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PEDIATRIC HISTORY AND PHYSICAL EXAM

HYSICAL EXAMINATION

very child should receive a complete systematic examination at regular intervals. One should not restrict thexamination to those portions of the body considered to be involved on the basis of the presenting complaint.

pproaching the Child
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dequate time should be spent in becoming acquainted with the child and allowing him/her to become acquain

ith the examiner. The child should be treated as an individual whose feelings and sensibilities are well develo

nd the examiner's conduct should be appropriate to the age of the child. A friendly manner, quiet voice, and ow and easy approach will help to facilitate the examination.

bservation of the Patient

though the very young child may not be able to speak, one still may receive much information from him/her eing observant and receptive. The total evaluation of the child should include impressions obtained from the he child first enters until s/he leaves; it should not be based solely on the period during which the patient is onhe examining table. In general, more information is obtained by careful inspection than from any of the other

ethods of examination.

equence of Examination

kill, tact and patience are required to gather an optimal amount of information when examining a child. Thero routine one can use and each examination should be individualized. Ham it up and regress. Get down to t

hild's level and try to gain his trust. The order of the exam should conform to the age and temperament of th

hild. For example, many infants under 6 months are easily managed on the examining table, but from 8 mono 3 years you will usually have more success substituting the mother's lap. Certain parts of the exam can

ometimes be done more easily with the child in the prone position or held against the mother. After 4 years, re often cooperative enough for you to perform the exam on the table again.

Wash your hands with warm water before the examination begins. You will impress your patient's mother and

egin with an adverse reaction to cold hands in your patients. With the younger child, get to the heart, lungs a

bdomen before crying starts. Save looking at the throat and ears for last. If part of the examination isncomfortable or painful, tell the child in a warm, honest, but determined tone that this is necessary. Looking nimals in their ears or listening to birdies in their chests is often another useful approach to the younger child

your bag of tricks is empty and you've become hoarse from singing and your lips can no longer bring forth a

histle, you may have to turn to muscle. Various techniques are used to restrain children and experience will our best ally in each type of situation.

emember that you must respect modesty in your patients, especially as they approach pubescence. Some timuring the examination, however, every part of the child must have been undressed. It usually works out best

tart with those areas which would least likely make your patient anxious and interfere with his developing

onfidence in you.

eneral Physical Examination

Vital Signs and Measurements

Temperature, pulse rate, and respiratory rate (TPR); blood pressure (the cuff should cover 2/3 of the

upper arm), weight, height, and head circumference. The weight should be recorded at each visit;

the height should be determined at monthly intervals during the first year, at 3-month intervals in

the second year, and twice a year thereafter. The height, weight, and circumference of the childshould be compared with standard charts and the approximate percentiles recorded. Multiple

measurements at intervals are of much greater value than single ones since they give informationregarding the pattern of growth that cannot be determined by single measurements.

I. General Appearance

oes the child appear well or ill? Degree of prostration; degree of cooperation; state of comfort, nutrition, and


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onsciousness; abnormalities, gait, posture, and coordination; estimate of intelligence; reaction to parents,

hysician, and examination; nature of cry and degree of activity, facies and facial expression.

II. Skin

Color (cyanosis, jaundice, pallor, erythema), texture, eruptions, hydration, edema, hemorrhagic

manifestations, scars, dilated vessels and direction of blood flow, hemangiomas, cafe-au-lait areasand nevi, Mongolian (blue-black) spots, pigmentation, turgor, elasticity, and subcutaneous nodules.

Striae and wrinkling may indicate rapid weight gain or loss. Sensitivity, hair distribution andcharacter, and desquamation.

*Practical notes:

A. Loss of turgor, especially of the calf muscles and skin over abdomen, is evidence of dehydration.B. The soles and palms are often bluish and cold in early infancy; this is of no significance.

C. The degree of anemia cannot be determined reliably by inspection, since pallor (even in the

newborn) may be normal and not due to anemia.

D. To demonstrate pitting edema in a child it may be necessary to exert prolonged pressure.

E. A few small pigmented nevi are commonly found, particularly in older children.

F. Spider nevi occur in about 1/6 children under 5 years of age and almost of older children.

G. "Mongolian spots" (large, flat black or blue-black areas) are frequently present over the lowerback and buttocks; they have no pathologic significance.

H. Cyanosis will not be evident unless at least 5 gm of reduced hemoglobin are present; therefore, it

develops less easily in an anemic child.

