Pearls and Pitfalls of Pediatric Assessment: Secrets for Approaching Children in the Emergency Department
Pearls and Pitfalls of Pediatric Assessment: Secrets for Approaching Children in the Emergency Department
Authors: Mark Lopez, MD, FAAEM, FACEP, Assistant Professor, Departments of Emergency Medicine and Pediatrics, Section of Pediatric Emergency Medicine, Medical College of Georgia, Augusta; and Larry B. Mellick, MD, FAAP, FACEP, Professor, Departments of Emergency Medicine and Pediatrics, Section of Pediatric Emergency Medicine, Medical College of Georgia, Augusta.
Peer Reviewers: Steven Krug, MD, Professor of Pediatrics, Northwestern University's Feinberg School of Medicine, Chicago, IL; and Steven Winograd, MD, FACEP, Adena Regional Medical Center, Chillicothe, OH.
While children typically have a lower severity of illness than their adult counterparts during visits to the emergency department (ED), they also present with some of the most serious illnesses.1 Furthermore, there are a wide range of possible illnesses with potentially devastating outcomes for children.2,3 Unfortunately, the relative rarity of critically ill or injured children means that clinical experience potentially may be lacking or even atrophied over time. This clinical inexperience coupled with the unique management issues of children has the potential to create some degree of uneasiness in even the most experienced emergency physicians and prehospital providers. In that 20-40% of patients presenting to the ED are children, a level of comfort on the part of the health care provider is essential.4
The treating physician must make cognitive adjustments in approach when managing the pediatric patient.4 For example, when considering a chief complaint, a significantly different spectrum of diseases must be considered as compared to adults while allowing for overlap. A well-thought-out and practiced approach in the evaluation of children can reduce everyone's stress and maximize the quality of emergency medical care.
Even though the majority of childhood illnesses are not life-threatening, misdiagnosis and poor physician-patient interaction can have undesirable clinical and medico-legal consequences. If an uncooperative pediatric patient and distraught parents are merged with an apprehensive health care giver, significant obstacles to care can unfold. These dynamics may increase the risk for errors in the ED.6
—The Editor
Special Characteristics of Children
The clinician must interpret the symptoms of a sick child within the context of the child's unique personality and temperament. Temperament is another way to describe behavioral differences in emotion. It can be apparent in the newborn period and continue through adulthood. Temperament is the personal style and way of interacting with, or responding to, the environment. Flexible children have a generally positive mood and adapt quickly to their environment. Fearful or cautious children are slower to adapt to the environment and will be shy in new situations. They tend to seek out the caregiver and require the security of the parent's proximity and more time to adapt to new situations. The final type, so-called feisty or difficult children, may be active, intense in their reactions, distractible, sensitive, irregular in biological rhythms, and moody. They tend to be demanding on their environment and caregivers. They require special attention to adapt to new situations.7
The caregiver's report often can be helpful to the examiner. If a child usually is socially withdrawn, he or she may seem unusually quiet, causing concern to the examiner. Knowing that this is the child's underlying temperament can be helpful. Likewise, an ill child who normally is more interactive may be mistaken as shy during the exam, or a hungry infant may appear excessively irritable. Finally, children often are less cooperative or responsive during the time of day when they usually nap. Sleepiness can make them appear confused, intoxicated, or lethargic.
Parent-Child Attachment
The quality of the parent-child attachment influences the child's level of security and may influence the presentation. Crittenden and Ainsworth classified three different parent-child attachment relationships: Secure, insecure avoidant, and insecure ambivalent.8 In a secure attachment, the caregivers are responsive to the infant's signals, emotionally available, display a warm and accepting attitude, and have a continuous relationship that isn't interrupted by long separations. As the infants get older, they use the parents as a secure base for support in exploration of the environment. The child is assured that his or her needs will be met and thus is free to explore.
In an insecure avoidant relationship, the caregivers are inaccessible, unresponsive, or inappropriately responsive to the infant's cues. The caregiver may withhold close bodily contact. Infants in these relationships show little distress when removed from the caregivers and may ignore them upon reunion. Instead of focusing on people, these infants may focus on inanimate objects since experiences have caused them to distrust that their needs will be met.
In the final type, insecure ambivalent, the infants cannot predict when their needs will be met since their caregivers are intermittently inaccessible, unresponsive, or inappropriately responsive. They learn that their bids for attention may be thwarted and they approach the caregiver with anger or ambivalence. They tend to be anxious and hypervigilant for any indication that their caregiver is leaving them and may be inconsolable even when their needs are met.
Emotional Regulation and Self-Control
In addition to the parent-child attachment, emotional regulation and self-control factors can influence the presentation or examination. There are several key components to emotional regulation, including attention processes, social communication, and neuroendocrine functioning.7 This is linked to positive social development and the care-giving environment, especially during infancy. Cortisol is the primary hormone that is associated with activation of the central nervous system during times of stress.7
Developing the ability to regulate emotions is an important task of early childhood. It is shaped by temperament as well as the caregiver's relationship. Deficits in emotional and behavioral regulation may underlie most forms of child psychopathology.7 However, as children grow older they can use their cognitive abilities to modulate their behavior.
Chronology of Developmental Periods
When evaluating children in the ED, it is helpful to understand the characteristics of children at different developmental stages. The following section addresses the major milestones and characteristics of children at different ages.
Birth to 2 Years. The major tasks in this age range are the regulation of diurnal cycles, autonomic and motor systems, and transitions in their state of alertness. Full-term infants can become alert for brief periods and fixate on caregivers' faces. In the following weeks, the period of alertness increases and attention improves. By three months, infants can differentiate their response between their primary caregivers and other adults.
