The Pediatric Examination

LEARNING OBJECTIVES	PROCEDURES
Pediatric Office Visits
1. List the components of the well-child visit. 2. State the usual schedule for well-child visits. 3. Explain the purpose of the sick-child visit. 4. List the procedures performed by the medical assistant during pediatric office visits. 5. Explain why it is important to develop a rapport with the pediatric patient.	Carry an infant using the following positions: Cradle Upright
Growth Measurements
6. State the importance of measuring the child’s weight, height (or length), and head circumference during each office visit. 7. State the functions served by a growth chart.	Plot pediatric growth values on a growth chart. Measure the weight and length of an infant. Measure the head and chest circumference of an infant.
Pediatric Blood Pressure Measurement
8. State the importance of measuring a child’s blood pressure. 9. List the three factors that determine whether a child has hypertension.	Measure the blood pressure of a child.
Collection of a Urine Specimen
10. List the reasons for collecting a urine specimen from a child.	Collect a urine specimen using a pediatric urine collector.
Pediatric Injections
11. State the range for the gauge and length of needles used for intramuscular and subcutaneous pediatric injections. 12. Explain the use of each of the following pediatric injection sites: vastus lateralis and deltoid.	Locate the following pediatric intramuscular injection sites: Vastus lateralis Deltoid Administer an intramuscular injection to an infant. Administer a subcutaneous injection to an infant.
Immunizations
13. Describe the schedule for immunization of infants and children recommended by the American Academy of Pediatrics. 14. State the information that must be provided to parents as required by the National Childhood Vaccine Injury Act. 15. List the information that must be recorded in the medical record after administering an immunization.	Read and interpret a vaccine information statement. Record information on an immunization administration record.
Newborn Screening Test
16. Explain the purpose of a newborn screening test. 17. List the symptoms of phenylketonuria. 18. State what occurs if phenylketonuria is left untreated.

Introduction to the Pediatric Examination

Pediatrics is the branch of medicine that deals with the care and development of children and the diagnosis and treatment of diseases in children. A pediatrician is a physician who specializes in pediatrics. Many physicians in general practice accept pediatric patients. It is essential that the medical assistant develop the skills needed to assist the physician in the care and treatment of children.

Pediatric Office Visits

There are two broad categories of pediatric patient office visits. The first is the well-child visit (also termed health maintenance visit), in which the physician progressively evaluates the growth and development of the child. A physical examination is performed during each well-child visit and is directed toward discovering any abnormal conditions commonly associated with the stage of development reached by the child. Table 24-1 provides an outline of normal development during infancy. The child also receives necessary immunizations during these visits.

Table 24-1

Milestones of Gross and Fine Motor Development in Infancy

Average Age (mo)	Gross Motor	Fine Motor
1	Turns head from side to side	Grasping reflex present
2	Holds head at 45-degree angle when prone	Holds rattle briefly
3	Begins rolling over	Grasps rattle or dangling objects
4	Slight head lag when pulled to sitting position	Brings objects to mouth
5	No head wobble when held in sitting position	Transfers objects from hand to hand
6	Sits without support	Manipulates and examines large objects with hands
7	Stands while holding on	Reaches for, grabs, and retains object
8	Pulls self to stand	Grasps objects with thumb and finger
9	Crawls backward	Begins to show hand preference
10	Creeps on hands and knees	Hits cup with spoon
11	Walks using furniture for support	Picks up small objects with thumb and forefinger (pincer grasp)
12	Stands alone easily	Puts three or more objects into container
12-16	Walks alone easily	Turns two or three pages in large cardboard book

From Leahy JM, Kizilay PE: Foundations of nursing practice, Philadelphia, 1998, Saunders.

Another important component of the well-child visit is anticipatory guidance. Anticipatory guidance is the process of providing parents with information to prepare them for anticipated developmental events and to assist them in promoting their children’s well-being. Topics that are commonly included are safety, nutrition, sleep, play, exercise, development, and discipline.

The interval between well-child visits depends on the medical office, but it frequently follows this schedule after birth: 1 month, 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months, 24 months, and yearly thereafter.

