Toddler and Preschool Child Exam

Toddlerhood through preschool age is a time of significant physical and developmental growth. Health examination of toddlers and preschool-age children is important for encouraging good health, diagnosing existing diseases, and preventing potential health problems.

The American Academy of Pediatrics has collaborated with several national groups to create a recommended schedule for health "check-ups" throughout childhood.

The frequency of check-ups is higher in infancy and early childhood – as this is the period of most rapid growth and development. This is also when the majority of vaccines are given.

The key to a successful exam of a toddler or preschool-age child is building rapport and trust between them and the clinician. Toddlers, in particular, may be wary of strangers and unwilling to cooperate with the exam – which is expected, age-appropriate behavior.

The clinician needs to tailor their interaction to the developmental stage of the child in order to obtain the necessary information to provide good care and create a comfortable patient experience. 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. Using play techniques will make it easier for a clinician to perform the exam and will make the experience more enjoyable for the child.

For example, the clinician can demonstrate the action that the child needs to do, such as sticking their tongue out and ask the child to copy the same.

Developmental evaluation is an important part of each visit. These milestones are assessed within the domains of speech, motor skills, problem-solving, and social-emotional development. 

There are many developmental screening tools available, such as "Parents' Evaluation of Developmental Status – Developmental Milestones" and the "Ages and Stages Questionnaire." These tools typically comprise a list of questions that parents answer based on their knowledge and observation of the child's behavior at home.

Progression of language, motor, and social skills is a reflection of children's brain growth and social environment. Using books during the exam is an excellent way to simultaneously assess fine motor, language, and social development while promoting the importance of reading.

Clinicians must ensure that children are meeting developmental milestones as expected and, if not, refer them early for special services. Through early recognition and referral to special services, children with delays have an opportunity for focused attention during a critical period of child development.

This video demonstrates physical and verbal interaction approaches that can be used to build rapport with young children to ensure a safe, playful, non-threatening, and thorough physical exam that also allows them to make choices where appropriate.

Before initiating the physical exam, sit several feet away from the child and give them time to become comfortable with your presence.

For toddlers and young children, avoid prolonged direct eye contact during the initial part of the visit, which will allow them to observe the pediatrician and recognize that they are not to be feared. Building rapport with the caregiver can also send this message to the child.

Next, build rapport with the child by providing 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.

Ask questions to the child on non-medical topics, such as what they like to do for fun. How is school going? Give compliments on an article of clothing or comment on a toy they have with them.

Once the child becomes more interactive and "warms up," inform the child that it is time for a "check-up." Avoid the use of medical jargon, such as the word "examination," which will be less threatening to the child. As children are constantly listening and learning, always try to use terminologies that kids can understand, even when talking to their caregivers.

If developmentally appropriate, ask the patient where they prefer to be examined – whether on the exam table or the caregiver's lap.

During the examination, allow the child to have choices and speak directly to them, which will help to empower them as an active participant in their care. Such practice lays important groundwork for future interactions with healthcare providers as they get older.

If a child shows interest, allow them to explore the medical equipment such as stethoscope, ophthalmoscope, and otoscope.

Briefly explain to them how to use such medical equipment and let them try it out. This exercise makes the child familiar with the equipment and reduces their fear of the examination.

If the child seems uneasy about a medical instrument, pretend to auscultate the parent.

Sometimes caregivers tend to jump in and answer questions that are posed to the child. In such scenarios, politely ask the caregiver to let the child answer first or allow the child to respond to the question even if the caregiver has already answered it.

Make sure to wash hands before starting the physical examination.

Start the exam with the least invasive components first, such as listening to the heart or lungs. As these maneuvers are not painful or scary, this approach will help to build a child's trust in the examiner.

Remain positive and relaxed during the exam. Children are aware of the comfort level of a nearby person and will respond accordingly.

Where appropriate, using play techniques will make it easier to perform the examination and, at the same time, make the experience more enjoyable for the child.

Demonstrate the action the child needs to do– like sticking tongue out and saying "ahhh" and then asking them to copy that action if developmentally appropriate.

For example, in a preschool-aged child, during the lung exam, pretend that the index finger is a candle and ask the child to take a deep breath and blow it out. This will ensure that they are taking nice deep breaths so that the breath sounds can be heard appropriately.

Next, for a neurological exam, assess the stability of their gait by asking them to walk around the room.

When examining the mouth for any redness, enlarged tonsils, or ulcers, ask the child to stick out their tongue and then observe deep in the back of their mouth.

