Pediatric Health Maintenance and Screening

Objectives

As you follow your patients in CCC, you will learn important differences between primary ambulatory patient care and the secondary and tertiary inpatient care of your in-hospital rotations.


Data collected on patients in this Clinic (an outpatient setting) is done in a stepwise fashion, over time ("longitudinally"), as opposed to the more in depth ("vertical") collection of information in a short time, which characterizes inpatient care.

Additionally, ambulatory patient care concerns itself with prevention of disease, as well as screening for disease in asymptomatic people. This area of health maintenance is a large and essential one in the practice of any form of primary care; and it is carried out in the context of ongoing medical care. This means, then, that you will be following and treating patients with established illnesses as well as acute and episodic problems and, simultaneously, will become involved in screening, prevention, and health maintenance. Preventive medicine can be divided into three levels:
 

  • primary-- preventing illness or injury 

  • before it begins.
  • secondary-- identification of illness at an 

  • early stage (screening).
  • tertiary-- directed toward minimizing 

  • disability and promoting rehabilitation. 

There are no absolute guidelines that physicians uniformly follow in providing these services. Instead, the methods are tailored to fit the type of practice and patient popula-tion the physician has. These variations will become apparent to you as you work in the Clinic with preceptors from a number of different practice settings.

If you look at how all these areas are attended and follow the Recommendations for Preventive Pediatric Health Care (Table 1), you will see a recommended schedule for following healthy children from infancy through adolescence.
First of all, a history and physical examination should be done at each suggested visit, as well as a developmental behavioral assessment and anticipatory guidance. Careful attention to these important areas will provide clues to unsuspected disease and, frequently, direct you to specific needs for patient or parent education and counsel. The Well Baby Cook-book and the Denver Developmental Screening Test, which are available to you in the Clinic, are good reference sources.

 

Certain measurements are a necessary part of the physical examination in infants and children in order to evaluate their growth and development. Specifically, height and weight should be measured at each visit from infancy through adolescence, and head circumference at each visit for the first year. Recording of blood pressure at least every 1 to 2 years, beginning at age 3, is important and often overlooked (Table 2).

Heredity/metabolic screening for PKU and hypothyroidism is required as a one-time screen with all infants at about 2 weeks. We also screen for sickle disease in all black children at about 9 to 12 months of age. A minimum of laboratory testing (i.e., hemoglobin or hematocrit and urinalysis) is desirable at least once in the first year (at 9 to 12 months), and again at ages 2, 8, and 14 to 18 years. Obviously, if circumstances suggest a variation from normal, additional checks are necessary.
The Committee on Infectious Diseases recommends tuberculin testing annually for high risk child-ren (blacks, Hispanics, Asians, American Indians, Alaskan natives, and contacts). Low risk groups should be tested at 12 to 15 months of age (either before or at the time of MMR administration), at 4 to 6 years of age, and at 14 to 16 years of age.

The success of protective immunization against certain infectious diseases in children has changed the face of practice to some extent, and continues to be an important part of preventive medicine in children and adults. A schedule of immunization is provided in the Clinic examining rooms, and you can offer your patients the option of obtaining these immunizations free, either in the Clinic or at the Health Unit.

The need for visual and auditory screening is being recognized now, as well as dental referral. These areas are usually assessed subjectively by careful history plus specific attention to abnormalities sugges-ted on physical examination on each visit until pre-school age (3 to 5 years), and are then evaluated objectively by specific screening tests or referral for these. Repeat objective evaluations are suggested in pre-adolescent and adolescent patients.

When you break down these different areas as we have done here, it begins to sound like a lot of information and also time consuming. I think, however, that by referring to schedules like these and others and making appropriate use of the Clinic personnel, you will find these areas of your practice very gratifying.

 

Pediatric Outpatient Encounter

Major objectives of the clinical encounter:
 

  • performance of an examination and obtaining necessary diagnostic information
  • development of a positive physician-patient relationship
  • observation of the parent-child subsystem during the office visit.

 

Clinical skills in examining children are a blend of:
 

  • specific examination techniques
  • perceptive approach to the 

  • child during the encounter. 

Specific techniques and procedures for examining children are widely described in texts and physical diagnosis courses (type of stethoscope, palpation techniques, lap exam, etc.).

Behavioral approaches to children often generalize a need for gentle-ness, kindness, warmth, and a friendly, unhurried attitude, without much specific information on how these are translated into action.

We all have been amazed, at times, at a clinician's "magical ability" to approach and examine an uncooperative or screaming child. Part of this art comes as you incorporate your own personal style and ability into the process. In order to de-mystify this seemingly magical ability, it is useful to organize the process around three general principles or concepts:
 

  • awareness (emotionally and physically) of self, parent(s), child, and developmental level of child 
  • contact
  • initially through nontactile senses-- visual, auditory
  • Table of Cognitive and Developmental Characteristics of the Child (Table 3) 
  • closure
  • summarize results of encounter
  • clarify-- ask questions and allow parent(s) to do the same
  • reassure
  • contract for follow-up evaluation
  • say goodbye with a touch or handshake

Table 3. Cognitive and Developmental Characteristics of the Child.
 

Infant
(birth to 18
months of age
Toddler
(ages 18 months
to 3 years)
Pre-School 
Child (ages 3 to 6 years)
Elementary
School Child
(ages 6 to 
puberty)
Adolescent
(puberty to late teens/early 20s)

Characteristics:
 

Responds to touch
(tactile), voice
(auditory), visual stimuli.
Playful, curious,negative, 
clings.
Communicates,
understands, wants
to please.
Sensitive, shy
modest.
Moody, overreact,
body image.

Therefore, avoid:
 

Cold, rattling
paper on table;treating as passive;
cold stethoscope.
Detaching from patient; rushing
through exam.
Direct ROS;
expression that frighten; rushing through exam.
Direct ROS;
expressions that frighten.
Direct ROS;
talking down to.

And, instead:
 

Place on blanket on lap for exam;
allow to grasp
finger; pat/stroke
them.
Reassure a lot; let them touch/hold
instrument; use
instrument first on Mom or bear;
involve parent.
Explain;
compliment or
flatter; give hero
badges; etc.

 

Watch their
expressions;
explain and
reassure.

 

Engage in
conversation;
show respect; be
straight-forward;
explain and 
reassure.

** Observation
** Communicate according to age and development
 

Physical Examination

Not systematic --> gradually more systematic --> more "head, chest, abdomen, etc."
Pediatric History and Physical

Much of our training in interviewing and pediatric history-taking takes place around well-defined or acute situations in which the "complaint" is easily stated and readily viewed (Johnny has a cold, sore throat, earache, fever, etc.).

Such is not the case with the normal newborn, who comes to your office for a two-week checkup. We are programmed to ask for a "chief complaint," which the mother doesn't have (she's there only because you asked her to come), a "present illness," which she can't elaborate on because the baby hasn't appeared ill, or a "past history," which seems essentially uneventful in that there has been no significant illness, surgery, injury, or allergy. So what do we do?


T. Davis, MD
updated 8/30/05


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