Overview: Working with Pediatric Patients

OBJECTIVES

The main purpose in learning how to work with pediatric patients is to have a clear idea of the potential challenges a medical assistant may encounter when dealing with this patient population. There are many topics to cover, including but not limited to:

Understanding correctly the language used within the different pediatric age groups, learning how to effectively communicate with toddlers, adolescents and parents along with finding best practices to proper document basic and vital pediatric information like: height, weight, circumference measurements, pulse, respiratory rates, blood type screening, as well as body motor developing, sensory and language milestones throughout the patient growth. Other important skills to learn are immunization guidelines along with the proper time in which vaccinations have to be administered. At the same time, describing appropriately and effectively different signs and changes during puberty, including secondary sex characteristics. Last, but no least, providing parents with education guidelines for safety along with discussing social issues that are affecting our youth’ health today.

Pediatric age classifications and proper communication

Although often we may perceive the word “pediatric” as babies or toddlers, this conception is wrong. In reality, when we refer to pediatric we are covering from new born through 18 years of age. The medical assistant must be knowledgeable in all stages and must be able to handle the challenges these bring forth. The following terms are critical to understand and it is imperative to learn how they are related to one another in communication skills, patient/parents education and documentation. The age ranges are classified as follows:

• Newborn.- It is the initial period following birth
• Neonate.- It is the first month of life
• Infant.- It is the first year of life
• Toddler.- From the first year of life to preschool age
• Child.- It often starts with school attendance into the middle childhood
• Adolescent.- Puberty starts here, reproduction is possible and development of secondary sex characteristics

It is highly recommended to practice appropriate communication based in the patient’s age and the patient’s family. Speaking down to or over the head of an individual often creates barriers in the patient responses. It is very important to speak the language that both, the patient and his/her parents understand. When talking to a parent is vital to remain professional and call by their name, in the other hand, when talking with small children who often have not developed verbal interactions, it may be appropriate to communicate through expressions or motions.

When speaking with older children or adolescent, communication barriers may come up. Never assume a meaning or intention. Always attempt to clarify what a patient is communicating; it is valid to consider that the patient may be testing the caregiver’s reactions to words or phrases. Communication, if appropriately used, can be a major tool for great evaluations and examinations. It can increase the patient confidence to the healthcare provider and as result; enable high quality health care to the patient.

Infant/Toddler Measurements

Infants and toddlers grow at an impressive velocity, therefore accurate and consistent measurements are highly necessary to evaluate normal or abnormal development patterns. This practice is helpful in identifying any potential health issues in which early detection will be the key to prompt prevention procedures

Height and weight measurements in children at young age can be a clear indicator of potential health issues. Therefore, the medical assistant must be proficient in obtaining and recording this vital information. Being accurate is essential, especially during the early years. Indicators of questionable health may be determined based not only on initial size, but on growth pattern or trends. The National Center for Health Statistics provides charts for height, weight and head circumference. These charts use percentiles, which compare the child’s measurements with an average range of growth for children in the United States. Many factors come to play when assessing measures, one of them is familial stature, gestational age at birth, and chronic disease.

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When measuring the height of an infant is recommended to get another person to help, when possible, children under 2 years of age are measured in a horizontal position with the body fully extended, although a “caliper” (an instrument used to measure the distance between two points) is used by most practitioners, some clinics still use a tape measure to complete this task. Children with two years of age or more can be measured while standing. This procedure should be done by removing the patient’s shoes and having the patient’s heels, back and head in the same plane, it is a good practice having the patient standing against the wall. The same can be obtained with the use of an upright physician’s scale.

Weight measurement gives another way of asses the pediatric patient’s growth and development, as with height, accurate measurement documentation is used based in the statistics chart provided by the NCHS (National Center of Health Statistics). Young infants are weighed directly on an infant scale, ideally they should be weighed naked or in a diaper. Any item on the scale, aside of the child should be considered to add or subtract when taking measurements.

As children get older, techniques must adapted to the patient’s comfort, young children can be weighed in their underwear and using a standing scale. As they go into school age, a gown can be worn for more comfortable and accurate evaluation. The weight of the gowns and/or underwear do not have to determine at this age because of the constant fluctuation of ounces in these children would not be significant as they would for an infant. In the other hand, the use of accurate equipment is much more important and vital.

Head circumference and chest circumference is another source of health evaluation. Knowing the traceability of the cranium and the brain is critical in the kid’s health. Abnormally large or small head size must be monitored. Patient’s may encounter macrocephaly which is an abnormally growth of the head circumference larger than 97^th. Percentile. Before jumping to conclusions, familial or generic trends need to be considered. In the other hand, microcephaly, the abnormally small head may also indicate a pathologic condition, such as chromosomal disorder. When the head is measured, it is important to always measure the same area at all times; it is recommended to it just above the eyebrows. The information can document in either inches or centimeters according to office protocol. The chest measurement may or may not be done due to various locations being measured. This procedure is an additional calculation that is used to identify low birth weights in preterm babies and may also be used when there is a suspicion of lung or heart disease

Pediatric Vital Signs

Obtaining vital signs can be challenging at times, bold pressures are usually not taken until the age of two. Cuffs are used to measure blood pressure and they come in a variety of size and themes to make this task as pleasant as possible for the patient, although the use of new or unfamiliar equipment is often traumatic for a young child, many offices acquire equipment that is appealing to children. A good practice is to allow the child to safely touch and test the sphygmomanometer and stethoscope as well as mock with either a doll, stuffed animal or to a parent.

