Children are different from adults. Their difference in size is obvious. Their bodies grow in a predictable pattern that is assessed during the physical examination. However, their behavior also is different. Behavior grows and develops through predictable stages, just as the body does. Each examiner needs to know the expected emotional and cognitive features of these stages and to perform the physical examination based on developmental principles (Erikson, 1963; Wong, 1999)
With all children, the goal is to increase their comfort in the setting. This approach reveals their natural state as much as possible and will give them a more positive memory of health care providers. Remember that a “routine” examination is anything but routine to the child. You can increase their comfort by attending to the following developmental principles and approaches. The order of the developmental stages is more meaningful than the exact chronological age. Each child is an individual and will not fix exactly in one category. For example, if your efforts to “play games” with the preschooler are rebuffed, modify your approach to the security measures used with the toddler.
THE INFANT
Erikson defines the major task of infancy as establishing trust. An infant is completely dependent on the parent for his or her basic needs. If these needs are met promptly and consistently, the infant feels secure and learns to trust others.
Position
• The parent always should be present to understand normal growth and development and for the child’s feeling of security.
• Place the neonate or young infant flat on a padded examination table. The infant also may be held against the parent’s chest for some steps.
• Once the baby can sit without support (around 6 months), as much of the examination as possible should be performed while the infant is in the parent’s lap.
• By 9 to 12 months, the infant is acutely aware of the surroundings. Anything outside the infant’s range of vision is “lost, so the parent must be in full view.
Preparation
• Timing should be 1 to 2 hours after feeding, when the baby is not too drowsy or too hungry.
• Maintain a warm environment. A neonate may require an overhead radiant heater.
• An infant will not object to being nude. Have the parent remove outer clothing, but leave a diaper on a boy.
• An infant does not mind being touched, but make sure your hands and stethoscope endpiece are warm.
• Use a soft, crooning voice during the examination; the baby responds more to the feeling in the tone of the voice than to what is actually said.
• An infant likes eye contact; lock eyes from time to time.
• Smile; a baby prefers a smiling face to a frowning one. (Often beginning examiners are so absorbed in their technique that they look serious or stern.) Take time to play.
• Keep movements smooth and deliberate, not jerky.
• Use a pacifier for crying or during invasive steps.
• Offer brightly colored toys for a distraction when the infant is fussy.
• Let an older baby touch the stethoscope or tongue blade.
Sequence
• Seize the opportunity with a sleeping baby to listen to heart, lung, and abdomen first.
• Perform least distressing steps first. Save the invasive steps of examination of the eye, ear, nose, and throat until last.
• Elicit the Moro or “startle” reflex at the end of the examination because it may cause the baby to cry.
