The Paediatric Consultation
Paediatricians need to be happy with informality, enjoy humour and appreciate the unpredictability that children bring to consultations! Young children do not have a full understanding of the role of health professionals. Children will naturally be anxious and uncertain in an unfamiliar environment. They may not understand all of the language in the consultation, but they quickly detect a sense of personal warmth, friendliness and relaxed mood in adults around them. It helps to have pictures, toys and videos to help children understand that the room is a good place for children.
In paediatrics, the focus of the consultation changes with the age and understanding of the child. In a young baby, the discussion is entirely with the carers (usually parents) who act as advocates for the child’s needs. As children mature, they need to be included in the discussion. It is important to understand children’s concerns and their right to be involved in decisions. Paediatricians need also to consider the concerns of the family and communicate sensitively with all family members.
Approaching the consultation
• Try to be friendly, confident and non-threatening. It may be best to examine an exposed part of the body first before undressing the child, or do a pretend examination on their teddy bear.
• Try to get down to the child’s level kneel on the floor or sit on the bed. Look at the child as you examine them. Use a style and language that is appropriate to their age ‘I’m going to feel your tummy’ is good for a small child but not for an adolescent.
• Explain what you are going to do, but be careful of saying ‘can I listen to your chest’ as they may refuse!
• Babies are best examined on a couch with the parent nearby; toddlers may need to be examined on the parent’s lap.
• In order to perform a proper examination, the child needs to be undressed, but this is often best done by the parent and only the region that is being examined needs to be undressed at any one time.
• Older children and adolescents should always be examined with a chaperone usually a parent but, if the child prefers, a nurse. Allow as much privacy as possible when the child is undressing and dressing.
• Sometimes, you may need to be opportunistic and perform what ever examination you can when you can. Always leave unpleasant things until the end for example, looking in the throat and ears can often cause distress.
• Hygiene is important both for the patient and the paediatrician to prevent the spread of infection to other patients. Always wash your hands before and after each examination.
• Always sterilize or dispose of equipment that has been in contact with a patient, such as tongue depressors or auroscope tips.
The history often indicates the diagnosis before examination or investigations. The history can be taken from a parent, a carer or from the child. Record who gave the history and in what context. Use an independent interpreter if there are language difficulties.
Beginning the examination observation
Much information can be gained by careful observation of the child. This starts while you are first talking to the parents.
• Signs of acute severe illness (need urgent intervention):
• severe respiratory distress
• altered consciousness level
• Signs of pain or anxiety
• Growth and nutrition
• Features of syndromic disorders
• Developmental progress:
• gross motor and fine motor movement
• social interaction
• speech and understanding
• Interaction with carers
• Hygiene and clothing
• Mood and behaviour.
The examination of individual systems is discussed in detail in the following chapters.