure to sunlight, on the other hand, stimulates the melanocytes to produce more melanin, thereby increasing the color of the skin. Individuals who are deeply suntanned require as careful observation as those who are genetically dark skinned.
In general the amount of adipose tissue does not markedly affect the skin color because the deposition of fat cells is below the pigmented layers of the skin. However, the doctor should be aware that overnutrition may not mean adequate nutrition, and the observation of pallor that may be indicative of nutritional-iron deficiency should be carefully assessed.
Reliable areas for the assessment of color. Color changes are most reliably assessed in those areas of the body where melanin production is least: sclera, conjunctiva, nail beds, lips, tongue, buccal mucosa, palms, and soles. These areas are rarely affected by edema or amount of adipose tissue but are sensitive to changes from physical factors, such as use of cosmetics, ingestion of colored food substances, or poor hygiene.
Variations in the skin color. In general color changes of significance include pallor, cyanosis, erythema, plethora, ecchymosis, petechiae, and jaundice.
Pallor and cyanosis. The skin receives its pigmented color of yellow, brown, and black from melanin and its shades of red or blue from the color of hemoglobin. Oxygenated hemoglobin in the superficial capillaries of the dermis gives a rosy, pink glow. Reduced (deoxygenated) hemoglobin reflects a bluish tone through the skin, called cyanosis, which is evident when reduced hemoglobin levels reach 5 mg/dl of blood or more, regardless of the total hemoglobin. In general the darker the skin pigmentation is, the greater the amount of deoxygenated hemoglobin must be for cyanosis to be evident.
Pallor, or paleness, is evident as a loss of the rosy glow in light-skinned individuals, an ashen-gray appearance in black-skinned children, and a more yellowish brown color in brown-skinned people. It may be a sign of anemia, chronic disease, edema, or shock. However, it may be a normal complexion characteristic or an indication of indoor living.
Pallor or cyanosis is most evident in the palpebral conjunctiva (lower eyelid), nail beds, earlobes (mainly for light-skinned children), lips, oral membranes, soles, and palms. Pallor or cyanosis can be compared to the color change normally produced by blanching. For example, ionpigmented nails, pressing down on the free edge of the nail on the index or middle finger of a child with good skin color produce marked blanching or whitening as compared to the return blood flow. In a child with pallor the difference in color change will be slight. The blanching color change can be observed in dark-skinned individuals by gently applying pressure to their lips or gums.
Erythema. Erythema, or redness of the skin, may be the result of increased temperature from climatic conditions, local inflammation, or infection. It may also appear as a sign of skin irritation, allergy, or other dermatoses. The degree of redness reflects the amount of increased blood flow to the area. The doctor notes any reddening and describes its location, size, presence of warmth, itching, type of distribution (diffuse, clearly circumscribed, parallel to a vein, and so on), and the presence of characteristic lesions, such as maculae, papules, or vesicles (see tables 3.1-2). Because erythema is much more difficult to assess in darkly pigmented individuals, the doctor must rely heavily on careful palpating the area for the evidence of associated signs, such as warmth or skin lesions. Primary lesions appear on the nondamaged skin. Secondary lesions come out after primary ones.
There are two types of lesions on the skin – primary and secondary. Primary lesions are divided into nonvesicle and vesicle.
Plethora. Plethora is also seen as redness of the skin but it is caused by increased numbers of red blood cells as a compensatory response to chronic hypoxia. Intense redness of the lips or cheeks is observed.
Ecchymosis and petechiae. Ecchymosis and petechiae are caused by extravasation or hemorrhage of blood into the skin, the only difference between the two is in size. Ecchymoses are large, diffuse areas, usually black and blue in color, and are typically the result of accidental injuries in healthy, active children. Since ecchymotic areas can be indicative of systemic disorders or of child maltreatment, the doctor should always investigate the reported cause of the bruises, especially when they are located in suspicious areas, such as the back or buttocks, rather than on the knees, shins, elbows, or forearms.
Petechiae are small, distinct pinpoint hemorrhages 2 mm or less in size, which can denote some type of blood disorder, such as decreased platelets in leukemia. Because of their size, ecchymoses are more readily observed than are petechiae, which may only be visible in the areas of very light-colored skin, such as the buttocks, abdomen, and inner surfaces of the arms or legs. They are usually invisible in heavily pigmented skin, except in the oral mucosa, the palpebral conjunctiva of the eyelids, and the bulbar conjunctiva covering the eyeball.
