HISTORY. CF has a highly variable presentation and course, ranging from mild to severe. Parents often report that the child's skin has a characteristic taste of salt when they kiss the child. Hence, this classic early symptom is referred to as the "kiss of salt." In addition, during the first year or two of life, the child experiences repeated upper respiratory infections such as nasopharyngitis, croup, bronchiolitis, and pneumonia. Although the child has a voracious appetite, he or she does not gain weight and has steatorrhea (frequent foul-smelling, fatty stools). Moreover, the child may not achieve developmental milestones, particularly in the area of gross motor skills.

PHYSICAL EXAMINATION. The newborn may have a meconium ileus; this finding occurs in about 10% to 15% of the newly diagnosed cases. The infant or child may be classified as exhibiting organic failure to thrive and may fall below the 10th percentile. Early in the disease, the lungs have many adventitious breath sounds, such as rales, rhonchi, and wheezes. The anterior posterior to lateral diameter begins to increase as the disease progresses so that the child appears barrel-chested. Clubbing of the nails is indicative of advanced progression of the disease and may be noted in a toddler or a preschooler who has a severe form of the disease.

PSYCHOSOCIAL. Children or adolescents with CF deal with a chronic illness that makes them unique from their peers. They need to feel as if they have a degree of control in their lives;

262 Cystic Fibrosis this need may be manifested in refusing to take their enzymes with their meals or their insulin if they become diabetic. Body image is especially critical because of their short stature and small body structure. Many adolescents are embarrassed and try to cover up a protuberant abdomen with baggy clothing and large shirts or to disguise the clubbing of their nails with dark nail polish. In addition, the patients often learn early to achieve a sense of competency by performing well in their academics or becoming computer "wizards," because they are unable to compete in sports.

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