It is important from the outset to put the child at ease by creating a warm, relaxed, and unhurried atmosphere. In this clip the health station nurse meets the mother and child in the reception area and guides them into a smaller room. The nurse then elicits some information from the mother, and allows the child to play and explore.
Clip no.2 - Undressing, weighing, etc
Mom undresses the child and is close at all times. You can leave the diaper/nappy on for weighing if it has been recent changed and is dry. You can then subtract the diaper weight from the total weight you record. For simplicity the Health Station might have a list of the dry weights of common diapers.
It is useful to have toys and other objects available which can distract the child and decrease anxiety. A one-year-old who is neurologically normal can be weighed while sitting on the scale.
A board is used for measuring height. It is necessary to hold the child down briefly for this, and children of this age often do not appreciate being held firmly. Try to do this a quickly as possible, and be quick to console the child if he/she becomes unhappy. Mom's or Dad's lap is a safe haven in this situation, and toys or small rewards can also help.
Head circumference is measured with a flexible tape, and the tape should be placed around the forehead and occiput where the distance is greatest.
Remember to record the numbers for weight, height, and head circumference as you read them off your instrument. It is easier than you think to forget what the numbers were if you plan to record the numbers later.
Clip no.3 - Meeting and interviewing with the MD
The pediatrician introduces herself to the mother and child. Notice how, as she chats with Mom and explores the child's progress, she occasionally interacts with the child in order to communicate that she likes him and that he is part of this, also. Give the child a small toy or something else for the child to investigate. If the child begins to squirm on Mom's lap, it is good to let the child down for a little while to explore.
The pediatrician interviews Mom about eating and sleeping habits. She also ascertains certain elements of psychomotor development. Is the child walking yet? Does he appear to hear and see normally? Does he pick up small objects with his fingers? Has he started speaking? Have there been problems with respiration or skin?
Finally, the pediatrician enquires about child care. Is Mom back at work? How is the child cared for when Mom is at work? The answers to such questions provide a background "tapestry" for the child's current life and health.
Clip no.4 - Observation, nuerological, red reflex and light reflex
Mom undresses the child for examination by the pediatrician. Whenever possible, handling and holding of the child should always be by one of the parents.
You can learn a lot about a child just by observing it carefully without even touching. One of your important challenges in pediatrics is to hone your skills as an observer, and the routine examination at the Health Station is a great setting for such practice!
The room needs to be warm. It is often helpful to count the child's respiratory rate and observe for any sign of respiratory distress before he/she is undressed.
Observe for skin color and rashes. Note the movement pattern during spontaneous activity.
The pediatrician examines pincer grasp by giving the child a raisin to pick up - a healthy little "prize" for performing. She gives him blocks and observes how he holds and handles these. She evaluates his concepts of constancy by hiding a toy under a cup - although "gone" it is clearly still part of the child's universe, and he has no difficulty finding it by removing the cup.
The pediatrician examines the red reflexes, the light reflexes in the eyes by having the child look at a little toy. She uses the same toy to examine for squinting.
Clip no.5 - Chest Exam
Thus far, the pediatrician has only touched the child briefly. By now the child is clearly comfortable with her presence, and does not appear apprehensive. She has already observed his chest and breathing pattern for signs of respiratory difficulties. She puts a hand on his chest over the heart to feel for a thrill, which may occasionally be present when there is a loud murmur.
She introduces the Teddy bear and demonstrates how she uses the stethoscope to listen to Teddy's heart and lungs. She then proceeds to "listen" to Mom also. These are useful preambles to the next step, which is listening to the child himself. He will now be familiar with the concept, thus reducing the chances that he will react negatively. Always remember to warm the stethoscope if it appears cold to your touch.
Start by localizing the heart sounds. Are they shifted to right or left, or are they compatible with a normal localization of the heart? What is the heart rate?
Auscultation of a child's heart may be difficult, and requires a lot of practice. Because the heart rate is faster than in adults, I always find it useful to focus on one element at a time: 1st heart sound, 2nd heart sound, systolic interval, and diastolic interval.
1st heart sound - is it single or is it split?
2nd heart sound - is it single or is it split?
Systolic interval - is there a murmur? If so, is it continuous/long, or decrescendo/short? Is it quite loud, or barely audible? Does it vary with respiratory phase? The challenge is to distinguish a "physiological" murmur from a significant one.