During the first 15 months, infants develop head and trunk control and the abilities to roll over, crawl, pull up to standing, and finally to walk. They develop the understanding of words and phrases and can evoke changes in their environment with gestures and words.
Their relationship with their caregivers matures to include reciprocal exchanges. They develop object permanence around 9-12 months. Object permanence is the child's ability to understand that objects exist independently from the child. Prior to attaining object permanence, an infant will not search out a dropped toy. During this developmental period, anxiety and distress are displayed when the caregivers are absent (separation anxiety). This typically is manifested by the child clinging to his or her parents with the approach of strangers.
Preschool: 2 to 5 Years. The important tasks in this time period are maturation of language and communication skills, socialization, and understanding of social customs. They also develop "magical thinking," sexual curiosity, and better self-control.
Preschoolers have a preoperational approach to thinking and therefore may seem egocentric as they often cannot perceive another point of view. They learn best through seeing and touching. They begin with parallel play and then move on to interactive play as well as fantasy. They imitate their environment to enhance learning.
While their caregivers continue to maintain a central role, children at this age gain a sense of independence through interactions with other children and adults. This leads to trying things on their own. When their independence is threatened, they exhibit frustration with strong emotional responses. Nevertheless, personal boundaries eventually are developed, preparing them for functioning in more independent situations.
Elementary School: 6 to 11 Years. During this chronological period, the primary tasks include the acquisition of symbol-associative learning, rule-governed play, awareness of social expectations, and more complex cognition. Children at this age think in terms of realistic or concrete operations. They typically show a lot of initiative in learning, which adds to their self-esteem. Play is more complex, and they can follow complex rules. It is during this time that attention deficit hyperactivity disorder (ADHD) and mood disorders are manifested.
Adolescence: 12 to 20 Years. Principal tasks in this time period include rapid biologic and physical changes and the ability to think abstractly and hypothetically. Adolescents have an increased ability to monitor their own thoughts and emotions that can lead to an egocentric thinking style. This can lead to risky behaviors since they believe themselves to be invincible.
Socially, they lose their early childhood attachments and interactions with their parents and develop a relationship that is on a more equal level. They spend more time with peers, allowing for identity exploration, autonomy development, and appropriate sexual socialization. Interpersonal intimacy becomes more important than the need for acceptance.
Barriers to Caring for Infants and Children
Both sides involved in the clinical interface may enter into the interaction with some degree of angst. While children may be distrustful of the unfamiliar surroundings, sights, sounds, and smells, their parents/caretakers may experience confusion and distrust with procedural aspects of the ED. These care-related barriers can be temporary stumbling blocks for both the health care provider and those seeking care.
Physician's Psyche. The treating physician's level of clinical equanimity and confidence is an important element contributing to the effective management of pediatric emergencies. In fact, some physicians seem better suited to deal with children. They have an intuitive feel for kids that helps them establish an immediate and productive rapport. In contrast, others may not be as kid competent and, consequently, have difficulty gleaning important historical and physical pearls required to formulate an accurate diagnosis. Some even may have an irrational fear of hurting the child or concern over losing emotional control in the face of a stressful situation. These distracting fears may sidetrack the health care provider from noting important but subtle physiological signs.
Society views the death of a child as premature and tragic with unfulfilled opportunities.9 For the emergency physician with an awareness that illnesses in the very young can deteriorate quickly, a distracting level of apprehension can develop when the child is critically ill. Furthermore, awareness of the child's impending death, disability, or poor prognosis also can compromise an effective response. If the consequences arise from misdiagnosis or suboptimal therapy, the possibility is even more likely.
Countertransference. Countertransference, or the physician's emotional response to the patient and his or her family, can be-come a barrier during the assessment of the child. In the face of demonstrations of temper or anger from the parent or child, reactive hostility can be provoked from the health care provider. While it may be tempting to respond in a reciprocal manner, such emotional responses interfere with the success of a clinical evaluation.
Practitioner Defense Mechanisms. While defense mechanisms may be normal responses to stress, they potentially may interfere with sound clinical judgment. For example, one common defense mechanism, denial, can be propagated by emotionally unacceptable circumstances causing one to underestimate the severity of a child's illness or to ignore subtle warnings signs.
Distracting Frustrations. In the midst of the encounter other distractions can wear down the emergency physician's professional bearing. The crying child and distraught family as well as non-productive responses by other team members can push the physician into less fruitful performance patterns. Additionally, parents instinctually react to protect their children from perceived harm, which sometimes may lead them to get into the way of ongoing care. Family religious views and personal biases also can impede diagnostic evaluation and therapeutic interventions.10,11 The lack of nursing experience or comfort with children also may try the physician's equanimity. Finally, a clinical setting not adequately prepared to handle pediatric patients may lead to the unraveling of emergency care delivery. Inadequate equipment or resources not suited for the care of children are significant problems that can interrupt care delivery while the practitioner attempts to find suitable clinical tools. Finally, a lack of ready reference materials can interfere with efficient emergency care. Dosage handbooks and pediatric texts must be readily available in the ED libraries to allow practitioners efficient access to critical information. Personal digital assistants (PDAs) with pediatric references are other valuable and efficient information resources.16,17
Barriers to Communication
Data Collection. Even though history acquisition sometimes is difficult, the physician should not be deterred from taking a thorough and complete history. The physician who can reassure as well as steadfastly interview the anxious, scattered, upset, or inarticulate caregiver will have the most success. At times, it may be necessary to seek out the best historian (child, parent, caregiver, or baby sitter) to obtain a reliable and accurate history of present illness.