The second category of pediatric patient office visits is the sick-child visit. The child is exhibiting the signs and symptoms of disease, and the physician evaluates the patient’s condition to arrive at a diagnosis and to prescribe treatment.

During well-child and sick-child visits, the medical assistant performs many of the same procedures that have been presented in previous chapters (e.g., measurement of temperature, pulse, respiration, and blood pressure; measurement of weight and height; measurement of visual acuity; assisting with the physical examination). This chapter discusses procedures specifically related to the pediatric patient and variations in procedures previously presented.

What Would You Do? What Would You Not Do?

Case Study 1

My-Lai Chang comes into the office with Christopher Chang, her 2-month-old son. Christopher is here for his 2-month well-child visit. Mrs. Chang is very distraught. She says that Christopher has episodes of nonstop crying every day that last 2 to 3 hours at a time. She is breastfeeding Christopher and says that the crying is worse after he nurses. Although Mrs. Chang realizes that Christopher has colic, she feels guilty because it seems “her milk” is making it worse. She also is having problems with sore nipples and engorgement. She really wanted to breastfeed Christopher, but she is thinking of stopping because it just seems too hard to do. Christopher measures in the 50th percentile for weight and length. Mrs. Chang is worried that he is not growing enough and thinks it is because she is not producing enough milk.

Developing A Rapport

The medical assistant must establish a rapport with the pediatric patient. If the medical assistant gains the child’s trust and confidence, the child is likely to cooperate during an examination or procedure. Interacting with children requires special techniques. The techniques employed depend on the age of the child. Toddlers and preschool children often respond well to making a game of the procedure. Explaining the purpose of an instrument (e.g., the stethoscope) to a school-age child and allowing him or her to hold the instrument or even to help during the procedure may overcome fears in that age group (Figure 24-1).

Figure 24-1 The medical assistant should develop a rapport with children to gain their trust and cooperation. Making a game of the procedure **(A)** and explaining the purpose of the stethoscope and allowing the child to hold it **(B)** help the child overcome fears.

The medical assistant should always explain the procedure to children who are able to understand. Each child must be approached at his or her level of understanding. To do this, the medical assistant should know what to expect from a child at a particular age, in terms of motor and social development. Each child has his or her own individual rate of development; the descriptions of normal development based on age are meant to serve as a guide only and may have to be modified to meet individual needs. In addition, it is normal for an ill child to regress to an earlier level of behavior. Table 24-2 outlines techniques that can be used with various age groups to gain their cooperation during an examination or procedure.

Table 24-2

Techniques for Interaction with Children

Technique	Infant (Birth-1 yr)	Toddler (1-3 yr)	Preschool (3-6 yr)	School Age (6-12 yr)	Adolescent (12-18 yr)
Avoid sudden motion and loud or abrupt noises.
Limit number of strangers in room.
Use distractions, bright objects, rattles, and talking to gain cooperation.
Physically restrain child if necessary to ensure safety.
Allow physical contact with parent during procedure.
Encourage parent to comfort child after procedure.
Use play to explain procedure (e.g., dolls, puppets).
Perform procedures quickly, if possible.
Use concrete terms, rather than abstract terms.
Avoid words that have more than one meaning (e.g., shot).
Give child permission to cry, yell, or otherwise express pain verbally.
Praise child for cooperative behavior.
Allow child to handle equipment, if possible.
Make sure child understands body part to be involved.
Try to describe how procedure will feel.
Tell child about any discomfort that may be felt, but don’t dwell on it.
Stress benefits of anything child may find pleasurable afterward (e.g., stickers, feeling better).
Give child choices when possible (e.g., arm to use).
Suggest ways to maintain control (e.g., counting, deep breathing, relaxation).
Use drawing and diagrams to illustrate parts of body that will be involved.
Encourage participation such as holding instrument during procedure.
Include child in decision-making process.
Discuss risks of procedure.
Provide information about appearance changes that might result.
Give child educational brochures or have him or her view videos about procedure.
Ask parent to step out if child does not want parent in examining room.