History
Pediatrics gained recognition as a distinct medical discipline in the United States in the mid-19th century as an appreciation of the burden of infant mortality and awareness of the unique vulnerability of children to certain diseases increased. Before that, the medical concerns of children were viewed as the domain of internal medicine or obstetrics/gynecology, and there was little consideration given to the unique development and physiology of children. The first hospital dedicated to the treatment of children was the Children’s Hospital of Philadelphia, founded in 1855. Abraham Jacobi, a German immigrant who is considered by many to be the father of American pediatrics, established the children’s clinic at New York Medical College in 1860. In 1876, an emerging leader in pediatric medicine, Job Lewis Smith, was appointed Clinical Professor of the Diseases of Children at Bellevue Hospital in New York City. Lewis authored a textbook, Treatise on the Diseases of Infancy and Children , which was adopted by virtually all medical schools until the late 1890s.
The decline in infant mortality rates seen in the 20th century is one of the great public health success stories of modern times. In 1900, mortality rates in the first year of life approached 30% in some U.S. cities. By the end of the 20th century, infant mortality rates had declined by 99%, with fewer than 0.1 death per 1000 live births. In the early part of the 20th century, improvements in infant mortality were largely due to public health measures, including milk hygiene, clean water, and improved sanitation. In 1912, the Children’s Bureau was formed within the Department of Labor and played an important role in improving maternal and infant welfare in the first half of the century. The discovery and widespread use of antibiotics, fluid and electrolyte replacement therapy, and safe blood transfusions were also critically important factors in improving infant mortality rates by midcentury.
The latter half of the 20th century saw continued improvements in medical care and public health measures, including great strides in perinatal and neonatal medicine, precipitous declines in vaccine-preventable illnesses, and improved access through the implementation of Medicaid in 1965. In 1994, with funding from the U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, the first edition of Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents was published with the goal of ensuring that all children in the United States could look forward to a bright future, regardless of race, religion, or socioeconomic factors ( https://www.healthypeople.gov/2020/tools-resources/evidence-based-resource/bright-futures-guidelines-for-health-supervision-of ). With release of the third edition in 2008, the American Academy of Pediatrics (AAP)’s Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents became recognized as the standard for recommendations on preventive care of children. In 2010, the Patient Protection and Affordable Care Act was passed into law and included a provision that all children receive the standard of preventive screenings and services, as recommended in the third edition of the AAP’s Bright Futures Guidelines .
In 1930, the AAP formed when the pediatric section of the American Medical Association (AMA) broke away. The American Board of Pediatrics was founded in 1933 with the goal of raising standards of pediatric care in the United States. The first pediatric board examination was administered in 1934. In 1965, Henry Silver, MD, and Loretta Ford founded the nurse practitioner (NP) profession by creating a pediatric nurse practitioner (PNP) program at the University of Colorado. Three years after the first physician assistant (PA) program was founded at Duke University in 1965, Dr. Silver created the Child Health Associate program at the University of Colorado School of Medicine. This program, based on the PA model, offered specialty training in pediatrics and was the first PA program to confer a master’s degree.
Pediatric Rotations
All Physician Assistant students are assigned to a required pediatric rotation/experience during their clinical year. A key purpose of this chapter is to prepare students for this experience. Pediatric clinical rotations take place in a wide range of settings including ambulatory experiences in group and private practices, community health centers, public health settings and school based clinics. Hospital-based pediatrics experiences are found in children’s hospitals,academic health centers, community hospitals, and charity-funded settings andspecialty hospitals. What all of these rotations and experiences have in common is that the care of pediatric patients also includes involvement with their families, their cultural environment and their socioeconomic status—which includes their access (or lack of access) to health care. Table 28-1 . provides on-line resources on pediatric topics. The sections in this chapter provide detailed clinical information which will be useful across the pediatric experience.
Well Child Visits and Immunizations
The periodic evaluation of a well child is the cornerstone of pediatric primary care practice. From birth through adolescence, the growth and development of children is a complex and variable process that requires frequent monitoring and preventive intervention. The AAP’s Bright Futures guidelines recommends no fewer than 10 scheduled well-care visits between birth and age 2 years and yearly visits through adolescence. Even with this frequency of visits, pediatric PAs are challenged to cover all of the necessary tasks in each 15- to 30-minute visit. At each well-care visit, the pediatric patient must be evaluated for disease and screened for problems with nutrition, growth, and development, and appropriate counseling should be delivered on prevention and health promotion. Particularly in the early childhood years, immunizations are a key feature of every well-child visits. Frequently changing and updated, the American Academy of Pediatric’s recommended schedule, Bright Futures can be accessed at www.aap/en.us . For children with developmental disabilities or chronic illness, extra time should be planned for the well-care visit.
