Introduction

One of the most anxiety-provoking experiences for medical students is pediatrics. Dealing with children brings special challenges and problems that are generally not encountered in other fields. In fact, I've seen intelligent, proficient students stopped dead in their tracks, intimidated by a willful 15-month-old, completely unsure of what to do next.

As students, you're still busy learning how to conduct a good physical exam, and it's hard enough to get an adult to breathe deeply in and out on command. But try it with a crying newborn, or a shy 2-year-old, and it suddenly gets even harder.

However, even if you are not planning on going into pediatrics or family practice, many different types of providers may still end up seeing children, particularly if they are working in areas without easy access to pediatric subspecialists. For example, it's not unusual for neurologists in smaller cities to see children since a pediatric neurologist may be a few hours away.

While frustrated clinicians will often document that an exam was difficult or impossible due to a crying or uncooperative child, we all know that the best care is delivered when we can do our best to elicit a good history and examination. In this article, I'll discuss some general tips and techniques that I've picked up over time that will not only make your (and your patient's) life easier, but will also help you deliver good-quality healthcare.

Many of the tips focus on the most difficult age group: 12-36 months. These children are still being seen fairly often for well-child exams and minor illnesses, and can make up the biggest challenge in terms of exam skills. Sometimes using these tricks with older children will work, but often they'll simply look at you like you're crazy.

Invest the time up front; it'll pay off in the end. Often, when we're in a rush, we'll leap right into a physical exam soon after walking into the room. For a young child, having a stranger come right in and begin touching him is frightening. Well-meaning parents may compound the problem by taking the child away from his toys or books and placing him up on the exam table the moment you walk in. Instead, walk in, say hello, and wave briefly at the child. Sit down and begin taking a history. This will allow the child to get used to your presence and also to see that you are talking with his parents -- if mom and dad are okay with you then you can't be all that bad.

Those who forget history are... History is tremendously important in pediatrics. Parents tend to know what's "normal" for their child. Don't be afraid to ask if what you're seeing is "usual" for their child, particularly if you haven't seen them before. Also, children can act very differently in your exam room; don't assume that because they're sitting quietly means that they aren't speaking yet -- or aren't throwing tantrums with alarming regularity at home.

It's okay to cry -- or cause it. I always take trying to get through an entire visit without frightening a child as a "little personal challenge," but it doesn't always work out. While no one likes having to deal with a screaming child, sometimes you have to. Keep in mind that infants will often cry for what appears to be no reason at all. Many students worry that the parents will think they are incompetent, but most parents will be too embarrassed about their child's behavior to focus on you. Also, don't take it personally: Remember that stranger anxiety starts around 9 months of age, peaking at 15 months.

Incidentally, auscultating lungs while a child is crying is indeed possible. Just remember that even when screaming at the top of their lungs, all children have to pause to take a deep breath so they can keep crying. That pause is your opportunity!

Be flexible -- in more ways than one. Don't be afraid to sit on the floor if that's where the child seems most comfortable. Also, be open to different ways of examination. Most of my pediatric exams were conducted with the child in the mother's lap. This way, the child felt secure, could be held briefly in place, and was at a good height to work with. Think about the "child's-eye view." Standing in front and leaning down may seem looming to them and provoke anxiety. Crouching down to say hello at the beginning is great, and asking the child to "give you 5" works well. While not all will do so at the outset, many will do so at the end once they've discovered you're not so scary.

Don't ask, don't...lie. Don't lie to children. They won't forget it if you say "No shots" even if you know they'll be receiving immunizations later. Also, be careful with inadvertently asking permission. What do you do if you ask, "I'm going to look in your ear now, okay?" and the answer is "No!" Calm, declarative statements are best -- and feel free to give children choice where it doesn't matter to you. "Which ear shall I look in first?" is just fine.

Be infantile. Be willing to quickly change a diaper instead of leaving it, or swaddling a baby properly in a receiving blanket: You'll win friends among staff and parents. If you don't know how to do either, ask. I'll never forget the mother who kindly taught a hapless student (me) how to swaddle a newborn properly.

Lose the white coat...maybe. Many people suggest not wearing a white coat in pediatrics since it may frighten the children. This is certainly true in some cases; at the same time, during my student days and early in practice, I would have been lost without the pockets of my coat for umpteen little reference books. My suggestion: Walk in and if the child seems suddenly scared by you, pull off the coat. Many kids will focus more on your demeanor and attitude than your clothing.

