How Do I Approach the Pediatric Patient?

Evaluation in pediatrics requires attention to development. Some patients may be unable or unwilling to cooperate, including nonverbal infants, anxious toddlers, and adolescents who are complex and protective of their privacy. The sequence, structure, and content of the interview; the optimal approach to verbal and physical interactions; and the focus of the physical examination all depend on the age and developmental stage of the patient and the reason for the evaluation. If you are aware of development, you will be able to anticipate patient responses and interpret findings. Information specific to newborn infants is found in Chapters 14 and 67; for more about adolescents, see Chapters 15, 18, and 54. Development is discussed in Chapter 9.

How Do I Begin?

Be aware of your previous experiences, current abilities, and anxieties so that you can make the best decisions during the interview and physical examination. Ask for assistance when performing an evaluation for the first time or whenever you have questions. Anticipate developmentally appropriate behaviors and reactions. Think about your impact on a child or adolescent: A loud voice, cold hands, and abrupt movements are likely to trigger crying and withdrawal by young patients; failure to recognize emerging independence may shut off information from an adolescent. Watch experienced clinicians interact with and examine patients of different ages and developmental stages. Listen as parents tell you about their children and adolescents. Engage parents as your allies to explain or interpret your questions and actions, reassure and calm children, and restrain them if necessary. Keep the parents involved when you evaluate older children and adolescents, but remember to pay attention to confidentiality, privacy, emerging maturity, and autonomy. Ask questions directly of children and adolescents and listen to what they have to say. Be gentle, efficient, and persistent during the examination, but also be realistic: When patients do not cooperate sufficiently to allow you to examine them, let the resident or faculty physician complete that part of the examination. On the other hand, do not “throw in the towel” too soon.

How Do I Incorporate Development into the Evaluation?

A basic understanding of development can be gained from your personal experiences and from Chapter 9. Do not make assumptions. Instead, use history, observations, and physical findings to guide your assessment of an individual’s development. Careful observation of your patient will allow you to compare developmental progress with the milestones highlighted in resources such as the Denver Developmental Assessment (Denver II) (Figure 9-1). The Bright Futures Pocket Guide (www.brightfutures.org/pocket/) helps you develop a developmentally appropriate approach to patients, especially with regard to the information you provide to parents about healthy children.

How Does the Age of the Child Influence My Approach?

Understanding the dynamic process of growth, development, socialization, and maturation will allow you to plan your interview and examination. Your interactions with a child and parent will vary depending on the patient’s age, the parent’s experience, and the reason for the visit. As the human grows, body size increases dramatically, physiologic processes mature, cognition and behavior develop, and relationships mature and change. Parents, other family members, and the community all influence the growing child. In addition, risk factors, exposures, and disease processes change from home, to daycare, to school, and ultimately to the wider world as the adolescent gains independence and mobility. The content of health supervision visits at different ages is discussed in Chapter 11.

How Should I Approach Newborns and Young Infants?

Newborns and young infants (birth to 9 months) prefer a sleeping or quiet, alert state, so speak softly to avoid frightening an infant. The responses of the infant to your presence, to verbal interactions, and to games such as peek-a-boo can help you understand developmental progress. Before you touch the infant, wash your hands, wipe your stethoscope, and warm them both. When you do touch the infant, use gentle, gradual, rocking motions. Take advantage of the sucking reflex by using a pacifier or a gloved finger to calm an infant. Be thorough but gentle with the examination (Table 5-1). Review measurements and the pattern of growth. Listen carefully to the heart for new murmurs. Observe movements and motor skills, and assess development. Perform potentially uncomfortable maneuvers last (e.g., ear examination, Ortolani and Barlow maneuvers, Moro reflex). As discussed in Chapters 11 and 15, you must be prepared to answer many questions and provide anticipatory guidance, as parents need reassurance that they are doing the right things for their infants.

How Should I Approach Older Infants and Toddlers?

