Overview

Source: Heather Collette and Jaideep Talwalkar; Yale School of Medicine

The key to a successful exam of a toddler or preschool-age child is building rapport and trust between them and the provider. Toddlers, in particular, may be wary of strangers and unwilling to cooperate with the physical exam, which is expected age-appropriate behavior. In order to provide good care and create a comfortable patient experience, clinicians need to tailor their interaction to the child's developmental stage. Ensuring positive medical encounters for children will increase their likelihood of seeking medical care as they age into adulthood. Clinicians must be creative and flexible as they work with children to achieve their care goals. Suggestions on how to facilitate these interactions will be covered in this video, with less of a focus on specific organ system components, as these are similar to other age groups.

Toddlerhood through preschool age is a time of significant physical and developmental growth. Progression of language, motor, and social skills is a reflection of children's brain growth and social environment. Normal development follows a typical progression, but exact time points for achieving developmental milestones can vary among children. Achieving a specific milestone a few months later than another child or based on a time point listed on a development chart does not necessarily indicate a problem. Providers must ensure that children meet developmental milestones as expected and, if not, refer them early for special services to promote the best outcome possible. 

Procedure

1. Building rapport and empowering the patient

1. Start by sitting several feet away, giving the child time to become comfortable.
2. To build rapport with a young child, provide direct but non-threatening attention in the form of informal conversation or play. Such attention is not possible if a child is sleeping or very ill.
3. For toddlers and young children, avoiding prolonged direct eye contact during the initial part of the visit will allow them to observe and recognize that pediatricians are not to be feared. Building rapport with the caregiver can also send this message to the child.
4. It is often helpful to talk first about non-medical topics such as what the child likes to do for fun, compliment them on an article of clothing, or comment on a toy they have with them.
5. Once the child becomes more interactive and "warms up," let them know it is time for their "check-up." Avoiding medical jargon, such as the word "examination," will be less threatening to the child.
6. Ask the child or caregiver where they prefer to be examined – whether on the exam table or their caregiver's lap – either is acceptable.
7. As mentioned previously, allowing the child to have choices and speaking directly to them will help empower them as active participants in their care, laying important groundwork for future interactions with healthcare providers as they get older.
8. Use terminologies that kids understand, even when talking to the parents. Children constantly listen and learn, even if it doesn't seem obvious.
9. If they show interest, allow them to explore the medical equipment, including a stethoscope, ophthalmoscope, and otoscope. Show them how to use it, and let them try it out.
10. Some parents tend to jump in and answer questions that are posed to their children. After listening to the parent, politely suggest that it is better to hear what the child says.

2. Physical exam

1. Wash hands before starting the physical exam.
2. When examining young children, it is best to start with the least invasive components, such as listening to the heart or lungs. This will continue to build their trust once they realize these maneuvers are not painful or scary.
3. It is important to remain positive and relaxed during the exam. Children are aware of their comfort level and will respond accordingly. 
4. Get creative! Using play techniques will make it easier to perform the exam and make the experience more enjoyable for the child. For example:
   1. Starting with the lung exam, pretend that the finger is a candle and ask the child to take a deep breath and blow it out. This will ensure they take nice deep breaths so that breath sounds can be heard.
   2. Next, during neurological exams, assess their gait stability by asking them to pretend to "walk on a tightrope" and assess their motor skills by challenging them to a jumping contest to see who can jump higher.
   3. When examining the mouth for any redness, enlarged tonsils, or ulcers, ask the child to "stick out your tongue at me" to see deep in the back of their mouth. When looking in the nose, ask them to make a "pig nose" to assess the nasal mucosa for any swelling or discharge. 
5. The ear exam deserves special attention since it is often a source of fear for young children. A particularly gentle approach is warranted starting in infancy to avoid creating fear of the ear exam in the future (e.g., overly aggressive manipulation of the pinna or insertion of the speculum can cause unnecessary pain).
6. In the ears, look for any redness, swelling, or scarring of the eardrum or ear canal, discharge or obstruction (e.g., cerumen) in the ear canal, and integrity of the eardrum. 
7. Involve the child in the exam and allow them to make choices. This will make them feel more in control. For example, ask them to choose whether to look in their right or left ear first with the otoscope.
8. Before looking into the child's ears, encourage them to touch the light on the otoscope first to show them that it does not feel hot.
9. Ask them to put the "hat" on the otoscope – meaning the otoscope cover – to keep them involved and interested in their exam.
10. Demonstrate the actions – like taking exaggerated deep breaths, sticking the tongue out, saying "ahhh" and asking them to copy the same.
11.  If the child seems uneasy about a medical instrument, pretend to auscultate their stuffed animal or doll if available, or ask the parent if it is OK to look in their ear with the otoscope. This helps to show the child that it is a safe and non-painful experience. 