I. Carotenemic pigmentation is usually most prominent over the palms and soles and around the

nose, and spares the conjunctivas.

V. Lymph Nodes

ocation, size, sensitivity, mobility, consistency. One should routinely attempt to palpate suboccipital,

reauricular, anterior cervical, posterior cervical, submaxillary, sublingual, axillary, epitrochlear, and inguinal

mph nodes.

*Practical notes:

A. Enlargement of the lymph nodes occurs much more readily in children than in adults.

B. Small inguinal lymph nodes are palpable in almost all healthy young children. Small, mobile, non-

tender shotty nodes are commonly found in residue of previous infection.

. Head

ze, shape, circumference, asymmetry, cephalhematoma, bosses, craniotabes, control, molding, bruit, fontanesize, tension, number, abnormally late or early closure), sutures, dilated veins, scalp, hair (texture,

stribution, parasites), face, transillumination.


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*Practical notes:

A. The head is measure at its greatest circumference; this is usually at the midforehead anteriorly

and around to the most prominent portion of the occiput posteriorly. The ration of headcircumference to circumference of the chest or abdomen is usually of little value.

B. Fontanel tension is best determined with the quiet child in the sitting position.

C. Slight pulsations over the anterior fontanel may occur in normal infants.

D. Although bruits may be heard over the temporal areas in normal children, the possibility of an

existing abnormality should not be overlooked.

E. Craniotabes may be found in the normal newborn infant (especially the premature) and for thefirst 2-4 months.

F. A positive Macewen's sign ("cracked pot" sound when skull is purcussed with one finger) may be

present normally as long as the fontanel is open.

G. Transillumination of the skull can be performed by means of a flashlight with a sponge rubbercollar so that it forms a tight fit when held against the head.

I. Face

ymmetry, paralysis, distance between nose and mouth, depth of nasolabial folds, bridge of nose, distribution air, size of mandible, swellings, hypertelorism, Chvostek's sign, tenderness over sinuses.

II. Eyes

hotophobia, visual acuity, muscular control, nystagmus, Mongolian slant, Brushfield spots, epicanthic folds,

crimation, discharge, lids, exophthalmos or enophthalmos, conjunctivas; pupillary size, shape, reaction to lignd accommodation; media (corneal opacities, cataracts), fundi, visual fields (in older children). At 2-4 weeksfant will follow light. By 3-4 months, coordinated eye movements should be seen.

*Practical notes:

A. The newborn infant will usually open his eyes if he/she is placed in the prone position, supportedwith one hand on the abdomen, and lifted over the examiner's head.

B. Not infrequently, one pupil is normally larger than the other. This sometimes occurs only inbright or in subdued light.

C. Examination of the fundi should be part of every complete physical examination, regardless of the

age of the child; dilatation of pupils may be necessary for adequate visualization.

D. A mild degree of strabismus may be present during the first 6 months of life but should be

considered abnormal after that time.

E. To test for strabismus in the very young or uncooperative child, note where a distant source oflight is reflected from the surface of the eyes; the reflection should be present on corresponding


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portions of the two eyes.

F. Small areas of capillary dilatation are commonly seen on the eyelids of normal newborn infants.

G. Most infants produce visible tears during the first few days of life.

III. Nose

xterior, shape, mucosa, patency, discharge, bleeding, pressure over sinuses, flaring of nostrils, septum.

t birth the maxillary antrum and anterior and posterior ethmoid cells are present. At 2-4 years pneumatizatio

he frontal sinus takes place but is rarely a site of infection until the 6th - 10th year. Though the sphenoid sinuresent at birth, it does not assume clinical significance until the 5th to 8th year.

X. Mouth

ps (thinness, downturning, fissures, color, cleft), teeth (number, position, caries, mottling, discoloration,otching, malocclusion or malalignment), mucosa (color, redness of Stensen's duct, enanthems, Bohn's nodule

pstein's pearls), gum, palate, tongue, uvula, mouth breathing, geographic tongue (usually normal).

. Throat

onsils (size, inflammation, exudate, crypts, inflammation of the anterior pillars), mucosa, hypertrophic lympho

ssue, postnasal drip, epiglottis, voice (hoarseness, stridor, grunting, type of cry, speech). The number andondition of the teeth should be recorded. (A child should have 20 teeth by age 2 years. When the teeth be

o erupt is quite variable but most infants have their two lower central incisors by 8-10 months.

