PHYSICAL ASPECTS Growth rate slows significantly during this period, and appetite decreases further. Children develop a more lean body habitus. The incidence of injuries increases with increasing activity. The preschool child is no longer restrained in a car seat and is at risk for defined injury complexes from improperly fitting lap and shoulder belts. A DPT booster is given shortly before beginning school, between the ages of 4 and 6 (see T§ble...111:3).
NEUROLOGIC ASPECTS Preschool children develop progressive autonomy in terms of mobility and self-care. Attraction to books, drawing, and coloring is common. Expressive language skills expand rapidly, and children this age are often able to identify site(s) of specific complaint. However, a strong sense of fear of pain remains, and the level of anxiety remains high in the emergency setting. Preschool children live in the present and have a limited sense of time and history, so that prior symptoms are frequently forgotten. Self-centered "magical" reasoning is the rule, so that many preschool children believe that emergency department care is punishment for misbehavior. This is occasionally reinforced by parents who state they will "have the doctor give you a shot," which should be discouraged.
AGE-SPECIFIC APPROACH Many preschool children may be directly approached and examined in the traditional systematic fashion. However, some will require the indirect approach described for toddlers, and the nearby presence of a parent is typically essential for cooperation. The examiner should always talk directly with the preschooler to establish rapport and confirm the general complaint. Identification of recent positive experiences such as birthdays or favorite cartoon characters is frequently helpful in gaining cooperation. However, preschool children should be expected to identify only the current complaint, and reliance on parental history should remain. Cooperation during the physical examination is likely, although less comfortable components are still best performed at the end. The performance of painful procedures requires a careful approach. It is always best to be honest regarding discomfort, but information should be given immediately before performing the procedure to minimize the effects of fantasy regarding pain and causality as well as delaying tactics. Comfort and distraction by the parent is frequently effective for minor procedures; however, restraint as for toddlers is typically necessary. Rewards such as verbal praise and a sticker for bravery often significantly enhance the memory of the experience for the child and family.
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