The doctor can distinguish the areas of erythema from ecchymosis or petechiae by blanching the skin. Since erythema is the result of increased blood flow to the area, exerting pressure will momentarily empty the engorged vessels and produce blanching. Because the other discolorations are produced by blood leaking into tissue spaces, blanching will not occur.
Jaundice. Jaundice, a yellow staining of the skin usually caused by bile pigments, is always a significant finding. It is most reliably observed in the sclera of the eyes in both dark- and light-skinned children, but it may also be evident in the skin, fingernails, soles, palms, and oral mucosa membranes of the latter group. If a yellow-orange cast is noted in an otherwise healthy child, the doctor should inquire about the quantity of ingested yellow vegetables, such as carrots, which in excess produce a yellow-orange color from deposits of carotene in the skin, called carotenemia.
The doctor palpates the skin for texture, noting moisture and temperature. Any marks or scars that are suggestive of healed injuries are noted, and inquiries are made about their origin. Normally the skin of young children is smooth, soft, and slightly dry to the touch, not oily or clammy. Any variations from these findings are noted, because they may indicate common problems of childhood such as cradle cap (scaliness on the scalp), eczema (scaliness and desquamation on the scalp, cheeks, knees, and elbows), diaper rash (redness and dryness in the genital area), or excessive dryness (xeroderma) all over the body from too frequent bathing, exposure to the weather, or vitamin-A deficiency. Excessively moist, clammy skin may indicate serious health problems, particularly heart disease.
Assessment of the temperature. A doctor evaluates the skin temperature by symmetrically feeling each part of the body and comparing the upper areas with the lower ones. Any distinct difference in temperature is noted. Although not a common anomaly, one of the key signs for coarctation of the aorta is warm upper extremities and cool lower ones. A doctor also observes the skin temperature of the dressed child. Young children produce heat rapidly, and they quickly become overheated if dressed too warmly. Many parents do not realize this and fail to change the amount of clothing to accommodate climactic variations.
Assessment of the texture of the skin. A doctor palpates the skin in symmetric spots of the body and in the extremities particularly on the palms and soles and notes their moisture and temperature. Normally the skin of young children is smooth, soft and slightly dry to the touch, not oily or clammy.
Assessment of the skin elasticity. It is best determined by grasping the skin on the external surface of the palms or flexor surface of an elbow between a thumb and index finger, pulling it taut, and quickly releasing it. Elastic tissue immediately assumes its normal position without residual marks or creases. In children with poor skin elasticity and turgor the skin remains suspended or tented for a few seconds before slow falling back.
Assessment of the skin turgor. It is determined by tension of the soft tissues of the shoulder or the femur with fingers. Normally the doctor must feel flexibility or elasticity of the tissues.
The skin turgor and its elasticity are the best estimates of an adequate hydration and nutrition.
While evaluating turgor, the nurse also inspects for signs of edema, normally evident as swelling or puffiness. Periorbital edema is a sign of several systemic disorders, such as kidney diseases, but may normally be seen in children who have been crying or sleeping or who have allergies. Edema should be evaluated for change according to position, its specific location, and response to pressure. For example, in pitting edema, pressing a finger into the edematous area will cause a temporary indentation.
Accessory organs
Hair. The hair is inspected for color, texture, quality, distribution, and elasticity. Children’s scalp hair is usually lustrous, silky, strong, and elastic. Genetic factors affect the appearance of hair. For example, the hair of black children is usually curlier and coarser than that of white children. Hair that is stringy, dull, brittle, dry, friable, and depigmented may suggest poor nutrition. Any bald or thinning spots are recorded. Although alopecia can be a sign of various skin disorders, such as tinea capitis, loss of hair in infants may be indicative of lying in the same position and may be a clue for counseling parents concerning the child’s stimulatioeeds.
The doctor also inspects the hair and scalp for general cleanliness. Various ethnic groups condition their hair with oils or lubricants, which, if not thoroughly washed from the scalp, clog the sebaceous glands, causing scalp infections. The doctor also inspects hair shafts for lice, whose ova appear as grayish translucent flakes. The doctor can distinguish the ova or nits from dandruff because the eggs adhere to the hair. If pediculosis capitis is suspected, the doctor should be careful to guard against self-infestation of the lice by wearing gloves, washing the hands after the examination, and standing away from the child when looking through the hair.