Obtaining an accurate history from a child often is challenging and is inversely proportional to the child's age. Infants, toddlers, and preschoolers are limited in their ability to verbalize and localize their pain and concerns. Therefore, the role of parents or guardians is crucial in constructing an accurate history of present illness. Once children reach school age (5-10 years of age) they are better at communicating their symptoms. However, information distortions still may occur secondary to pain, fear, anxiety, and guilt, and supplementary information from the parent still is needed.
Children are most responsive and interactive when their environment engenders trust. The physician's body language and speech should project a kind, calm, and soothing demeanor. The parents also may help calm the child and should be included as often as possible. Finally, use age-appropriate and culturally appropriate words and terms to elicit answers. If the child doesn't understand, allow the parent to rephrase it for you. If language barriers exist, use resources for language translation.
Pitfalls in the History
Parents and other caregivers on occasion can provide the interviewing physician with unreliable historical accounts. An over-emphasis on specific information or innocent exaggeration may occur. A report of "vomiting all day," when clarified, in reality might be only four episodes throughout the entire day.
The other extreme may be caused by parental defense mechanisms or lack of experience. Inexperienced or medically naive parents may not know what symptoms to look for nor how to gauge behavioral changes indicative of a serious ailment or deterioration. This may cause them to underestimate the symptoms or present a benign rendering of the sequence of events that led to the traumatic incident or clinical deterioration. Other parents simply may be poor historians or inattentive observers.
For some, family finances or the necessity of working parents can lead to a presentation delay.18 On occasion under- or non-insured families are influenced by their finances and may wait out an illness in hopes of avoiding a costly medical bill. When they finally do present, the gravity of the complaint may be downplayed in a face-saving manner. Working parents, on the other hand, may find themselves relaying information reported to them by day-care center employees or other baby sitters. Their informants themselves may be poor historians if they are young and inexperienced. Consequently, a full and accurate account may not be presented during this multi-layered transfer of information.
Practical Clinical Strategies
General Principles. The clinician's assessment should approach the child from an age and developmentally appropriate perspective. (See Table 1.) The ED physician who understands the fears and anxieties particular to each stage of development will be able to adjust the approach accordingly. Infants and toddlers typically manifest stranger anxiety that can be intensified by the white coats and scrubs of the medical staff or the gear of the rescue personnel. The practitioner should use age-specific techniques to allay these and other specific anxieties of the patient. For example, keeping the parent or caregiver in the visual field of infants or toddlers often will abate their fears. Also, maintaining an ongoing verbal rapport with pre-schoolers, such as discussing a favorite television character, potentially may distract them from painful interventions such as venipunctures. Play therapists or volunteers can be especially successful in calming a child's fears by talking or playing with bubble machines or toys. Children as young as 2 or 3 years may appreciate demonstrations of respect for their dignity and modesty. The inclusion of children in discussions of their illness and evaluation also is beneficial at times. Adolescents, especially, will be more willing and cooperative if they are allowed to participate in their medical care.
Including the parents or caregivers in the process nearly always can facilitate the examination and procedures needed. Knowing what to expect and trusting in the competency of the care staff will allow parents to contribute in even the most challenging situations. Nevertheless, direct and specific guidance and sometimes encouragement to be a strong, stabilizing force sometimes is needed. Even parents who typically may become vasovagal during their own venipunctures are able to support their child during a laceration repair. Nevertheless, it always is advisable to have the parents seated during procedures to prevent any events or injuries. If a child's caretakers are unable or unwilling to help, a nurse, play therapist, or volunteer can assume this role. It also is advisable to have someone available to explain to the caregiver what is going on during the procedure or resuscitation.
In the case of a resuscitation, many parents want to be present and can give support to the child. While the sequence of events involved in a resuscitation may be frightening to the parents, they may feel the need to be near their child at possibly the last minutes of their lives. This experience can give them closure or allow them to see the aggressive medical care provided by the resuscitation team. This, however, requires someone specifically assigned to stay at the parents' side, to explain events to them, and to keep them updated (e.g., clergy, trained volunteers, or administrators).22,23
Pain Management. Pain management for children is another area where there is room for improvement.23,24 Studies have demonstrated that analgesia administration in the ED often is inadequate.25 This may be especially true in the ED where emergency physicians grow accustomed to crying children. Differentiating between tears associated with pain vs. fear of new surroundings is not easy in a child with limited verbal skills. For this and other reasons, observers have noted that some physicians may fail to treat the pain of infants and toddlers who cannot localize their pain.26 Pain assessment tools such as the Wong-Baker FACES Pain Rating Scale may be useful in children as young as 3 years.27,28 (See Figure 1.)
| Figure 1. Wong-Baker FACES Pain Rating Scale |
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If the child needs a surgical consult (e.g., acute abdominal pain), there is less of a tendency to provide adequate pain control.29 The control of and therapeutic response to physical distress also may be compromised because emergency physicians are trained to deal with life-threatening emergencies before turning their attention to pain control. Nevertheless, children are not alone when it comes to less-than-timely pain management.26
In recent years, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has issued new pain management standards that require physicians to better document their treatment decisions. The standards emphasize that pain requires explicit attention and they require accredited health care organizations to recognize patient rights to appropriate assessment and management of pain; to have the nature and intensity of their pain assessed; and, among other things, to record the results of the assessment in a way that facilitates regular reassessment and follow-up.30 With greater knowledge, sensitivity, and awareness in this area, pain management may be improved.
Setting or Environment. The actual physical environment affects the child patient and the presentation. A cold exam room potentially may agitate the infant and change the child's heart rate as well as skin appearance (mottling). The simplest approach is to allow the child to stay fully clothed until the examination begins or to provide warm blankets.