A. Before examining a child's throat it is advisable to examine his mouth first. Permit the child tohandle the tongue blade, nasal speculum and flashlight so that he/she can overcome his fear of theinstruments. Then ask the child to stick out his tongue and say "Ah" louder and louder. In some

cases this may allow an adequate examination. In others, if the child is cooperative enough, he/she

may be asked to "pant like a puppy;" while he/she is doing this, the tongue blade is applied firmly tothe rear of the tongue. Gagging need not be elicited in order to obtain a satisfactory examination.

In still other cases, it may be expedient to examine one side of the tongue at a time, pushing the

base of the tongue to one side and then to the other. This may be less unpleasant and is less apt tocause gagging.

B. Young children may have to be restrained to obtain an adequate examination of the throat.

Eliciting a gag reflex may be necessary if the oral pharynx is to be adequately seen.

C. The small child's head may be restrained satisfactorily by having the mother place her hands at

the level of the child's elbows while the arms are held firmly against the sides of his head.

D. If the child can sit up, the mother is asked to hold him erect in her lap with his back against her

chest. She then holds his left hand in her left hand and his right hand in her right hand, and placesthem against the child's groin or lower thighs to prevent him from slipping down from her lap. If thethroat is to be examined in natural light, the mother faces the light. If artificial light and a head

mirror are used, the mother sits with her back to the light. In either case, the physician uses one

hand to hold the head in position and the other to manipulate the tongue blade.

E. Young children seldom complain of sore throat even in the presence of significant infection of the


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pharynx and tonsils.

I. Ears

nnas (position, size), canals, tympanic membranes (landmarks, mobility, perforation, inflammation, dischargastoid tenderness and swelling, hearing (including hearing screen).

*Practical notes:

A. A test for hearing is an important part of the physical examination of every infant.

B. The ears of all sick children should be examined.

C. Before actually examining the ears, it is often helpful to place the speculum just within the canal,

remove it and place it lightly in the other ear, remove it again, and proceed in this way from one earto the other, gradually going farther and farther, until satisfactory examination is completed.

D. In examining the ear, as large a speculum as possible should be used and should be inserted no

farther than necessary, both to avoid discomfort and to avoid pushing wax in front of the speculum

so that it obscures the field. The otoscope should be held balanced in the hand by holding thehandle at the end nearest the speculum. One finger should rest against the head to prevent injuryresulting from sudden movement by the child.

E. The child may be restrained most easily if he/she is lying on his abdomen.

F. Low-set ears are present in a number of congenital syndromes, including several that areassociated with mental retardation. The ears may be considered low-set if they are below a linedrawn from the lateral angle of the eye and the external occipital protuberance.

G. Congenital anomalies of the urinary tract are frequently associated with abnormalities of the

pinnas.

H. To examine the ears of an infant it is usually necessary to pull the auricle backward and

downward; in the older child the external ear is pulled backward and upward.

II. Neck

osition (torticollis, opisthotonos, inability to support head, mobility), swelling, thyroid (size, contour, bruit,

thmus, nodules, tenderness), lymph nodes, veins, position of trachea, sternocleidomastoid (swelling, shorten

ebbing, edema, auscultation, movement, tonic neck reflex.

*Practical notes:

In the older child, the size and shape of the thyroid gland may be more clearly defined if the gland is

palpated from behind.

III. Thorax

hape and symmetry, veins, retractions and pulsations, beading, Harrison's groove, flaring of ribs, pigeon breannel shape, size and position of nipples, breasts, length of sternum, intercostal and substernal retraction,

symmetry, scapulas, clavicles.

*Practical notes:


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At puberty, in normal children, one breast usually begins to develop before the other. In both sexes

tenderness of the breasts is relatively common. Gynecomastia is not uncommon in the male.

IV. Lungs

ype of breathing, dyspnea, prolongation of expiration, cough, expansion, fremitus, flatness or dullness toercussion, resonance, breath and voice sounds, rales, wheezing.

*Practical notes:

A. Breath sounds in infants and children normally are more intense and more bronchial, and

expiration is more prolonged, than in adults.

B. Most of the young child's respiratory movement is produced by abdominal movement; there isvery little intercostal motion.

C. If one places the stethoscope over the mouth and subtracts the sounds heard by this route fromthe sounds heard through the chest wall, the difference usually represents the amount produced

intrathoracically.

V. Heart

ocation and intensity of apex beat, precordial bulging, pulsation of vessels, thrills, size, shape, auscultation (rahythm, force, quality of sounds - compare with pulse as to rate and rhythm; friction rub-variation with pressu

urmurs (location, position in cycle, intensity, pitch, effect of change of position, transmission, effect of exerci

*Practical notes:

A. Many children normally have sinus arrhythmia. The child should be asked to take a deep breath

to determine its effect on the rhythm.