The doctor also inspects the scalp for ticks, which appear as grayish or brown oval bodies. Although they can be found anywhere on the body, the most common sites are exposed parts, such as the head. Although not all dog or wood ticks transmit serious disease, a notation is made on the child’s chart of its removal in case symptoms appear.
Unusual hairiness anywhere on the body, such as arms, legs, trunk, or face, is noted. Tufts of hair anywhere along the spine, especially over the sacrum, are significant because they can mark the site of spina bifida occulta.
In older children who are approaching puberty, the doctor observes for growth of secondary hair as signs of normally progressing pubertal changes. Precocious or delayed appearance of hair growth is noted because, although not always suggestive of hormonal dysfunction, it may be of great concern to the early- or late-maturing adolescent.
Nails. The nails are inspected for color, shape, texture, and quality. Normally the nails are pink, convex in shape, smooth, and hard but flexible, not brittle. The edges, which are usually white, should extend over the fingers. Dark-skinned individuals may have more deeply pigmented nail beds. Variation in color, such as blueness, is suggestive of cyanosis, and a yellow tint may indicate jaundice. Bluish black discoloration usually indicates hemorrhage under the nail from trauma. Fungal infections cause the entire nail to become whitish in color, with a pitting surface. Short, ragged nails are typical of habitual biting. Uncut nails with dirt accumulated under the edge are sometimes an indication of poor hygiene.
Changes in the shape of nails are also significant. For example, concave curves or “spooails”, called koilonychia, are sometimes seen in iron-deficiency anemia, a commoutritional problem of children. Clubbing of the nails is always a significant finding and it is usually associated with chronic cyanosis. In clubbing the base of the nail becomes visibly swollen and feels springy or floating when palpated, rather than firm as in the normal nail.
Dermatoglyphics. Each individual has a distinct set of handprints and footprints created by epidermal ridges and creases formed in the third month of prenatal life and cracks that develop subsequently throughout the individual’s life-time. The patterns, or dermatoglyphics, are unique to the individual and vary a great deal in detail and complexity of patterns. For example, fingerprint patterns consist of loops, swirls, and arches in highly individualized types and combination. Flexion creases also appear on the palm of the hand and the sole of the foot. The palm normally shows three flexion creases. In some situations the two distal horizontal creases are fused to form a single horizontal crease called a single palmar crease, or simian crease, which is noted in almost all conditions that are caused by chromosomal abnormalities. Another variatiooted by some investigators is the Sydney line, in which the transverse palmar crease extends to the ulnar margin of the palm. This is seen in a large percentage of children with rubella syndrome. If grossly abnormal lines or folds are observed, the doctor should sketch a picture to describe them and refer the finding to a specialist for further investigation.
Assessment of the lymph nodes
Lymph nodes are usually assessed when the part of the body in which they are located is examined. Although the body’s lymphatic drainage system is extensive, the usual sites for palpating accessible lymph nodes are shown in Fig. 6.2. Since the major function of lymph nodes is to collect and filter the lymph of bacteria and other foreign matter as it returns to the circulatory system, a doctor must have knowledge of the lymph’s directional flow. Tender, enlarged warm lymph nodes are generally indicative of infection or inflammation proximal to their location. For example, occipital or postauricular adenopathy is often seen in local scalp infection, such as pediculosis, tick bite, or external otitis. Cervical adenopathy usually accompanies acute infections in or around the mouth or throat. In children, however, small, nontender, movable nodes are frequently normal.
Nodes are palpated with the distal portion of the fingers, by gently but firmly pressing in a circular motion along the regions where nodes are normally present. When assessing the nodes in the head and neck, the child’s head is tilted upward slightly but without tensing the sternocleidomastoid or trapezius muscle. This position facilitates palpation of the submental, submaxillary, tonsillar, and cervical nodes. The axillary nodes are palpated with the arms relaxed at the side but slightly abducted. The inguinal nodes are best assessed with the child in the supine position.
Localization, quantity, size, shape, mobility, consistency (elastic or dense), temperature, and tenderness are noted, as well as reports by the parents regarding any visible change of enlarged nodes.
