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Children account for approximately 30% of visits to most EDs. The majority have minor or self-limited illness, which may optimally be cared for in a nonemergent setting. However, the recognition of acutely ill children who are at risk for organ system failure from the larger number of children with similar complaints who will recover spontaneously represents one of the most important and challenging diagnostic skills for emergency physicians. The key to mastering this process of identifying ill children is knowledge of child development as applied to the emergency setting.

Although there are many specific aspects of the developmental approach, a few general principles are applicable to all age groups of children and their families.

Communicate with the Child

Approach children with a positive and gentle manner. The child’s first impression sets the tone for the encounter. Review the emergency record for patient name and age so that an introduction and a developmentally structured interaction may be planned, based upon the child’s age-related communication skills and perspective. Whenever possible, look at the child at his or her own eye level or below. Use the child’s motor skills, vocabulary, and specific life experiences as reference points. Hunger, discomfort, fear of separation or pain, and feelings of loss of control should be directly addressed. Recognize that the ED is a strange and threatening environment, and, whenever possible, isolate children from the sights and sounds of other patient care experiences that may heighten their own anxiety. Most importantly, be honest with children regarding expectations for their experience so that trust can be established.

Communicate with the Family

Assess and treat the child in the context of his or her family, avoiding separation whenever possible. ED policy should encourage parental accompaniment of children to the clinical area, for minor complaints as well as resuscitations where parental presence can be particularly important. It is best to recognize that there are two patients, child and parent(s), each with expectations that must be addressed. Caregivers have essential historical information and, in the case of infants and toddlers, are physically necessary to the performance of a meaningful physical assessment. At all ages, children watch their parents for cues with respect to how to respond to the medical staff. Parents who understand and accept the sequence of events involved in emergency care become allies in enlisting their child’s cooperation. Whenever possible, encourage parents to remain present during procedures and to maintain visual and physical contact with the child from a sitting position. Appropriate exceptions include parental discomfort and critical illness. Finally, because parents are intimately familiar with their child’s range of verbal and nonverbal behavior, the examiner must take the phrase “this is not my child” as a valid parental concern. Reliance on parental knowledge is particularly applicable to the assessment of a child with developmental delay.

Assess by Means of Observation

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