While evaluating the nose, ask the child to make a "pig nose" so that the nasal mucosa can be assessed for any swelling or discharge.

The ear exam deserves special attention since it is often a source of fear for young children. A particularly gentle approach is needed starting in infancy to avoid creating fear of the ear exam in the future.

The more you involve the child in the exam and allow them to make choices, the more in control they will feel. For example, ask them to choose whether they want to examine their right or left ear first with the otoscope.

Before looking in the child's ears, encourage them to touch the light on the otoscope to show them that it does not feel hot.

If possible, show the child how to put the "hat" on the otoscope – meaning the otoscope cover – which will help to keep them involved and interested in the exam.

During the ear examination, avoid overly aggressive manipulation of the pinna or insertion of the speculum, which can cause unnecessary pain in the ear.

Now assess the ears for any redness, swelling, or scarring of the eardrum or ear canal, discharge or obstruction, such as cerumen, in the ear canal, and integrity of the eardrum.

Developmental evaluation is an important part of each visit, and milestones are assessed within the domains of speech, motor skills, problem-solving, and social-emotional. This is done through formal screening using instruments for this purpose, such as surveys that caregivers answer based on their knowledge and observation of the child's behavior at home.

The expressive language of the child generally progresses with their age. A child says their first word at around 1 year of age, progressing to over 2000 words by age 4.

To assess a child's speech, read a book with them or ask the caregiver to do so. While reading the book, ask the child to name pictures, colors, or animals shown in the book.

If the child is willing, engage them in conversation or a game and then assess their spontaneous speech for appropriate vocabulary acquisition, and speech impediments.

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 to the caregiver appropriate to language development based on the child's age. For example:

How many words does the child know?

How many words does the child put together? How well do strangers understand your child?

Does your child understand things you say, even for words they can't say themselves?

To assess motor development, observe the child throughout the visit for demonstration of fine and gross motor skills.

The expected progression of fine motor skills involves a reflexive grasp of objects at birth to a controlled, raking grasp at 6 months, where the infant reaches for objects with their whole hand. The fine motor skills progress to a more precise pincer grasp at 9 months, where the child uses their thumb and forefinger to pick up objects.

Use small blocks or a rattle to assess the fine motor skills of a child. Place these objects in the hands of the child and then observe their grasp.

After that, place items on a flat surface in front of the child. Examine how the child reaches for the objects and picks them up, and then take note of their raking or pincer grasp.

The expected progression of a child's gross motor skills includes lifting their head up at 1-2 months, rolling front-to-back at 4 months and back-to-front at 6 months, and taking their first independent steps at 1 year.

In the case of a child, have them walk around the room to assess their motor coordination and balance.

As per the timeline for normal progression of a child's social-emotional development, babies have a social smile in response to others at 2 months and express fear of strangers at around 7 months. Babies engage in parallel play at 2 years old, and they start to play with one another and demonstrate an imagination at 3-4 years old.

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 is completed by parents 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.

The M-CHAT-R is scored by the provider, and depending on the number of abnormal behaviors identified, the child is stratified as low, moderate, or high risk for autism and referred accordingly to a developmental-behavioral pediatric specialist.

The M-CHAT-R can help to identify autism early so that intervention treatment services can improve a child's development over time.

If developmental delays are identified during the check-up, rule out any organic medical causes using appropriate tests. For example, perform a hearing test through a referral to an audiologist to rule out hearing loss in the setting of a child with speech delay.

Also, if a patient is showing concerns for motor skill delay, perform a thorough physical exam for musculoskeletal injuries or deformities.

Next, evaluate the child's environment for appropriate stimulation and resources. Ask the family about their current living situation - including access to stimulating toys and books.

Screening for social determinants of health is part of the pediatric encounter, with appropriate referrals to support services when indicated. Ask about access to food, shelter, clothing, transportation and education.

Discuss age-appropriate use of screens. The American Academy of Pediatrics recommends less than 1 hour per day for 2-5 year-old children and no screen time for younger children, excluding video-chatting. Adequate supervision is needed regarding online content consumed by the child.

Advise screen-free family meals, which have been shown to encourage healthier eating behaviors and foster language development in children.

Once organic or environmental causes are ruled out, make referrals for the type of therapy required - including physical therapy, occupational therapy, speech therapy, or behavioral therapy.

When finished with the child's exam, say "all done" and back away from the child, giving them their personal space back while praising them for doing a great job.