Assessment of the skinfold thickness
It is examined by grasping the fold of the skin and subcutaneous fat on the abdomen, under the scapula, the shoulder blade and thigh between a thumb and an index finger.
Normally the skinfold thickness is 1.5-2.0 cm.
Skin disorder syndromes
1. Syndrome of changing the color of the skin and the mucous membranes (symptom of cyanosis, jaundice, paleness and hyperemia).
2. Syndrome of exudative diathesis (maceration, weeping, erosion, scaling, hyperemia, cradle cap).
3. Hemorrhagic skin syndrome (petechiae, hematoma, ecchymosis).
4. Dystrophy syndrome (thin skin, trophic rash, scaling, fissure).
5. Syndrome of injuring the skin (scratches, intertrigo, ulcer, excoriation or erosion, wound).
6. Pigmentation changes syndrome (local or total hyperpigmentation or depigmentation).
7. Moisture changes syndrome (dry skin, wet or mist skin).
8. Sensation changing the skin syndrome.
9. Elasticity changing the skin syndrome.
10. Itching syndrome (total or local).
11. Syndrome of general skin lesions.
12. Syndrome of local skin lesions.
The mucous membranes disorder syndromes
1. Fungous damage of the mucous membranes (candidosis, oral moniliasis).
2. Syndrome of inflammation of the mucous membranes (ulcer, erosion, hyperemia, aphtae).
The lymph nodes disorder syndromes
1. Hyperplastic syndrome of lymph nodes (local, general).
2. Lymphadenitis (local, general).
The Subcutaneous fat disorder syndromes
1. Syndrome of sclerema.
2. Syndrome of sclerederma.
3. Syndrome of decreased turgor.
4. Syndrome of decreased trophy (local, general (anasarca)).
5. Syndrome of excessively developed fat (paratrophy, obesity).
6. Syndrome of edema (total, local).
7. Syndrome of thickening (infiltration) of subcutaneous fat.
8. Syndrome of myxedema.
Appendages of the skin disorder syndromes Hair disorders syndromes
1. Alopecia syndrome (universal, circumscribed).
2. Hypertrichosis or hyrsutism (excessive pilosis).
3. Hypotrichosis.
4. Dystrophic disorders of hair (thin hair, tailing of hair, fragility of hair,lusterless of hair).
5. Syndrome of untypical growth of hair.
Nails disorders syndromes
1. Dystrophic disorders of nails:
a) micotic lesion;
b) trauma;
c) congenital disease.
2. Syndrome of inflammation of nail.
3. Nail dysplasia.
4. Deformation of nails syndrome (congenital, acquired).
5. Growth of the cartilage and the bone
6. Growth of the skeleton follows a genetically programmed developmental plan that furnishes not only the best indicator of general growth progress, but also provides the best estimate of biologic age. Some degree of assessment can be achieved by observation of facial bone development (nasal bridge height, prominence of malar eminences, and mandibular size), but the most accurate measure of general development is the determination of osseous maturation by roentgenography. Skeletal age appears to correlate more closely with other measures of physiologic maturity (such as the onset of menarche) than with chronologic age or height. This “bone age” is determined by comparing the mineralization of ossification centers and advancing bony form to age-related standards. Skeletal maturation begins with the appearance of centers of ossification in the embryo and ends when the last epiphysis is firmly fused to the shaft of its bone.
7. In the healthy child skeletal growth and development consist of two concurrent processes: (1) the creation of new cells and tissues (growth), and (2) the consolidation of these tissues into a permanent form (maturation). Early in fetal life embryonic connective tissues begin to differentiate and become more closely packed to form cartilage. This cartilage is enlarged by cell division and expansion within the forming structures and by the laying down of successive layers on the surface of the mass. During the second month of fetal life, bone formation begins when calcium salts are deposited in the intercellular substance (matrix) to form calcified cartilage first and then true bone. There are some differences in this bone formation. In small bones, the bone continues to form in the center and cartilage continues to be laid down on the surfaces. Bones of the face and cranium are laid out in a tough membrane and directly ossified into bone during fetal life.