B. Extrasystoles are not uncommon in childhood.

C. The heart should be examined with the child recumbent.

VI. Abdomen

ze and contour, visible peristalsis, respiratory movements, veins (distension, direction of flow), umbilicus, heusculature, tenderness and rigidity, tympany, shifting dullness, tenderness, rebound tenderness, pulsation,alpable organs or masses (size, shape, position, mobility), fluid wave, reflexes, femoral pulsations, bowel

ounds. If the liver is palpable below the right costal margin, its total span must be recorded. A deep abdomealpation must be done on every child.

*Practical notes:

A. The abdomen may be examined while the child is lying prone in the mother's lap or held over her

shoulder, or seated on the examining table with his back to the doctor. These positions may beparticularly helpful where tenderness, rigidity, or a mass must be palpated. In the infant the

examination may be aided by having the child suck at a "sugar tip" or nurse at a bottle.

B. Light palpation, especially for the spleen, often will give more information than deep.

C. Umbilical hernias are common during the first 2 years of life. They usually disappear


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spontaneously.

VII. Male Genitalia

rcumcision, meatal opening, hypospadias, phimosis, adherent foreskin, size of testes, cryptorchidism, scrotumydrocele, hernia, pubertal changes.

*Practical notes:

A. In examining a suspected case of cryptorchidism, palpation for the testicles should be done beforethe child has fully undressed or become chilled or had the cremasteric reflex stimulated. In somecases, examination while the child is in a hot bath may be helpful. The boy should also be examined

while sitting in a chair holding his knees with his heels on the seat; the increased intra-abdominal

pressure may push the testes into the scrotum.

B. To examine for cryptorchidism, one should start above the inguinal canal and work downward to

prevent pushing the testes up into the canal or abdomen.

C. In the obese body, the penis may be so obscured by as to appear abnormally small. If this fat is

pushed back, a penis of normal size is usually found.

VIII. Female Genitalia

agina (imperforate, discharge, adhesions), hypertrophy of clitoris, pubertal changes.

*Practical note:

Digital or speculum examination is rarely done until after puberty.

IX. Rectum and Anus

ritation, fissures, prolapse, imperforate anus. The rectal examination should be performed with the little fingnserted slowly). Note muscle tone, character of stool, masses, tenderness, sensation. Examine stool on glov

nger (gross, microscopic, culture, guaiac), as indicated.

X. Extremities

A. General: Deformity, hemiatrophy, bowlegs (common in infancy), knock-knees (common after age2), paralysis, edema, coldness, posture, gait, stance, asymmetry.

B. Joints: Swelling, redness, pain, limitation, tenderness, motion, rheumatic nodules, carrying angle

of elbows, tibial torsion.

C. Hands and feet: Extra digits, clubbing, simian lines, curvature of little finger, deformity of nails,

splinter hemorrhages, flat feet (feet commonly appear flat during first 2 years), abnormalities of

feet, dermatoglyphics, width of thumbs and big toes, syndactyly, length of various segments,dimpling of dorsa, temperature.

D. Peripheral Vessels: Presence, absence or diminution of arterial pulses.

XI. Spine and Back

osture, curvatures, rigidity, webbed neck, spina bifida, pilonidal dimple or cyst, tufts of hair, mobility, Mongol

pots, tenderness over spine, pelvis or kidneys.


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XII. Neurologic Examination

A. Cerebral Function: General behavior, level of consciousness, intelligence, emotional status,memory, orientation, illusions, hallucinations, cortical sensory interpretation, cortical motor

integration, ability to understand and communicate, auditory-verbal and visual-verbalcomprehension, recognition of visual object, speech, ability to write, performance of skilled motor

acts.

B. Cranial Nerves:

1. I (olfactory) - Identify odors; disorders of smell

2. II (optic) - Visual acuity, visual fields, ophthalmoscopic examination, retina.

3. III (oculomotor), IV (trochlear), and VI (abducens) - Ocular movements, ptosis,dilatation of pupil, nystagmus, pupillary accommodation, and pupillary light reflexes.

4. V (trigeminal) - Sensation of face, corneal reflex, masseter and temporal muscles,

maxillary reflex (jaw jerk).

5. VII (facial) - Wrinkle forehead, frown, smile, raise eyebrows, asymmetry of face,strength of eyelid muscles, taste on anterior portio of tongue.

