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The child with Down syndrome (trisomy 21) usually has a small, rounded head, a flattened nasal bridge, oblique palpebral fissures, prominent epicanthal folds, small, low-set, shell-like ears, and a relatively large tongue. Associated features include generalized hypotonia, transverse palmar creases (.simian lines), shortening and incurving of the 5th fingers (clinodactyly), Brushfield's spots (see p. 771), and mental retardation.

The child who has been physically abused (battered) may have old and fresh bruises about the head and face and may either look sad and forlorn or be actively seeking to please, sometimes even particularly involved with and attentive to the abusing parent. Other stigmata include: bruises in areas (axilla and groin) not usually subject to injury rather than the bony prominences, x-ray evidence of fractures of the skull, ribs, and long bones in various stages of healing, and skin lesions that are morphologically similar to implements used to inflict trauma (hand, belt buckle, strap, rope, coat hanger, or lighted cigarette).

Perennial Allergie Rhinitis Hyperthyroidism

The child suffering from perennial allergic rhinitis has an open mouth (cannot breathe through the nose) and edema and discoloration of the lower orbitopalpebral grooves ("allergic shiners"). Such a child is often seen to push the nose upward and backward with a hand ("allergic salute") and to grimace (wrinkle the nose and mouth) to relieve nasal itching and obstruction. (Photograph reproduced with permission from Marks MB: Allergic shiners: Dark circles under the eyes in children. Clin Pediatr 5:656, 1966)

Thyrotoxicosis (Graves' disease) occurs in approximately 2 per 1,000 children under the age of 10 years. Affected children exhibit hypermetabolism and accelerated linear growth. Facial characteristics shown in this 6-year-old girl are "staring" eyes (not true exophthalmos, which is rare in children) and an enlarged thyroid gland (goiter). See p. 208.

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