Older infants and toddlers (9 months to 3 years) usually demonstrate stranger anxiety and fear of separation from parents, beginning at about 9 months and peaking about 18 to 24 months. A calm, measured approach works best. You may need to avoid direct communication or even eye contact with a toddler until the child “warms up” to you. Sit down and speak softly to the parent, and let the child “invite” you to make direct contact. The interview must focus on the specific reasons for the visit, but health supervision (Chapter 11) will always emphasize developmental progress, risks associated with increasing mobility and independence, exposures to illness at home or in daycare, immunization status, behaviors such as tantrums and negativity, and nutrition. When you start the physical examination, look before you touch! Anything that you accomplish from a distance reduces the likelihood that an infant or toddler will “erupt,” making the rest of the examination difficult if not impossible. The physical examination of a child from 15 to 36 months is usually most successful when the toddler sits on the parent’s lap, with restraint provided by the parent as needed. Observe motor skills and social behaviors that signal developmental progress. Listen to language. Look for clues about illness. Most of the neurologic examination of a healthy toddler can be done by observation: language, symmetry, gait, balance, fine motor skills, and strength. Sometimes a flashlight or finger puppet can distract a child enough to allow completion of the examination. Do not hesitate to sit down on the floor with a toddler to perform parts of the examination.

How Should I Approach Young School-Age Children?

Preschool and early-school-age children (4 to 8 years) are less anxious about the doctor’s office than toddlers, unless they are ill or anticipate an immunization. Children appreciate being spoken to directly and can provide information about friends, school, food, music, physical activity and sports, as well as observations and worries about illness. Parents can corroborate or correct details of the history and are generally good observers of their child’s illness or developmental progress. Acknowledge a child’s emerging autonomy and independence by offering options (e.g., “Which ear should I look at first?”) and by asking the child to help with the examination (e.g., “Put your hands on mine so we can feel your tummy together”). Respect a child’s choice about sitting with a parent or on the examination table. Some young children do not like to be undressed completely, so the examination may proceed in stages, undressing the part to be examined then putting clothes back on. But definitely examine the whole child!

How Should I Approach Older Children?

Older children (9 to 12 years) almost always cooperate with the evaluation. They generally demonstrate a concern for physical modesty and privacy. If siblings accompany a patient to the doctor’s office, ask a parent to take them to the waiting room before discussing personal information or starting the physical examination. The preadolescent usually demonstrates an interest in health and the decisions that are made. Direct your questions to the child as you ask about concerns, problems, or the progress of an illness, and use language that is appropriate to the child’s cognitive abilities. Listen actively to the child and respond honestly to questions. Some 10- to 12-year-olds may already have entered physical puberty but still be quite immature socially and emotionally. Use an open-ended question to start a conversation about a sensitive topic (e.g., “What have you learned in school about growing up?”). Later in the evaluation, parents can be asked to confirm details or elaborate. Observe the child before, during, and after the examination, and use these observations to aid your evaluation. Review vital signs and physical growth, including percentiles and body mass index. During the examination, draw the curtain, close the door securely, and provide a gown or drape. Explain why you are performing specific maneuvers and what you find on examination. Assess speech and language, fine motor movements, handwriting, behavior, interactions between the child and adults, and pubertal development. You must be familiar with sexual maturity rating (Figures 15-1 to 15-3).

How Should I Approach Adolescents?

Adolescents are the most adult-like patients that you will examine during the pediatric clerkship, but they are not yet adult. Adolescents challenge the inexperienced clinician because they are complex—physically, emotionally, and socially. To work successfully with adolescents, you must acquire a basic understanding of the biopsychosocial stages of adolescence and the physical stages of puberty (Chapter 15). Typically, an adolescent can interact independently and participate directly in the examination process without intervention by the parent. An adolescent may not ask about what you find but will definitely appreciate and be interested in your explanations as the examination progresses. Parents need to know that they will be asked to bring the adolescent to the office but that they will not be present in the room during the interview or examination. Adolescents need to know that their parents have a legitimate role in the healthcare process. Both need to understand that confidentiality and privacy will restrict the information that you can share unless you have permission from the patient to discuss issues with the parent and vice versa. If at all possible, these details need to be communicated in advance of the visit (see confidentiality in Chapter 6).

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