The pulse in the young child varies with age and growth. The young infant or toddler may be very active, thereby increase the pulse rate. The primary location for measuring pulse in infants and young children are different than the location in adults. The radial artery is normally used to check on older kids and adults, at the same time, for infants and young children, the femoral or brachial arteries are the choices for patients of this age group. Another way of measuring pulse is through auscultation which is listening to the heart with stethoscope

Respirations in the infant and toddler can be measured with the pulse. The rates will vary, depending on the level of activity or illness. Let’s keep in mind that a fever can elevate the respiratory and pulse rates.

Obtaining an accurate body temperature is another skill that is essential for medical assistant. Fevers are very common in pediatric patients and they are more frequent compare to adults. There various methods to measure body temperature. In children and adolescents, auditory or aural readings are quick and relatively comfortable. Infants with two months of age or less are best evaluated with a temporal thermometer. Another option is obtaining rectal temperature reading.

Pediatrics measurements and vital signs are key evaluation tools for identification of any potential disorders

Pediatric Development

Aside of the measurements discussed earlier, other areas of growth and development include motor, sensory and language development. There are different milestones that indicate acceptable growth and development patterns. These milestones are used a guidelines to determine the normal growth in children, especially during the first two years of age, it is important to keep in mind that some children reach these sooner or later compared to others, however this is completely normal.

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Motor development usually includes three areas of growth: reflexes, gross motor and fine motor skills, – Reflexes refer to automatic responses to any stimulation. The following are the most common reflexes: Breathing, sucking, rooting, swimming, grasping and moro. Gross motor skills include motions such as rolling, scooting, crawling and walking. Fine motor skills develop utilizing smaller movements, these include touching, grabbing, poking, pulling, and pinching.

Sensory Development are related to vision and hearing senses along with the deep perception and motion assessment. Any single area that exhibits impairments will affect the growth in other areas of development. Visual development involves increasing distances in sight as brain matures. Color perception also develops as the child grows. In the other hand, hearing improves in normal development as the child matures

Language Development from infancy forward, the child begins with noises that elicit response. These become words, phrases and finally sentences. The timing in which these occur may be different due to educational and environmental circumstances

Visual and Auditory screenings are conducted as way of measurement the sensory development and to avoid potential problems that can be treated and corrected. Prior to school age some visual milestones are evaluated: blinking, fixation on objects, coordination of eye movements, and reaching for objects, shaking ere movements and wandering eyes.

Hearing screening in the newborn and infant begins. Lack of hearing is often interpreted as intellectual delay. Clues include responses to loud noises, facial expressions and turning head toward noises. As the child matures, more formal testing of hearing can be completed. Audiometric equipment can be used for this purpose.

Vaccinations or immunizations have been recommended by the World Health Organization in a constant effort to prevent the spread identified diseases. History shows that infectious diseases have led to worldwide epidemics and studies show that the infant fatality rate decrease due to the use of vaccinations, UNICEF studies show that these include smallpox, whooping cough, polio, diphtheria, tetanus, HIB, hepatitis B, measles, mumps and rubella

Pediatric visits include schedules of specifics vaccinations from the country in which the patient lives. The medical assistant is usually responsible for administration of these vaccinations, either orally, topically, or by injection. It is the job of the medical assistant to educate patient regarding the risks and side effects of each individual vaccine. As well as direct them to websites in which they can learn more about this topic. Documentation of the vaccine given must be through, the type, the lot number, the method of administration, and location of injections is placed in the patient record or immunization log. It is an important job of the medical assistant performing pediatric injections. Proper skills need to be developing for the comfort and safety of the patient to avoid physical or emotional trauma. Most pediatric injections are given intramuscularly. An important part of the medical assistant job is to calm the patient before and after the injection.

Blood screenings are done to all infants through their capillaries and they may occur within the first seven days of life. Some blood screening is done if symptoms are present or it the presence of family disease. These could be “sickle cell anemia”, “IRT”, “Hypothyroidism”, “Homocystinuria”, “Ketonuria”, “and Galactosemia”.

Circumcision or removal of foreskin of the penis is very common on newborn infants while they are still in the hospital; however there are occasions in which due to unforeseen circumstances this procedure is done in the pediatrics’ office which could turn in complications.

Adolescent Care could be very challenging for the medical assistant. This is when the secondary sex characteristics become more obvious. At this age in when youths could show manners of independency and even exploration of new avenues such as drugs, alcohol and other substances. Communication could also be challenging with care giver. The communication could persuade embarrassment and nonprofessional. It is important to remain nonjudgmental and at the same time show empathy and professional company. Adolescent can present hug concerns for their height and weight due the influence of society and media with unrealistic and unhealthy standards, therefore the importance of being sensitive when discussing with young people about normal height and weights

Puberty brings sexual changes and reproduction becomes a possibility. During this time estrogen and progesterone hormones are increasing in girls. In the other hand, boys will have the increase in the production of testosterone. Secondary sex characteristics are the visual changes seen when boys and girls as they grow to become adults. These are features that are not necessarily related to reproduction, these are voice changes, breasts, shoulder widening and facial hair.

Behavioral and Mental Health Issues such as depression, eating disorders, abuse, suicide are thought to be primarily for adults, however they can also occur in the pediatric patients. The health professional must be aware of these signs and symptom in order to provide diagnosis and treatment to these problems