The child's emotional environment cannot be overlooked. A child brought to the ED by someone other than parents can experience increased emotional distress. Despite their best intentions, the paramedics, school nurse, or baby sitter may not be able to provide the emotional environment needed by the child.
Auditory buffering of the patient from loud or frightening sounds also is extremely important. The sounds of other patients in pain or vomiting may cause levels of apprehension that can complicate the evaluation. This especially is true of older children, as they may feel that they are vulnerable and next to experience pain. If feasible, closing the door when performing a procedure such as phlebotomy is another simple but easily overlooked solution.
Finally, it generally is assumed that a room's colors and decor can be emotionally soothing to a child. A room with colorful or playful images and familiar storybook or cartoon characters on the walls can make the environment feel more comforting.
Emergency Health Care Goals. Emergency physicians should approach every pediatric patient with two primary questions in mind. First, does the child appear sick or toxic, or is there evidence of a serious or life-threatening illness (i.e., what do I see when I walk in the room)? Second, once the level of illness severity is assessed, what is the most appropriate treatment algorithm for this child (i.e., airway management, evaluation for sepsis, trauma team activation)?
Once these two primary decision pathways are completed, the physician can move on to decipher the specific etiology of the child's illness and presentation. It is preferable to err on the side of caution with a reasonably aggressive diagnostic process. This often includes creating a comprehensive database to rule out or confirm whether life-threatening or other more challenging conditions are in the differential diagnosis. If evaluation by a subspecialist or admission to the hospital is needed to fully elucidate the problem, then the physician should not hesitate to utilize these resources.
History. The art of efficiently acquiring an accurate history is a fundamental part of the pediatric assessment. The caretaker and the child's complaint may not reflect the organ system involved (i.e., crying) or may distract the physician from the actual area of concern. An accurate history should include the evolution of the present illness or, in the case of trauma, the circumstances that led up to the event.
In the ideal pediatric core history, information will be included concerning prenatal, birth, postnatal, allergies, past medical conditions, family medical history, medications, weight, immunization status, development, and medical conditions. (See Table 2.) The complete compilation of this information may not always be practical, but can yield valuable clues to the current illness.
Fever is one of the most common complaints for a child in the ED. A simple list of questions can focus the complaint and start a database for the emergency nurse and physician. (See Table 3.)
The evaluation of children with special needs can be especially challenging. Differentiating what elements are new in their current clinical presentation from chronic disease features often is difficult to ascertain. Here again, the child's caregivers must be relied upon to help. Another source is the nursing staff or medical records, since these children tend to be frequent visitors to the ED.
Differential Diagnosis. Physicians caring for children in the ED must be able to formulate a differential diagnosis based on the chief complain and pertinent history that also is focused to the age group of the child. Specific life-threatening situations should be considered as well as the common etiologies for the complaint in the context of the child's chronological age. This is the end result of a good history and physical with attention to the specific attributes of the child in question.
While fever is a common complaint for presentation to the ED, the cause of the fever and its workup vary by age group.31 The evaluation and management of the febrile child continues to evolve as a result of research, and the introduction of Haemophilus influenzae type b (HIB) and Streptococcus pneumoniae vaccines. The incidence of serious bacterial infections appears to have decreased significantly. Earlier studies established infants aged younger than 90 days as a distinct age group for diagnostic and treatment procedures.32-34 In an infant younger than 1 month of age, fever requires a workup to exclude the diagnoses of sepsis, meningitis, and other serious infections. Regardless of the age cutoff chosen, it is important to recognize that no age cutoff is absolute and should be considered a point on a continuum of growth and maturation.35
Optimal Examination and Observation
Techniques
Cooperation. The ideal setting for the pediatric assessment requires the full cooperation from the child patient as well as from the caregivers. This is not always possible. Therefore, the select use of observation tools as well as adjustments to the environment can be valuable. Crying seems to impact the observation process the most. Children who are crying may appear sicker than they actually are, vital signs will be abnormal (these should be documented as such in association with crying), and the family may be more tense and fearful. It often is fruitful to take the time to console the crying child. Distracting interventions such as toys or dolls can be useful to calm the child. An infant may be settled by breast or bottle-feeding during the exam. If necessary, the examiner can leave the room and observe from a distance while the child interacts with familiar people or caregivers.
Adjustments to the Initial Assessment. To make an accurate initial assessment, the examiner may need to wait until adjustments are made to the child's environment and emotional state. If the child is not severely ill, an observation period may be prudent. During that time, the febrile child may be given 15 mg/kg of acetaminophen or 10 mg/kg of ibuprofen and then reassessed. Sponging with tepid water also may be used to help control the fever, but this may cause more distress to the patient. Sponging has not been found to be more effective than fever-reducing medications.36 Acetaminophen and ibuprofen can be used to achieve better control of the fever; however, some literature suggests this is no more effective than one agent alone.37 Once the child's fever is lowered, the examiner can reassess the child's appearance and vital signs. This may lead to a broadening or narrowing of the differential.
Observation. Ideally, practitioners should begin the observation part of the exam from the moment the child enters the ED. The interaction between the child and the caregiver can give a clue as to the state of illness. A child observed from afar laughing and playing with the caregiver is more reassuring in terms of the extent of illness. The child may become frightened when the examiner approaches; therefore, repeated observations and multiple visits to the room are useful.