8. In long bones the ossification takes place in two centers. It begins in the diaphysis (the long central portion of the bone) from a “primary” center and continues in the epiphysis (the end portions of the bone) at “secondary” centers of ossification. Situated between the diaphysis and the epiphysis is an epiphyseal cartilage plate that is united to the diaphysis by columns of spongy tissue, the metaphysis (Fig. 7). It is at this site that active growth in length takes place, and interference with this growth site by trauma or infection can result in deformity. Under the influence of hormones, primarily pituitary growth hormone and thyroid hormone, bones increase in circumference by the formation of a new bone tissue beneath the membrane that surrounds the bone (periosteum) and in length by proliferation of the cartilage.
9. Over the growth period of approximately 19 to 20 years, this development can be divided into three distinct but over-phases: (1) ossification of the diaphysis, (2) ossification of the epiphysis, and (3) invasion and subsequent replacement of growth cartilage plates with bony fusion of epiphysis and diaphysis. These changes do not take place in all bones simultaneously but appear in a specific order and at a specific time. Although the speed of bone growth and amount of maturity at specific ages vary from one child to another, the order of ossification is constant. The first center of ossification appears in the 2-month-old embryo, and at birth the number is approximately 400, about half the number at maturity. New centers appear at regular intervals during the growth period and provide the basis for assessment of “bone age.” Postnatally, the earliest centers to appear (at 5 to 6 months of age) are those of the capitate and hamate bones in the wrist. Therefore, roentgenograms of the hand and wrist provide the most useful areas for screening to determine skeletal age, especially before age 6 years. A common rule of thumb is: age in years + 1 = number of ossification centers in the wrist. These centers appear earlier in girls than in boys.
10.Skeletal development advances until maturity through the growth of ossification centers and the lengthening of long bones at the metaphysis and cartilage plates. Linear growth can continue as long as the epiphysis is separated from the diaphysis by the cartilage plate; when the cartilage disappears, the epiphysis unites with the diaphysis and growth ceases. Epiphyseal fusion also follows an orderly sequence, thus the timing of epiphyseal closure furnishes another medium for measuring the skeletal age.
11.Investigation and assessment based on bone growth furnish a reliable index of growth rate in the individual child. In addition to the assessment of the general developmental and nutritional status of the child, the findings are of value in the diagnosis of many metabolic and endocrine disturbances affecting growth as well as some congenital conditions.
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13.Dentition
14.
15.The course of dentition is sometimes divided into four major stages: (1) growth, (2) calcification, (3) eruption, and (4) attrition. The primary teeth arise as outgrowths of the oral epithelium during the sixth week of embryonic life and begin to calcify during the fourth to sixth months. Tooth buds form at 10 different points in each arch and eventually become the enamel organs for the 20 primary (deciduous) teeth. All the buds are present at birth, but the amount of enamel laid down varies with each set of teeth. Hard tissue formation generally occurs between 4 and 6 months of fetal life.
16.Teeth are divided into quadrants of the lower mandible and upper maxilla and are named for their location in each quadrant of the dental arch, such as central incisor, lateral incisor, and first and second molars. Teeth are also named after their specific function in the mastication of food. The central and lateral incisors, which have a knifelike, or scissorlike shape, cut the food. The cuspids, also called canines, tear the food. The term cuspid refers to the single point or cusp shape of the crown. The two premolars, or bicuspids because of their two-pointed crown, crush the food. The permanent molars, which have four or five cusps, grind the food.
17.About the middle of the first year the primary teeth begin to erupt, although calcification is not completed until sometime during the third year. The age of tooth eruption shows considerable variation among all children, but the order of their appearance is fairly regular and predictable (Fig. A and B). The first primary teeth to erupt are the lower central incisors, which appear at approximately 6 to 8 months of age. This may vary from 4 months to 1 year iormal children, and infants may even be born with teeth. One incisor erupts, followed closely by the homologous incisor. The total of 20 primary teeth is acquired in characteristic sequence by 30 months of age. Calcification of the primary teeth is complete at this time. A quick guide to assessment of deciduous teeth during the first 2 years is: the age of the child in months – 6 = number of teeth that should be present.