3. Developmental evaluation and speech development assessment

1. Developmental evaluation is an important part of each visit. Developmental milestones are assessed within the speech domains (receptive and expressive), motor skills (fine and gross), problem-solving and social-emotional. This is done through formal screening using instruments for this purpose.
2. There are many developmental screening tools available. The tools typically comprise a list of questions that parents answer based on their knowledge and observation of the child's behavior at home.
3. Clinicians should have tools at their disposal to measure the normal progression of development while working with young children.
4. To assess a child's speech, read a book with the child and ask them to name pictures, colors, animals, etc. If they are willing, engage them in conversation or a game during which their spontaneous speech for appropriate vocabulary acquisition and speech impediments can be assessed.
5. Both expressive and receptive language may need to be assessed via caregiver report if a child is quiet, shy, or reserved during the encounter with the clinician, as is often the case. If the child's language cannot be assessed through direct interaction and observation, ask specific questions appropriate to language development based on the child's age. For example:
   1. "How many words does the child know?" (speaks at least 5 words at 15 months and 50 words at 24 months).
   2. "How many words does the child put together?" (at least 2-word phrases at 18 months, 3-word phrases at 30 months, 3-word sentences at 36 months).
   3. "How well do strangers understand your child?" (at least 50% understandable at 24 months, 75% at 36 months, 100% at 48 months).
   4. "Does your child understand things you say even for words they can't say themselves?" (Should follow simple commands by 12 months).

4. Motor revelopment

1. Observe the child throughout the visit for a demonstration of fine and gross motor skills.
2. The expected progression of fine motor skills involves a reflexive grasp of objects at birth, and a controlled raking grasp at 6 months, where the infant reaches for objects with their whole hand. This progresses to a more precise pincer grasp at 9 months, where the child uses their thumb and forefinger to pick up objects.
   1. During the visit, it can be useful to have small blocks or a rattle to help to assess fine motor skills. These objects can be placed in the hands of the child to assess grasp or on a table in front of them to see how the child reaches for and picks them up (raking vs pincer grasp). 
   2. Provide the child with a book to see how they manipulate the pages. A 12-month-old will grasp several pages of a board book at a time. A 24-month-old can turn pages of a board book individually. A 36-month-old experienced with books may turn paper pages individually.
3. A child's expected gross motor skills progression involves lifting their head at 1-2 months, sitting up by themselves at 6 months, and taking their first independent steps at 1 year.
4. During the visit, you can place a baby on their tummy to assess their head control, sit them up to assess trunk stability, or have them walk around the room, hop on one foot or skip down the hallway to assess motor coordination and balance.

5. Social-Emotional development

1. Babies have a social smile in response to others at 2 months. When someone smiles at the baby – they should smile back. Babies express fear of strangers around 7 months – this response can be assessed by noting a fear or crying reaction in the exam room. They engage in parallel play at 2 years old, where they will play next to another child but not with them.
2. At 3-4 years old, they start to play with one another and demonstrate an imagination. This type of interaction is usually assessed by asking the caregiver how they have observed their child interacting with others.
3. Autism is a developmental disability that can cause a range of social, communication, and behavioral challenges. The M-CHAT-R is a screening tool for autism that parents complete at the 18 and 24-month check-up visits. This tool screens for child behaviors consistent with autism, such as lack of eye contact, shared interest, or signs of affection.
4. The provider scores the M-CHAT-R, and depending on the number of abnormal behaviors identified, the child is stratified as low, moderate, or high risk for autism and referred to a developmental-behavioral pediatric specialist.
5. It is not known what causes autism, nor is there a cure for it. However, social-emotional screening tools, like the M-CHAT-R, can help identify autism early so that intervention treatment services can improve a child's development over time.
6. If developmental delays are identified during the check-up, organic medical causes should be ruled out. For example, a hearing test should be performed through a referral to an audiologist to rule out hearing loss in the setting of a child with speech delay. A thorough physical exam for musculoskeletal injuries or deformities should be performed if a patient is showing concerns for motor skill delay.
7. The child's environment should be screened for appropriate stimulation and resources.
   1. Ask the family about their current living situation, including access to stimulating toys and activities.
   2. Discuss age-appropriate use of screens. The American Academy of Pediatrics recommends less than 1 hour per day for children ages 2-5 and no screen time for younger children (not including video chatting). Adequate supervision is needed regarding content.
   3. Encourage screen-free family meals, which have been shown to encourage healthier eating behaviors and foster language development in children.
   4. Screening for social determinants of health is part of the pediatric encounter, with appropriate referrals to support services when indicated. For example, ask about food, shelter, clothing, and education access.
   5. Once organic or environmental causes are ruled out, referrals are made for the type of therapy required— including physical therapy, occupational therapy, speech therapy, or behavioral therapy.
   6. When finished with the young child's exam, say "all done" and back away from the child, giving them their personal space while praising them for doing a great job.