Previously described clinical assessment tools, such as the Yale Observation Scale, and risk stratification tools, such as the Rochester Criteria and the Philadelphia Protocol, are potential adjuncts to the observation process of febrile infants.38,39 These tools can provide objective data to augment decision-making based on clinical observations. While it clearly has been demonstrated that the Yale Observation Scale does not adequately define patients with occult bacteremia or serious illness, other evidence supports that clinical observations in general do benefit in assessing a child's demonstrated severity of illness or level of toxicity.40-45
Examiner Presentation. A physician who enters the examination room with a manner that is warm, friendly, cheerful, and enthusiastic will improve the receptivity of many children. When needed, soothing, gentle vocalization can have a calming effect. In some circumstances a level of showmanship as manifested by exaggerated facial expressions, gestures, or sounds also can ease the child.
Visual interaction is a developmental characteristic. An infant younger than 12 months may smile as a purely social behavior. An older infant sometimes will smile to establish a friendly encounter. If over-stimulated, the infant then will turn away so as to control the level of excitement while maintaining peripheral visual contact. When the child regains control, the eye contact returns. Attempts to regain the visual interaction when the child has turned away may result in objections from the infant.
It is common for children to be apprehensive at the initial entrance of the examiner. A brief initial greeting to the child is received better than an extended welcome.46 In fact, if the health care provider immediately looks intently at the child, the child may withdraw, and the initial rapport will be lost. Quiet introductions while making sure that the initial contact is with the caretaker (maintaining only peripheral visual interaction with the child) will achieve a more positive response from some children.
Distractions. A child's immature nervous system and level of development make him or her more susceptible to distractions. Newborns will react to lights, sounds, and faces. Older children may respond to a toy, a penlight, or a character attached to the examiner's stethoscope. During the brief periods of distraction, the examiner can assess the overall wellness of the child. The inability to distract the child may itself be an indicator of a more serious illness.
Toddlers and older children may respond to a conversation about their favorite characters or television shows. These diversionary topics should include subjects of specific interest to the child. The particular interest can be gathered quickly from a doll the child is carrying, a character on clothing, or from something the caregiver might say. Looking for Elmo or a dinosaur in the child's ear, asking, "Do I have a big nose?" while examining the reactivity of the child's pupils, or pointing to the belly button and asking "What is this?" to assess meningismus are other potentially useful tricks of the trade.
Tactile Techniques. Eventually during the examination process, the examiner needs to make physical contact with the child. This physical contact often is anxiety provoking to the child. If the examiner rushes for the examination, there likely will be more resistance, the exam will be suboptimal, and the confidence in the examiner from both the child and the parent may be diminished. The examiner can help the situation by ensuring that both hands and stethoscope are warm. Rubbing the stethoscope on the lab coat will warm the instrument. Rubbing one's hands or washing them in warm water will make them much more acceptable to the child.
It can take a few moments to gain the acceptance of the child. Since the face is viewed as the most vulnerable part of the body, it is best to start as far away from the child's face as possible. The physician first can examine the feet, legs, and hands, and then the back. The abdomen, chest, and finally the head and face should follow. The examiner can have the child hold the stethoscope to minimize its scary potential. The same is true with the otoscope. Children can look in the examiner's ear, one of the parents' ears, or hold the scope to their own ears for the examiner.
Examination Techniques. Low-impact restraint and coercion usually are more successful than assertive techniques. One can start by examining the child in the arms of the caretaker, thus preserving the child's comfort level. Allowing the exam to proceed on the parent's lap or in the least intrusive manner will preserve a thorough and clinically useful examination. The child may accept the otoscope, tongue blade, etc., from the examiner if it passes through the parent first. The parent then can encourage the child to try it.
There are times, however, when low-impact techniques may not be possible. For example, in the trauma setting it is necessary to quickly assess for serious injuries, and aggressive restraint is mandatory. However, the removal of the spine board and c-collar as soon as possible will allow the child to be more relaxed for a tertiary exam. Another case for restraints is in procedures such as laceration repair or other invasive procedures. If procedural sedation is not appropriate, the physician should not be averse to using a papoose board or sheets to prevent further injury and allow for the best cosmetic result during wound closure. Keeping the caregiver, an assigned nurse, or a volunteer at the bedside or enlisting the help of a play therapist will go a long way to easing the child's apprehension.
Ideally, keeping children from the same family together can be beneficial. For example, pediatric trauma patients can be evaluated collectively in the same trauma room depending on the needs and relationships of each patient. If there are no parents available, then the quick reunion of the siblings can be an important step toward preserving normalcy and the perception of personal control. However, if several children are presented at the same time, the authors feel that it generally is helpful to start with the older child and perform the examination in the presence of the younger child. If the older child is observed having a non-threatening experience, the younger child will be put at ease. On the other hand, if the developmentally and emotionally more fragile pre-school age child initially is frightened, the resulting outburst may cause the other children to become distraught.
Confidence in the Examiner. There may be times when the examination is compromised by outside influences. For example, if the caregiver lacks trust or confidence in the examiner or hospital, this negative message may be transmitted to the child and interfere with the examination outcome. Additionally, the natural parental impulse to protect and shield their child from fear and pain is a reality of that relationship and should not be interpreted as confrontational. Defensive or resentful postures by the healthcare provider will only complicate the already fragile relationship. The healthcare provider's best response is to maintain a professional and confident posture as well as to demonstrate a high level of expertise in the emergency care of children.
The examiner also can try to solicit the expectations of the parent for the care of the child and address them if possible. Even if the expectations are unreasonable, the opportunity to bring them up for discussion is important to personalize the care given. Sitting during the visit, making eye contact, engaging handshakes, returning to discuss the results of tests, and finalizing the care are simple but proven ways of improving the interaction. Also, making an attempt to discuss the visit with the child's pediatrician will aid in gaining the trust of the caregivers.