The approach to the physical examination of the child depends on the age, verbal capacity, and cooperativeness of the patient. With preverbal children, typically birth through age 2 or 3 years, careful observation of the child for developmentally appropriate behaviors, including interactions with the caregiver, is an important component of the examination and should be accomplished before approaching or touching the child. Children often develop stranger anxiety beginning between 6 and 12 months of age and persisting until age 2 or 3 years. It is important to develop strategies for examining a child who is quite apprehensive. Use a soothing, calm voice and slower movements. It may be helpful to approach at eye level rather than from above, and with most children in this age group, it is best to perform most elements of the physical examination with the child in the caregiver’s lap. The sequence of the examination is best approached case by case, and the PA should take advantage of opportunities unique to this age group. For example, with a sleeping infant, auscultation of the heart and chest with a warmed stethoscope may yield excellent results without waking the child. The most invasive examinations such as the ear and throat examination should be reserved to the end of the examination for this age group. It is important to prevent the child from moving while the otoscope tip is in the auditory canal; therefore, take extra care that the child is properly restrained either against the caregiver’s shoulder or chest. If the caregiver is not able to effectively hold the child, the ear examination is probably best done on the examination table with the child restrained on his or her side by a caregiver. The knee-to-knee position is helpful for examining the oropharynx of young children. The provider should sit facing the caregiver with his or her knees close together, forming a “table” on which to lay the child. The caregiver initially holds the child on the lap facing him or her and then lays the child back so that the child’s head lies in the lap of the provider. The examination of the oropharynx is generally viewed as invasive by most small children, so this examination position is helpful in reducing their anxiety.
An alternative to the knee-to-knee position in an apprehensive child is to lay the child on the examination table with a caregiver holding the child’s arms above his or her head with the elbows positioned against the ears so the child’s head cannot move side to side. Many young children will clench their teeth together to prevent the tongue blade from entering their mouths. Because young children do not have a second molar, it is very effective to slide a tongue blade, held on its side, into the mouth between the teeth and buccal mucosa and then turn the blade so it is flat when it is at the back of the teeth and move it through the gap between their mandible and maxilla directly onto the base of the tongue. This will elicit a gag reflex and allow an opportunity for a quick look at the child’s pharynx.
A 19-month-old boy is in the clinic for a well-child care visit. As you enter the examination room, the child begins screaming and struggling in his mother’s arms. When you attempt to get closer to the child, he begins to kick his legs, trying to crawl up higher in his mother’s arms. The mother seems frustrated and is having difficulty holding him. What strategies might help you complete a physical examination on this boy?
Preschool-aged children (aged 3–5 years) are generally cooperative and curious and may engage in the visit without protest. It is often helpful to engage the child in conversation or tell a story while performing the examination. Allowing the child to hold the stethoscope or other diagnostic equipment, demonstrating the examination techniques on yourself, an older sibling, or a doll, and encouraging engagement of the parent or other caregivers are strategies that can help alleviate apprehensiveness. When possible, attempt to make the examination fun for the child using toys or games. Some children may have unpleasant memories associated with previous visits or anxiety about immunizations or other painful procedures. Unusual reticence or avoidance at this age warrants additional investigation to determine if the child is reaching age-appropriate developmental milestones or has been the victim of child abuse. Most children develop modesty around age 4 or 5 years, so the provider should expect some reluctance to remove the gown or clothing. This is an excellent opportunity for the provider to engage the child and caregiver in a discussion around teaching the child appropriate interaction with adults that protect the child from becoming a victim of sexual abuse.
School-aged children (5–10 years) are typically easy to engage in conversation, and the PA will find few barriers to performing a thorough and thoughtful evaluation in this age group. It is very important to establish rapport with children in this age range while appreciating that modesty is very important to many school-aged children. Allowing the child to disrobe out of sight of others and offering appropriate gowning and draping can help to develop trust and maintain modesty. An important component to the pediatric well visit that begins in this age range is the assessment of school performance or any school-based concerns. Addressing school performance issues and any school-based social concerns early and directing caregivers to resources may be helpful in preventing self-esteem and school avoidance issues in the future. See Table 28.1 for resources.
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