6. VIII (acoustic) -

a. Cochlear portion - Hearing, lateralization, air and bone conduction,

tinnitus.b. Vestibular - Caloric tests.

7. IX (glossopharyngeal), X (vagus) - Pharyngeal gag reflex, ability to swallow and

speak clearly; sensation of mucosa of pharynx, soft palate, and tonsils; movement ofpharynx, larynx, and soft palate; autonomic functions.

8. XI (accessory) - Strength of trapezius and sternocleidomastoid muscles.

9. XII (hypoglossal) - Protrusion of tongue, tremor, strength of tongue.

C. Cerebellar Function: Finger to nose, finger to examiner's finger, rapidly alternating pronation andsupination of hands; ability to run heel down other shin and to make a requested motion with foot;ability to stand with eyes closed; walk; heel to toe walk; tremor; ataxia; posture; arm swing when

walking; nystagmus; abnormalities of muscle tone or speech.

D. Motor System: Muscle size, consistency, and tone; muscle contours and outlines; muscle

strength; myotonic contraction; slow relaxation; symmetry or posture; fasciculations; tremor;

resistance to passive movement; involuntary movement.

E. Sensory System: Hearing, vision, light touch, pain, position, vibration.

F. Reflexes:

1. Deep reflexes - Biceps, brachioradialis, triceps, patellar, Achilles; rapidity and

strength of contraction and relaxation.


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2. Superficial reflexes - Abdominals, cremasteric, plantar, gluteal.

3. Pathologic reflexes - Babinski, Chaddock, Oppenheim, Gordon.

G. Newborn Neurological Examination

*Practical Points:

Observe the normal flexion of the term infant in contrast to the nonflexed, even flaccid appearance

of the normal resting premature. The shape of the premature skull is usually dolichocephalic (longand narrow). Elicit the normal reflexes of grasping (hand and foot), sucking, rooting, Moro andautomatic walking. Palpate the head to identify the anterior and posterior fontanelles as well as the

sagittal, coronal, metopic and lambdoid sutures.

ORMAL NEWBORN: HISTORY AND PHYSICAL EXAM OUTLINE

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Chapter 47Kawasaki DiseasePATHOPHYSIOLOGYKawasaki disease is an acute, self-limited vasculitic syndrome affecting infants and young children. Kawasaki

disease is distinguished by marked immune system activation that contributes to the injury of small- and medium-

sized blood vessels, with a predilection for the coronary arteries. Also known as mucocutaneous lymph node

syndrome, Kawasaki disease affects multiple body systems and can have life-threatening cardiovascular

consequences, including thrombosis of coronary arteries, coronary artery aneurysms, and coronary stenosis.

Researchers speculate that Kawasaki disease has an infectious cause; however, the specific etiology remains

unknown. The disease occurs in three phases; acute febrile, subacute, and late or convalescent. Diagnosis, which is

sometimes confusing, has been based on strict adherence to clinical criteria. However, a substantial subset of

children present with illnesses that do not completely fulfill the diagnostic criteria and are associated with the coronary

diseases similar to that of the typical Kawasaki disease. These cases are labeled atypical Kawasaki disease. Initial

treatment focuses on reducing the vascular inflammatory process. With early recognition and treatment, prognosis is

excellent. The long-term prognosis for children with coronary artery abnormalities who survive the disease is

unknown, but recent surveys suggest that the sequelae of Kawasaki disease are likely important causes of ischemic

heart disease in young adults.INCIDENCE

1

Of all children with diagnosed Kawasaki disease, 80% are 5 years of age or younger, with toddlers most commonly

affected (50% are younger than 2 years of age).


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2In the United States the peak age for being diagnosed with Kawasaki disease is 18 months.

3Adults, adolescents, and children less than 6 months of age are rarely affected.

4

Outbreaks of Kawasaki disease are more common in the late winter and early spring but can be seen at any time duringthe year.

5

Annual incidence in the United States is 5.6 per 100,000 individuals as compared to 67 per 100,000 individuals in

Japan.

6The incidence is higher in boys than in girls (1.5:1). Boys have a higher ratio of fatalities due to Kawasaki disease.

7

The disease occurs in all races but has a higher predilection for Japanese children, followed by Asian and PacificIslanders, African Americans, Hispanics and, finally, is at its lowest incidence in whites.

8Kawasaki disease occurs more often in twins and siblings than in the general population.

9No evidence exists to suggest that Kawasaki disease is spread by person-to-person contact.