Parental Pitfalls. The cooperation of the parents in holding and reassuring the child during the examination process is always valuable. However, there are some parents who are unable to help or do not have the skills to aid in the examination. Their own fears or ignorance of the need for certain procedures may get in the way. For example, some parents may remove the spine board or c-collar in an effort to make the child more comfortable. They may even give the child forbidden food despite the complaint of abdominal pain, vomiting, and the need for a surgical consult. It is imperative to recognize early when parental collaboration is inadequate and make necessary adjustments. Emotional support from medical personnel has been found to be helpful in alleviating the stress experienced by parents.47 Taking the time to explain processes and procedures and, if necessary, give specific guidance to the caregivers may be all that they require. Finally, reassurance from the examiner or nurses such as, "You are doing a good job," will go a long way toward effectively recruiting parental support and assistance.
Sometimes parents may inadvertently or unintentionally undermine the physician's relationship with the child with statements like, "I won't let the mean doctor hurt you," or, "You better be good or you will get a shot." This sends an undesirable negative message to the child. The examiner only can reassure the child and continue. Another statement is, "It won't hurt too bad." The child only hears "hurt" and focuses on that specific, fear-inducing word. It is best to guide the parents by giving them examples of helpful things to say to the child, such as, "It will be over quick," or, "This will make you better." Another technique is to say, "Mommy did not know you would feel this." Many times the explanation of, "I need to take some blood," is enough for the child. If children are warned adequately, they may be better able to endure the procedure, especially if the caregiver is with nearby.
Pediatric Examination Pearls
In addition to the advice already presented, there are helpful techniques to follow in specific aspects of the examination of children. This advice is offered in the following sections.
General Assessment
• Pediatric patients in respiratory distress should be examined in their position of most comfort (usually upright) and in the location that produces the least anxiety (i.e., in the mother's arms).
• Use a child's parental attachment as an ally and allow the mother's lap to be the child's safe haven. In evaluating a child's gait (e.g., limping child) the clinician should restrain the child briefly while the parent moves to the opposite side of the room. The clinician should observe the child's gait when he or she is released to return to the security of the parent's arms.
• Use modeling, such as "first we will tap mommy's knee, then we will tap yours" or "first we will look in your bear's ears then in yours."
• It is not always necessary for the patient to verbalize where it hurts. Pointing to the discomfort, or observing for wincing, papillary dilation, or withdrawal frequently will be more reliable.
• The pediatric physical examination should not be overly prolonged. With practice, 10 minutes or fewer should be adequate.
• Ideally, a fully undressed patient is the most informative; however, modesty concerns of the child should be recognized and adequate covering should be allowed when appropriate. Furthermore, in the setting of cold exam rooms, sequential undressing may be preferred.
Vital Signs
• All vital signs should be documented. This includes heart rate, respiratory rate, temperature, weight, and blood pressure.
• Weighing the caregiver while he or she is holding the child and then re-weighing the caregiver alone and subtracting the difference can accomplish weight.
• Using phrases like "this will give you a little hug" and "let me see if your finger glows" can help in obtaining an accurate blood pressure and oxygen saturation.
• Normal vital signs are available in pediatric texts and handbooks and need not be memorized. However, familiarity is mandatory to recognize when they are abnormal and should be investigated further.
• Respiratory rates of young infants are accomplished best by observing them for 60 seconds. Shorter intervals may be erroneous secondary to periodic breathing by the infant. If the infant is crying while the respiratory rate is being counted, this should be documented.
• While measuring a respiration rate, it may be easier to count the abdominal movements of small infants instead of chest wall movements since infants tend to be abdominal breathers.
Inspection
• For children who are not critically ill, the ideal examination location is in the caregiver's lap.
• If the child is asleep when the examiner enters, obtain the initial portion of the examination before rousing the child.
• Children who are focused on their breathing rather than on their surroundings may be in respiratory distress.
• Short cries or grunting (usually heard on expiration) with rapid breathing also may be signs of respiratory distress.
Auscultation
• When it is difficult to determine whether the source of the lung sounds is from upper airway congestion or from the lungs, simply move the stethoscope from the lungs to the nose to the throat to help ascertain the true origin of the sounds.
• Having children "breath like a puppy" or "take a deep breath like this" or asking them to "blow out a candle" will improve the effectiveness of the respiratory effort.
• It can be difficult to count the rapid heart rate of an infant. Feeling the pulse and tapping one's fingers while listening to the heart will help to avoid doubling or over-counting.
• In a crying child, listening to the lungs as the child inhales between cries may reveal wheezes, stridor, congestion, and other valuable information.
• A coughing child with no audible wheezes may deserve a trial of beta-2 agonists to bring out the wheezes.
• A change in the child's voice as noted by the parents or caregivers can be a sign of distress.
Palpation
• The examiner should strive to keep hands and equipment warm.
• Pushing the feet up to flex the knees and hips of a supine infant can facilitate the abdominal examination. This will relax the abdominal musculature.
• Distracting older children by having them snap or tap their fingers while flexing their knees also will relax their abdominal musculature.
• Tapping the heels or shaking the pelvis of the supine child or having the child jump up and down can be an indicator of abdominal tenderness or peritoneal signs.
• Deep palpation can be accomplished by using one hand in the back to push the organs forward (i.e., kidney) while palpating the abdomen with the other hand.
• Rectal examination can be accomplished in a frog-leg position, with the child lying on his or her back (supine) or in the caregiver's lap. If fecal blood or leukocytes are the goal of the exam, using a cotton swab may be preferable.
Neck Stiffness
• Nuchal rigidity, when present, is a reliable clinical observation; however, it often is absent in children younger than 2 years of age.