18.The first permanent (secondary) teeth erupt at about 6 years of age. Before their appearance they have been developing in the jaw beneath the deciduous (primary) teeth. Meanwhile, the roots of the latter are gradually being absorbed so that at the time a deciduous tooth is shed, only the crown remains. At 6 years of age all the primary teeth are present and those of the secondary dentition are relatively well formed. At this time eruption of the permanent teeth begins, usually starting with the 6-year molar, which erupts posterior to the deciduous molars. The others appear in approximately the same order as eruption of the primary teeth and follow shedding of the deciduous teeth. The pattern of shedding primary teeth and the eruption of secondary teeth are subject to wide variation among children. To allow the larger permanent teeth to occupy the limited space left by shed primary teeth, a series of complicated changes must take place in the jaws. It is at this time that many of the difficulties created by crowding of teeth become apparent. With the appearance of the second permanent (12-year) molar, most of the permanent teeth are present. The third permanent molars, or wisdom teeth, may erupt from 18 to 25 years of age or later. A quick guide to assessment of permanent teeth is: the age of the child in years x 4 – 20 = number of teeth that should be present.
19.Permanent dentition, as in other aspects of development, is somewhat more advanced in girls than it is in boys. The eruption of teeth is sometimes used as a criterion for developmental assessment, especially the 6-year molar, which seems to be the most universally consistent in timing. However, dental maturation does not correlate well with bone age and is less reliable as an index of biologic age. Retarded eruption is more common than accelerated eruption and may be caused by heredity or may indicate health problems such as endocrine disturbance, nutritional factors, or malposition of teeth.
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21.Growth of the muscle
22.As skeletal development is responsible for linear growth, muscle growth accounts for a significant portion of the increase in body weight. The number of muscle fibers is established by the fourth or fifth month of fetal life and remains constant throughout life. Differences in muscle size between individuals and differences in one person at various times during a lifetime are the result of the ability of the separate muscle fibers to increase in size. The increase in muscle fiber length that accompanies growth is also associated with an increase in the number of nuclei in the fibers. This increase is most apparent during the adolescent growth spurt. At this time the increase in secretion of growth hormone and adrenal androgens stimulates the growth of muscle fibers in both sexes, but the growth in boys is further stimulated by the secretion of testosterone. At about 6 months of prenatal life, muscle mass constitutes approximately one sixth of the body weight; at birth, about one fourth, and at adolescence, one third. The variability in size and strength of muscle is influenced by genetic constitution, nutrition, and exercise. At all ages muscles increase in size with use and shrink with inactivity. Consequently maintaining muscle tone to minimize the amount of atrophy in skeletal muscle through active or passive range of motion exercises is an important protective nursing function.
23.Peculiarity of musculoskeletal the system iewborn
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25.At birth the skeletal system contains larger amounts of cartilage than ossified bone, although the process of ossification is fairly rapid during the first year. The nose, for example, is predominantly cartilage at birth and is frequently flattened by the force of delivery. The six skull bones are relatively soft and not yet joined. The sinuses are incompletely formed in the newborn as well.
26.Unlike the skeletal system, the muscular system is almost completely formed at birth. Growth in the size of muscular tissue is caused by hypertrophy, rather than hyperplasia of cells.
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28.Physiologicoanatomical peculiarities of the chest
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30.Although the thoracic cavity houses two vital organs, the heart and lungs, the anatomic structures of the chest wall are important sources of the information concerning cardiac and pulmonary function, skeletal formation. The chest is inspected for size, shape, symmetry, movement and the presence of the bony landmarks formed by the ribs and sternum.
31.The doctor must become familiar with locating and properly numbering each rib, because they are geographic landmarks for palpating, percussing, and auscultating underlying organs. Normally all the ribs can be counted by palpating inferiorily from the second rib. The tip of the eleventh rib can be felt laterally, and the tip of the twelfth rib can be felt posteriorily. Other helpful landmarks include the nipples, which are usually located between the fourth and fifth ribs or at the fourth interspace and, posteriorly, the tip of the scapula, which is located at the level of the eighth rib or interspace. In children with thin chest walls, correctly locating the ribs presents little difficulty.
32.The thoracic cavity is also divided into segments by drawing imaginary lines on the chest and back: the anterior, lateral, and posterior divisions. The doctor should become familiar with each imaginary landmark, as well as with the rib number and corresponding interspace.
33.The size of the chest is measured by placing the tape around the rib cage at the nipple line. For the greatest accuracy at least two measurements should be taken, one during inspiration and the other during expiration, and the average recorded. The chest size is important mainly in comparison to its relationship with the head circumference. Marked disproportions are always recorded, because most are caused by abnormal head growth, although some may be the result of altered chest shape, such as barrel chest or pigeon chest.