10

The increased rates of occurrence in family members suggest there may be a genetic predisposition to Kawasaki

disease.

11Of untreated children with Kawasaki disease, 15% to 20% develop coronary artery aneurysms.

12

Of those children treated with intravenous gamma globulin (IVIG) in the acute phase of the disease, fewer than 5%develop coronary artery abnormalities.

CLINICAL MANIFESTATIONS

Acute Febrile Phase (0 to 19 Days)For Kawasaki disease to be diagnosed, the child must have a fever for 5 days and four of the following acute phasecriteria:

1

Fever is abrupt in onset, typically high (39 to 40 C), spiking, and remittent. If left untreated, the fever may persist for11 days on the average. The fever is present in 95% of children with Kawasaki disease.

2

Bulbar conjunctivitis is seen in the first few days of the illness, occurring shortly after the first fever. It is usuallypainless and not associated with exudate or edema.

3

Oropharyngeal manifestations include changes in the mouth and lips including erythema, dryness, fissuring, peeling,

cracking, and bleeding of the lips; a strawberry tongue; and diffuse erythema of the oropharyngeal mucosa(nonexudative and nonulcerative).

4

Extremity changes include swelling and induration of the hands and feet, erythema of the palms and soles, and painfulextremities; often, children no longer bear weight. The skin becomes shiny and stretched in appearance.

5

Erythematous body rash usually appears within 5 days of fever and may take many forms. Most commonly the rash is anonspecific, diffuse, maculopapular eruption. The rash is most extensive to the trunk but can involve the face and

extremities. The rash in the perineal area is accentuated, and early desquamation may occur.

6 Cervical lymphadenopathy is the least common of the criteria; it is usually unilateral and located in the anterior cervical


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triangle. The enlarged node is usually greater than 1.5cm in diameter, nonfluctuant, and nontender.

7

Cardiac abnormalities include myocarditis, arrhythmias, hyperdynamic precordium, tachycardia, gallop rhythm,depressed myocardial contractility, mitral regurgitation, and coronary artery abnormalities.

Subacute Phase (12 to 25 Days)

1Arthritis frequently includes multiple joints, most commonly large weight-bearing joints

2Decrease in fever

3Thick desquamation of the extremities, starting at the tip of the digits and progressing proximally

4

Panvasculitis of coronary arteries and formation of aneurysms; inflammation and thrombosis may lead to stenosis orobstruction

Convalescent Phase (6 to 8 Weeks)

1

Subsidence of the signs of illness

2

Appearance of deep linear transverse grooves across the fingernails and toenails (Beau's lines), which may progress tocomplete shedding of the nails

3Abnormal laboratory values begin returning to normal

4Normalization of personality, irritability, appetite, and energy level

COMPLICATIONS

1

Cardiac: myocardial infarction (the most common cause of death in Kawasaki disease), coronary artery aneurysms,coronary thromboses, congestive heart failure

2Gastrointestinal: hydrops of the gallbladder (resolves spontaneously)

3

Pulmonary: pleural effusion, pneumonitis, pulmonary nodules

4Neurologic: facial nerve palsy, hearing loss

LABORATORY AND DIAGNOSTIC TESTSRefer to Appendix Dfor normal values and/or ranges of laboratory and diagnostic tests.There are no specific diagnostic tests for Kawasaki disease; however, several abnormalities have been identified.

1

Electrocardiogram (ECG)to assess electrical conduction of the myocardium

a

Flat, depressed ST segment

Flat, inverted T wave

cConduction disturbances

2Echocardiogramto assess cardiac enlargement, contractility of ventricles, and coronary aneurysms
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3

Complete blood countto assess for suggestive indices of Kawasaki disease

aLeukocytosis with neutrophilia

Mild anemia with normocytic red cell indices

cThrombocytosis: usually seen by third week of illness; elevation may persist for 3 months after onset

4

Acute phase reactant elevationto assess inflammatory processes

aErythrocyte sedimentation rate

C-reactive protein level

5

Liver function studiesto assess involvement of liver function

a

Serum transaminase levels

Mild hyperbilirubinemia

cHypoalbuminemia

6

Serum lactic dehydrogenase level (LDH)elevated during acute febrile phase and decreased during convalescent phase

(LDH levels are nonspecific, but elevation is an early indicator of cellular death in the myocardium)

7

Immunoglobulin E and immunoglobulin Mto assess immune response during illness; elevation is observed during

acute febrile phase and decreased during convalescent phase

8Complement levels (C3 and C4)to assess immune response; is increased in the first several weeks of the illness