• Distinguishing patient resistance from actual neck stiffness can be accomplished by hanging the child's head over the edge of the examination table. The child naturally will tend to cooperate with flexing of the neck and, therefore, mobility, stiffness, and pain with motion can be assessed more easily.
• Having an older child look at his or her belly button or look up in the sky can facilitate neck stiffness evaluation.
Extremity Evaluation
• When the chief complaint is a painful extremity, it is important to inspect all the joints and bony structures of the involved limb.
• In the extremity, pain often is referred to the joint above or below the actual area involved.
Eye Examination
• The hand that is not holding the ophthalmoscope can be used to attract the child's attention. A toy or the parents can distract the child from looking directly into the light source.
• The use of force to open the eyelids of infants rarely is successful. Many infants will open their eyes while sucking on a bottle or pacifier or when rocked gently.
• The caregiver can hold the child over his or her shoulder, thus providing stability to the patient and improving the chances of a successful eye examination.
Ear Examination
• To obtain a good ear examination, it is essential to position the patient properly. In the caregiver's lap, it is best for the parent to hold the child firmly against his or her chest while maintaining control of the hands. The examiner then is able to hold or maneuver the head. On the exam table, the child can be placed supine with the parent lying over him or her while simultaneously restraining the child's hands. Again, this leaves the examiner free to hold or maneuver the head to the left or right against the table.
• Holding the otoscope with the handle pointing upward allows the medial aspect of the examiner's hand to rest against the child's head. This prevents inadvertent pushing of the otoscope tip into the ear should the child suddenly jerk.
• The removal of cerumen from the ear canal commonly causes some mild trauma and consequent bleeding. This risk should be relayed to the caregivers prior to the procedure to prevent a misunderstanding after the fact.
• The use of a cerumen loop or spoon usually is sufficient for minor debris. Docusate sodium followed by water irrigation also can be used to clear impacted cerumen.
• The examination of the ears usually causes distress to small children and is performed best just prior to the throat exam (so a good view is obtained during the cry with the mouth wide open). Crying often will cause the tympanic membranes to appear more erythematous (mimicking the inflammation of otitis media) as the child's face flushes.
Throat Examination
• The examination of the oropharynx is best saved for last. If the child cries briefly following the ear exam, a good view of the oropharynx may be obtained.
• In older children, asking the patient to "let me see your tongue," "pant like a puppy," or "sing with me" often will aid in success.
• For younger children and those who are not as compliant, gently holding the nose and pushing on the muscles of mastication often will bring their mouths open.
• For the teeth-clenching 2-year-old, the application of gentle, consistent pressure with a tongue blade placed lateral to the posterior molars will encourage the child to open the mouth long enough for the practitioner to depress the tongue (with the same blade) and expose the oral cavity.
• In the supine patient, examination of the throat can be facilitated by stabilizing and holding the head between the examiner's elbows while inserting the tongue blade.
Summary
The best assessment for a pediatric patient requires optimal conditions. The examiner should strive for environmental, clinical, and psychological conditions that allow the best and most appropriate assessment based on the child's health status, illness, or injuries. Evaluation of the examiner's practice setting, environment, and resources as well as preparation can pay clinical dividends when less-than-compliant patients tax the nerves of even the calmest and most experienced physicians.
References
1. Richman PB, Nashed AH. The etiology of cardiac arrest in children and young adults: Special considerations for ED management. Am J Emerg Med 1999;17:264-270.
2. Zaritsky A, Nadkarni V, Getson P, et al. CPR in children. Ann Emerg Med 1987;16:1107-1111.
3. Young KD, Seidel JS. Pediatric cardiopulmonary resuscitation: A collective review. Ann Emerg Med 1999;33:195-205.
4. Nelson DS, Walsh K, Fleisher GR. Spectrum and frequency of Pediatric illness presenting to a general community hospital emergency department. Pediatrics 1992;90:5-10.
5. Rupp T, Delaney KA. Inadequate analgesia in emergency medicine Ann Emerg Med 2004;43:494-503.
6. Cosby KS. A framework for classifying factors that contribute to error in the emergency department. Ann Emerg Med 2003;42:815-823.
7. Culberton JL, et al. Childhood and adolescent psychologic development. Pediatr Clin North Am 2003;50:741-764.
8. Crittenden PM, Ainsworth MDS. Child maltreatment and attachment theory. Child Maltreatment. New York: Cambridge University Press; 1989:432-463.
9. Greenberg LW, Ochsenschlager D, O'Donnell R, et al. Communicating bad news: A pediatric department's evaluation of a simulated intervention. Pediatrics 2002;110:839-840.
10. Asser SM, Swan R. Child fatalities from religion-motivated medical neglect. Pediatrics 1998;101:625-629.
11. Hedayat KM, Pirzadeh R. Issues in Islamic biomedical ethics: A primer for the pediatrician. Pediatrics 2001;108:965-971.
12. American Academy of Pediatrics. Periodic Survey 27. Elk Grove Village, IL: American Academy of Pediatrics; 1995.
13. ACEP Policy Statement: Care of Children in the Emergency Department: Guidelines for Preparedness, American College of Emergency Physicians; September 2000.
14. ACEP Policy Statement: Equipment for Ambulances, June 2000. American College of Emergency Physicians web site. http://www.acep.org/webportal/PracticeResources/PolicyStatements/EMS/EquipmentAmbulances.htm. Accessed 11/2/2005.
15. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine and American College of Emergency Physicians, and Pediatric Committee. AAP Policy Statement: Care of Children in the Emergency Department: Guidelines for Preparedness. Pediatrics 2001;107:777-781.
16. Carroll AE, Christakis DA. Pediatricians and personal digital assistants: What type are they using? Proc AMIA Symp 2003;130-134.