34.As the child grows, the chest normally increases in the transverse direction, causing the anteroposterior diameter to be less than the lateral diameter. In an older child the characteristic barrel shape of an infant’s chest is a significant sign of chronic obstructive lung disease, such as asthma or cystic fibrosis. Other variations in shape that are usually variants of the normal configuration are pigeon breast, or pectus carinatum, in which the sternum protrudes outward, increasing the anteroposterior diameter, and funnel chest, or pectus excavatum, in which the lower portion of the sternum is depressed. A severe depression may impair cardiac function, but in general neither condition causes pathologic dysfunction. However, these conditions often cause parents and children concern regarding acceptable physical appearance.
35.The doctor also notes the angle made by the lower costal margin and the sternum, which ordinarily is about 45 degrees. A larger angle is characteristic of lung diseases that also cause a barrel shape of the chest. A smaller angle may be a sign of malnutrition. As the rib cage is inspected, the junction of the ribs to the costal cartilage (costochondral junction) and sternum is noted. Normally the points of attachment are fairly smooth. Swellings or blunt knobs along either side of the sternum are known as the rachitic rosary and may indicate vitamin D deficiency. Another variation in shape that may either be normal or may suggest rickets (vitamin D deficiency) is Harrison’s groove, which appears as a depression or horizontal groove where the diaphragm leaves the chest wall. Usually marked flaring of the rib cage below the groove is an abnormal finding.
36.Body symmetry is always an important notation during inspection. Asymmetry in the chest may indicate serious underlying problems, such as cardiac enlargement (bulging on the left side of rib cage) or pulmonary dysfunction. However, asymmetry is most often a sign of scoliosis, lateral curvature of the spine. Asymmetry warrants further medical investigation.
37.Movement of the chest wall is noted. It should be symmetric bilaterally and coordinated with breathing. During inspiration the chest rises and expands, the diaphragm descends, and the costal angle increases. During expiration the chest falls and decreases in size, the diaphragm rises, and the costal angle narrows. In children under 6 or 7 years of age, respiratory movement is principally abdominal or diaphragmatic. In older children, particularly females, respirations are chiefly thoracic. In either type the chest and abdomen should rise and fall together.
38.Any asymmetry of movement is an important pathologic sign and is reported. Decreased movement on one side of the chest may indicate pneumonia, pneumothorax, atelectasis, or an obstructive foreign body. Marked retraction of muscles either between the ribs (intercostal), above the sternum (suprasternal), or above the clavicles (supraclavicular) is always noted, because it is a sign of respiratory difficulty.
39. Peculiarity of the chest iewborn The newborn’s chest is almost circular because the anteroposterior and lateral diameters are equal. The ribs are very flexible, and slight intercostal retractions are normally seen on inspiration. The xiphoid process is commonly visible as a small protrusion at the end of the sternum. The sternum is generally raised and slightly curved.
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41.Physiologicoanatomical peculiarities of the head in the newborn
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43.General observation of the contour of the head is important, since molding occurs in almost all vaginal deliveries. In a vertex delivery the head is usually flattened at the forehead, with the apex rising and forming a point at the end of the parietal bones and the posterior skull or occiput dropping abruptly. The usual more oval contour of the head is apparent by 1 to 2 days after birth. The change in shape occurs because the bones of the cranium are not fused, allowing for overlapping of the edges of these bones to accommodate to the size of the birth canal during delivery. Such molding does not occur in infants born by cesarean section.
44.Six bones – the frontal, occipital, two parietals, and two temporals – comprise the cranium. Between the junctions of these bones are bands of connective tissue called sutures. At the junction of the sutures are wider spaces of unossified membranous tissue called fontanels. The two most prominent fontanels in infants are the anterior fontanel formed by the junction of the sagittal, coronal, and frontal sutures, and the posterior fontanel, formed by the junction of the sagittal and lambdoidal sutures (Fig. 7.3). One can easily remember the location of the sutures because the coronal suture “crowns” the head and the sagittal suture “separates” the head.
45.Two other fontanels – the sphenoidal and mastoid – are normally present but are not usually palpable. An additional fontanel located between the anterior and posterior fontanels along the sagittal suture is found in some normal neonates but is also found in some infants with Down’s syndrome.
46.The presence of this sagittal or parietal fontanel is always recorded.