9Urinalysis may reveal a sterile pyuria

10

Cerebrospinal fluid may reveal aseptic meningitis with a predominance of mononuclear cells with normal protein andglucose

MEDICAL MANAGEMENTInitial therapy is aimed at reducing the vascular inflammatory process and preventing thrombosis by inhibiting platelet

aggregation. IVIG has made a tremendous difference to the treatment of Kawasaki disease. If given within 10 days

from the onset of symptoms, IVIG significantly shortens the disease duration and minimizes complications. IVIG is

given as a 2g/kg infusion delivered over 10 to 12 hours, ideally within the first 7 days of the illness. The mechanism of

action of IVIG is unknown, but it appears to have an antiinflammatory effect, which decreases the inflammation of the

coronary arteries and speeds the resolution of the fever. IVIG may be repeated at the same dose for a second

infusion if the fever persists longer than 36 hours after the first infusion.Aspirin therapy has been used for years in Kawasaki disease. Aspirin is used in the acute phase for its

antiinflammatory effect as well as for its antithrombotic effect. The dosing is divided into two different phases. During

the initial phase, aspirin is given at 80 to 100mg/kg/day in four divided doses. High-dose aspirin should be initiated as

soon as Kawasaki disease is suspected and given until the child remains afebrile for 48 to 72 hours. After the

resolution of the fever, the dose of aspirin is decreased to 3 to 5mg/kg/day in a single daily dose for 6 to 8 weeks.

After 6 to 8 weeks, if the echocardiogram is normal, the aspirin is discontinued. If the echocardiogram reveals

coronary artery abnormalities, low-dose aspirin therapy (3 to 5mg/kg/day) is continued indefinitely.

The use of corticosteroids is controversial, but may be used in children refractory to IVIG therapy. Warfarin

(Coumadin) is sometimes used in children who have developed giant aneurysms. The international normalized ratio


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(INR) should be maintained between 2 to 2.5 while the child receives warfarin. Furosemide (Lasix) may be used in

patients with congestive heart failure. Plasma exchange has been reported to be effective in treatment-refractory

children in uncontrolled clinical trials.

NURSING ASSESSMENT

1See the Cardiovascular Assessment section in Appendix A.

2Assess skin for color, moisture, texture, turgor, rashes, lesions, and integrity.

3Assess for clinical criteria of Kawasaki disease.

4Assess for febrile seizures.

5

Assess adequacy of hydration.

6

Assess pain with age-appropriate pain scale.

7

Assess for allergic reaction to IVIG administration.

NURSING DIAGNOSES

Fluid volume, Deficient

Oral mucous membrane, Impaired

Skin integrity, Impaired

Hyperthermia

Cardiac output, Decreased

Injury, Risk for

Pain

Nutrition: less than body requirements, Imbalanced

Mobility, Impaired physical

Anxiety

Therapeutic regimen management, Ineffective family

NURSING INTERVENTIONS

1

Monitor child's clinical status.

aRectal temperature

Skin integrity, mucous membranes, and anterior fontanelle
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cIntake and output (should be strictly recorded), daily weights

dStool output

eErythematous body rash

f

Vital signs

gPain

hEdema

2

Institute measures to lower fever.

a

Medicate with antipyretics; monitor child's response to medications.

Provide tepid sponge baths for high temperatures that are not responding to antipyretics.

cOffer cool fluids.

dAssess which fluids (such as popsicles and gelatin) child prefers, and provide as tolerated.

e

Maintain seizure precautions, because 3% to 5% of children between 6 months and 3 years of age may developseizures when they have fevers even as low as 101.8 F (38.8 C).

f

Explain unusual nature of fever to parents in terms of its intermittent pattern, duration, and resistance to antipyretics;anticipatory guidance will prevent parental anxiety about fever.

3

Monitor child for cardiac complications.

aUse cardiac monitor as ordered during acute and subacute phases; report arrhythmias to health care provider.

Explain purpose of ECG and echocardiogram, and aberrations caused by child's movement to parents and child.

c

Allow child to change his or her own electrodes during daily bath.

dAssess perfusion, vital signs, and level of consciousness for any changes and report to health care provider.

4

Monitor for untoward signs and symptoms (hypotension, diaphoresis, nausea and vomiting, chills) during IVIG

administration, and stop infusion until symptoms have subsided. Keep epinephrine available to treat anaphylaxis.