17. Torre DM, Wright SM. Clinical and educational uses of handheld computers. South Med J 2003;96:996-999.
18. Rucker D, Brennan T, Burstin H. Delay in seeking emergency care. Acad Emerg Med 2001;8:163-169.
19. Tsai A, Kallsen G. Epidemiology of pediatric prehospital care. Ann Emerg Med 1987;16:284-292.
20. Rivara FP, Kamitsuka MD, Quan L. Injuries to children younger than 1 year of age. Pediatrics 1988;81:93-97.
21. O'Brien MM, Creamer KM, Hill EE, et al. Tolerance of family presence during pediatric cardiopulmonary resuscitation: A snapshot of military and civilian pediatricians, nurses, and residents. Pediatr Emerg Care 2002;18:409-413.
22. Eppich WJ, Arnold LD. Family member presence in the pediatric emergency department. Curr Opin Pediatr 2003;15:294-298.
23. Alexander J, Manno M. Underuse of analgesia in very young pediatric patients with isolated painful injuries. Ann Emerg Med 2003;41:617-622.
24. Brown JC, Klein EJ, Lewis CW, et al. Emergency department analgesia for fracture pain. Ann Emerg Med 2003;42:197-205.
25. Jones JS, Johnson K, McNinch M. Age as a risk factor for inadequate emergency department analgesia. Am J Emerg Med 1996;14:157-160.
26. Selbst SM, Heneretig FM. The treatment of Pain in the Emergency Department. Pediatr Clin North Am 1989;36:965-977.
27. Belville RG, Seupaul RA. Pain measurement in pediatric emergency care: A review of the faces pain scale-revised. Pediatr Emerg Care 2005;21:90-93.
28. Wong D, Baker C. Pain in children: Comparison of assessment scales. Pediatr Nurs 1988;14:9-17.
29. Green R, Kabani A, Dostmohamed H, et al. Analgesic use in children with acute abdominal pain. Ped Emerg Care 2004;20:725-729.
30. Berry PH, Dahl JL, Donovan MI, et al, eds. Improving Quality of Pain Management Through Measurement and Action. Joint Commission on Accreditation of Healthcare Organizations web site. http://www.jcaho.org/news+room/health+care+issues/pain_mono_jc.pdf. JCAHO 2003. Accessed 11/2/2005.
31. Rosen P, Barkin R, et al. Emergency Medicine: Concepts and Clinical Practice. Mosby-Year Book, Inc.:St. Louis;1998: 1093-1096.
32. Baker MD, Bell LM, Avner JR. Outpatient management without antibiotics of fever in selected infants. N Engl J Med 1993;329:1437-1441.
33. Baskin MN, O'Rourke EJ, Fleisher GR. Outpatient treatment of febrile infants 28 to 89 days of age with intramuscular administration of ceftriaxone. J Pediatr 1992;120:22-27.
34. Dagan R, Powell KR, Hall CB, et al. Identification of infants unlikely to have serious bacterial infection although hospitalized for suspected sepsis. J Pediatr 1985;107:855-860.
35. American College of Emergency Physicians Clinical Policies Committee; American College of Emergency Physicians Clinical Policies Subcommittee on Pediatric Fever. Clinical policy for children younger than three years presenting to the emergency department with fever. Ann Emerg Med 2003;42: 530-545.
36. Sharber J. The efficacy of tepid sponge bathing to reduce fever in young children. Am J Emerg Med 1997;15:188-192.
37. Mayoral CE, Marino RV, Rosenfeld W, et al. Alternating antipyretics: Is this an alternative? Pediatrics 2000;105:1009-1012.
38. King C. Evaluation and management of febrile infants in the emergency department. Emerg Med Clin North Am 2003;21:89-99, vi-vii.
39. McCarthy PL, Sharpe RM, Spiesel SZ, et al. Observation scales to identify serious illness in febrile children. Pediatrics 1982;70:802-809.
40. Sagy M. Scoring systems in emergency pediatrics: "One cannot see the forest for the trees." Pediatr Emerg Care 1989;5:142-144.
41. Baker MD. Bell LM. Unpredictability of serious bacterial illness in febrile infants from birth to 1 month of age. Arch Pediatr & Adolescent Med 1999; 153:508-511.
42. Teach SJ, Fleisher GR. Efficacy of an observation scale in detecting bacteremia in febrile children three to thirty-six months of age, treated as outpatients. Occult Bacteremia Study Group. J Pediatr 1995;126:877-881.
43. Baker MD, Avner JR, Bell LM. Failure of infant observation scales in detecting serious illness in febrile, 4- to 8-week-old infants. Pediatrics 1990; 85:1040-1043.
44. Kuppermann N, Fleisher GR, Jaffe DM. Predictors of occult pneumococcal bacteremia in young febrile children. Ann Emerg Med 1998;31:679-687.
45. Pantell RH, Newman TB, Bernzweig J, et al. Management and outcomes of care of fever in early infancy. JAMA 2004;291:1203-1212.
46. Donate-Bartfield E, Passman RH. Establishing rapport with preschool-age children: Implications for practitioners. Children's Health Care 2000;29:179-188.
47. Hemmelgram AL, Glisson C, Dukes D. Emergency room culture and the emotional support component of family-centered care. Children's Health Care 2001;30:93-110.
While children typically have a lower severity of illness than their adult counterparts during visits to the emergency department (ED), they also present with some of the most serious illnesses. Furthermore, there are a wide range of possible illnesses with potentially devastating outcomes for children. Unfortunately, the relative rarity of critically ill or injured children means that clinical experience potentially may be lacking or even atrophied over time.Subscribe Now for Access
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