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?