47.The doctor palpates the skull for all patent sutures and fontanels, noting size, shape, molding, or abnormal closure. The sutures are felt as cracks between the skull bones, and the fontanels are felt as wider “soft spots” at the junction of the sutures. These are palpated by using the tip of the index finger and running it along the ends of the bones.
48.The fontanel of great size is assessed between middle points of the opposite sides of the fontanel (between the frontal and parietal bones).
49.The anterior fontanel is diamond-shaped, measuring 2.5 cm (1 inch) by 3 cm (about 1.5 inches). The posterior fontanel is triangular-shaped, measuring between 0.5 and 1 cm (less than l/2 inch) at its widest part. It is easily located by following the sagittal suture toward the occiput.
50.The fontanels should feel flat, firm, and well-demarcated against the bony edges of the skull. Frequently pulsations are visible at the anterior fontanel. Coughing, crying, or lying down may temporarily cause the fontanels to bulge and become more taut. However, a widened, tense, bulging fontanel is a sign of increased intracranial pressure. A markedly sunken, depressed fontanel is an indication of dehydration. Such findings are recorded and reported to the physician.
51.The doctor also palpates the skull for any unusual masses or prominences, particularly those resulting from birth trauma, such as caput succedaneum or cephalhematoma. Because of the pliability of the skull, exerting pressure at the margin of the parietal and occipital bones along the lambdoid suture may produce a snapping sensation similar to the identation of a Ping-Pong ball. This phenomenon is known as physiologic craniotabes and, although usually a normal finding, can be indicative of hydrocephalus, syphilis and ricket.
52.The degree of the head control in the neonate is also assessed. Although the head lag is normal in the newborn, the degree of the ability to control the head in certain positions should be recognized. If the supine infant is pulled from the arms into a semi-Fowler’s position, a marked head lag and hyperextension are noted. However, as one continues to bring the infant forward into a sitting position, the infant attempts to control the head in an upright position. As the head falls forward onto the chest, many infants attempt to right it into the erect position. If the infant is held in ventral suspension, that is, held prone above and parallel to the examining surface, the infant holds his head in a straight line with the spinal column. When lying on the abdomen, the newborn has the ability to lift the head slightly, turning it from side to side. A marked head lag is seen in Down’s syndrome, hypoxic infants, and newborns with brain damage.
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54.Examination of the spine
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56.While the child is prone, the spine, extremities, joints, and muscles are inspected. However, they are also observed with the child sitting and standing.
57.The general curvature of the spine is noted. Normally the back of a newborn is rounded or C-shaped from the thoracic and pelvic curves. The development of the cervical and lumbar curves approximates the development of various motor skills, such as cervical curvature with the head control, and gives the older child the typical double-S curve.
58.Marked curvatures in posture are noted, Scoliosis, lateral curvature of the spine, is an important childhood problem, especially in females. Although scoliosis may be palpated as one feels along the spine and notes a sideways displacement, more objective tests include some aspects.
59.1. With the child standing erect, clothed only in underpants (and bra if an older girl), he is observed from behind, noting asymmetry of the shoulders and hips.
60.2. With the child bending forward so that the back is parallel to the floor, he is observed from the side, noting asymmetry or prominence of the rib cage.
61.A slight limp, a crooked hemline, or complaints of a sore back are other signs and symptoms of scoliosis.
62.The hack, especially along the spine, is inspected for any tufts of hair, dimples, or discoloration. A small dimple usually with a tuft of hair called a pilonidal cyst may indicate an underlying spina bifida occulta. The nurse palpates the spine to identify each spiny process of the vertebrae or lack of them. Any masses, which may be meningoceles, evidence of tenderness, and swelling are noted.
63.Mobility of the vertebral column is easily assessed in most children because of their propensity for constant motion during the examination. However, mobility can be specifically tested for by asking the child to sit up from a prone position or to do a modified sit-up exercise. Maintaining a rigid straightness when performing these maneuvers is considered abnormal and may indicate central nervous system infection or irritation. However, some individuals who are unable to relax, despite normal skeletal function, may also retain a rigid posture.
64.Movement of the cervical spine is an important diagnostic sign for neurologic problems, such as meningitis. Normally movement of the head in all directions is effortless. Hyperextension of the neck and spine, called opisthotonos, which is accompanied by pain if the nurse attempts to flex the head, is always referred for immediate medical evaluation.