5

Monitor for signs of bleeding due to aspirin or anticoagulant therapy.

6

Provide comfort measures for child.

aPerform oral hygiene frequently.

Apply petroleum jelly to lips.

cAvoid soaps, ointments, and lotions on skin; keep skin clean, dry, and exposed to air.

d

Cool, moist compresses may be applied to itching areas.

e Provide sheepskin for child to lie on.


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f

Discourage scratching by means of diversional activities; for young children, soft, loose mittens may be helpful.

gEncourage bed rest and elevation of extremities until swelling has subsided.

h

Teach parents how to hold and comfort child who has IV line and electrodes in place.

iKeep stimulation to a minimum.

Explain to parents that tactile stimulation may be irritating but soothing voice may provide security.

kProvide dim lights.

l

Provide quiet music.

mAllow child to have comfort toy from home.

7

Provide for and promote child's nutrition.

a

Provide comfort measures for mouth (see item 6).

Begin with bland foods in small amounts.

c

Ask parents about child's favorite foods, and provide if possible.

dAvoid hot, spicy foods.

e

Offer high-calorie liquids.

fAvoid caffeinated beverages.

8

Prevent contractions related to imposed restrictions and range of motion (ROM) limitations.

a

Perform passive ROM exercises gently on edematous extremities during child's bed rest; teach parents how to dothese exercises, and explain their importance.

When child is able, use active ROM exercises, making them into game for child.

c

Place IV lines in position that allows maximal movement.

9

Alleviate anxiety caused by invasive procedures for diagnostic tests and by pain, new environment, strange people,

knowledge deficit, and age-related fears (refer to Appendixes B and CAppendix BAppendix C).

a

Provide play therapy during all phases of illness and for each new procedure (e.g., ECGs, needle-related); basetherapy on child's developmental level (refer to Appendixes B and FAppendix BAppendix F).

Explain each procedure at child's and parents' cognitive levels.

c

Suggest ways for parents to support their child during hospitalization and procedures (e.g., holding child during orafter procedures).

d

Consult parents and child about preferences among quiet toys and activities during acute phase of illness;encourage parents and volunteers to play with child, allowing for rest periods and then passive participation.

eExplain meaning of presence of swollen lymph nodes to parents.
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Discharge Planning and Home CareInstruct about long-term management.

1

Instruct parents and child, in developmentally appropriate manner, about importance of follow-up care including ECGs,echocardiograms, and chest radiographic studies (two thirds of coronary aneurysms regress within 1 year).

2

Instruct parents verbally and with written reinforcement about signs and symptoms of cardiac complications (i.e.,

aneurysms and coronary thromboses); tell them to contact health care provider immediately if child has any of thesesigns and symptoms.

3

Instruct parents about importance of anticoagulant therapy such as aspirin and about side effects to watch for; explain to

parents why some children with Kawasaki disease may need to undergo coronary artery bypass grafting.

4Instruct parents about importance of good nutrition and adequate fluid intake.

5Stress importance of adequate rest.

6

Educate parents about delaying administration of live virus vaccines (such as measles, varicella) for 11 months afterchild receives IVIG.

7

Avoid high-impact sports or activities while on anticoagulant therapy.

8

Instruct parents to have child checked for cardiovascular factors every 5 years.

9

Instruct parents to seek medical care immediately for flulike symptoms while on aspirin therapy.

CLIENT OUTCOMES

1

Child's temperature will return to normal.

2

Changes in skin will resolve.

3

Child will walk without joint pain.

4Child will remain hemodynamically stable.

5Child will remain free of nosocomial infections.

6Child will resume age-appropriate activities.

7Child will feel a sense of mastery about the illness experience.

REFERENCESNasr I, Tometzki AJP, Schofield OM: Kawasaki disease: An update. Clin Exper Dermatol 2001; 26:6.Newburger JW, et al: Diagnosis, treatment, and long-term management of Kawasaki disease: A statement for healthprofessionals from the committtee on rheumatic fever, endocarditis, and Kawasaki disease council on cardiovasculardisease in the young, American Heart Association. Pediatrics 2004; 114(6):1708.Shulman S: Kawasaki disease. In: Feigen RD, et al ed. Textbook of pediatric infectious disease, ed5. Philadelphia: WB Saunders; 2004.


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Shulman ST, Rowley AH: Advances in Kawasaki disease. Eur J Pediatr 2004; 163:285.Yamamoto LG: Kawasaki disease. Pediatr Emerg Care 2003; 19(6):422.

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