Diastolic interval - is there a murmur? This is an unusual finding which probably calls for further investigations.
In a one-year-old you listen to the lungs as the child breaths spontaneously. You would not expect the child to cooperate with instructions on how to breathe. However, you can, as shown here, assist expiration by compressing the chest with your hands.
Clip no.6 - Belly Exam
The one-year-old can often be examined while lying on Mom's or Dad's lap. This environment will feel safer to the child than putting him/her on an exam table. Observe the abdomen for symmetry and movement. If the child has a small toy or some other distraction, it may make the palpation easier. Palpate with warm hands.
Feel the groins for femoral pulses. Inspect the genitals, looking particularly for testicular descent in boys.
The pediatrician here makes an initial, exploratory exam of the hips while the child is still on Mom's lap. Essentially she proceeds much as for the Ortolani manoeuver (see a more detailed description in the video on examination of the newborn). She spreads the legs, making sure that abduction is symmetrical. Having familiarized the child with the process, she then does the same thing with the child on an exam table.
Clip no. 7 - Ear Exam
Holding the child in a firm grip is important for the ear exam. The pediatrician explains carefully to the mother how to hold the child, with one arm around the child's arms and chest, and the flat hand of the other arm pressing the child's head to Mom's chest. As long as the child cannot twist or turn his head, the ear exam can be done quickly and painlessly.
Clip no. 8 - Throat Exam
The story is much the same here as for the ear exam. Have the child seated on Mom's or Dad's lap facing forward. One parental arm around chest and arms, so that the child cannot get the hands up to grab the spatula, and the hand of the other arm on the forehead with the head facing the pediatrician.
Although you should not expect a one-year-old to voluntarily open his/her mouth, a little bit of coaxing with the spatula will usually get you the quick look inside which is all you need. But you need to train yourself to look quickly! The child will often gag, and often be rather unhappy afterwards. Words of praise and perhaps a little reward for being such a good boy/girl are quite appropriate when this exam is over.
Clip no.9 - Growth Chart
You should have plotted the weight, height, and head circumference on the growth chart when you obtained those numbers. Now is the time to review those numbers with the parents and discuss what they may mean for the child. Occasionally there will be a deviation of the curves. Remember that weighing and measuring a one-year-old is not an "exact science", so a smaller deviation in the curves is not unusual. If there is a trend in the curves which makes you concerned, you should schedule a follow-up appointment within a reasonable time frame. Try to find a balance in how you communicate with the parents about such issues. Notice how the pediatrician in this video, while she points out a possible trend in one of the curves, also stresses that the child appears very healthy and has a normal development.
Clip no.10 - Immunization
Immunizations are often part of the visit to the Health Station. You should ask about the child's reactions to previous immunizations. Make sure that you enquire about intercurrent illness and possible allergies that might impact on the immunization schedule. It is not advisable to immunize a child who is currently ill, or seems to be "coming down with something". This is not because the vaccine as such would necessarily be dangerous for the child, but if the child is in the process of coming down with a more serious infectious disease, the vaccine may easily (but falsely) be perceived as being causative for any complications that might follow from the disease.
Clip no.11 - Taking Leave
When the visit is over, remember to praise the child for having been so good. This really applies whether you think the child has been good or not! One-year-olds cannot be expected to be at the top of their form every time they see a doctor, and you might have caught the child on an off day. The doctor is a stranger, and strangers are often quite scary to toddlers. It is important for you to recognize that this is normal. You should never fault a child for a visit/an exam that did not go well! Always try to make up and be friends before the child leaves.
Credits
The video clips you will find here have been abstracted from a 27 min video entitled 'The one-year-old', which was produced for the 'Skills Center' (Ferdighetssenteret) by the University of Oslo Photo and Video Service. This video, which is available on loan from the Skills Center for medical students at The University of Oslo, was the result of a term project by medical students. The video shows a routine examination of a one-year-old at the "Health Station". The pediatrician is dr.Iren Matthews. Professor Thor Willy Ruud Hansen has written the text which accompanies the clips, and is responsible for the splitting of the video into clips. You may contact him if you have questions or suggestions.
The video has been made available to the Pediatrics Portal with the kind consent of the parents of the child being examined.