Don't be too silly. A common mistake is to try to be "too much of a friend." Acting very silly and messing around a lot often leads to a child who will not listen to your instructions when it's actually important. Joke around, be friendly, but don't overdo it.

Handy cartoon items of clothing. The ability to wear a tie or a scarf with cartoon characters is one of Dipesh's Two Major Advantages of Pediatrics (the other is being able to make booger jokes in a professional setting). Many parents will point and say, "Look, he has kitty cats on his tie." Additionally, with infants, waving the brightly colored tie or scarf around will distract them while you auscultate or palpate. Some people like to attach a small toy to their clothing or stethoscope. I tried this and found it had one major problem: The child would often remove the toy, and retrieving it became difficult, especially if (a) the toy was not safe for their age and (b) I didn't have an inexhaustible supply available. Also, it's particularly hard to auscultate well if a child is fixating on the little koala bear on the end of your stethoscope and grabbing it while you try to listen.

Enlist their help. Often a "safe" way to touch a patient starts with the stethoscope. Ask children for their help: Tell them you forgot where the earpieces go. If they seem unsure, ask if it goes on your nose, pinching your nose with the earpieces to create a comical nasal voice. When they tell you it goes in you ears, hang the stethoscope on one ear, like a large earring. Some kids will be shy enough still that they won't say anything, in which case a parent usually provides the "right answers," or you can mysteriously suddenly remember everything from your clinical skills course.

Listen and save. Start by auscultating their abdomen. As soon as the head touches the child, make an exaggerated surprised look on your face. Do this each time you auscultate. This has the effect of drawing the child's attention away from the stethoscope (and perhaps trying to push it away) as well as entertaining them. Practice making faces in the mirror -- most of us are capable of being fairly funny-looking.

A common concern among parents is the "rattling chest." Remember that upper airway congestion in a young child can easily transmit noise down the respiratory tree and can even be felt as "rattling." Don't minimize or ignore parents' concerns. Instead, explain how upper airway congestion can "echo" throughout the entire chest. Also, ask your preceptor to help you differentiate between transmitted upper airway noises and signs of actual lung pathology.

Stunt palpation. Tell children that you're going to figure out what they had for lunch (or breakfast or whatever). Palpate their abdomen gently and then stop. Claim it's something outrageous, like a truck. When told "No!," palpate again "for another try," and keep going. By the time you've "given up," you've completed your abdominal exam, often fairly deeply. As an aside, a child who states that her "belly hurts" each time you come within 6 inches of it can often have her claim verified by "stethoscope palpation" while you're "listening."

How to be "hip" for pennies a day. For the slightly older patients, learn something minor about very popular cartoons, toys, or sports, which can often be learned from newspapers (unfortunately, you cannot claim Continuing Medical Education credits for watching Saturday morning cartoons, even if it is technically "professional development"). One 6-year-old let me do whatever I needed after he discovered I knew how many different Pokémon there were, a fact I had gleaned solely through seeing the ad for the movie in the local paper.

Looking in ears and mouths without starting a major land war. The most difficult part of most pediatric exams is looking at eardrums and throats. Face it, otoscopes are fairly scary-looking, and kids are wary of being gagged by a tongue depressor. First of all, leave the HEENT exam for last. When you do get to that portion, tell the child that you want to show them something really cool. Take the otoscope and put your finger over the end and turn on the light. Point out how you have a cool "light up" finger now. Hold out the otoscope end and offer the child the chance to light up their finger. (Recalcitrant children are often convinced if a parent or sibling tries it out first.)

Now ask them to hold the otoscope tip for you and put it on the end like a hat. At this point, they've touched the otoscope enough times that they realize it isn't so scary. If you tell the child that you now want to see if they have light-up ears, most will not resist. Light-up noses and light-up teeth generally follow in quick succession.

This is more than just a game, incidentally. By doing the above, you've also learned a lot about the child's fine motor skills (placing an otoscope tip) and receptive language skills. It can surprise you that a shy 11-month-old can be grammatically sophisticated enough to understand "Can you put this on here?"

Warning signs, Part One. If you walk into a room and a child is lying still on the exam table, she's either sound asleep or very ill. A child who is not moving much or is "looking very sick" is a child who needs to be examined and possibly worked up very carefully.

Warning signs, Part Two. Be very aware of a child who is so fearful that he will not leave his parent's side at all and spends the entire visit eyeing you nervously. If there is no history of possibly traumatic medical encounters (a child who has been hospitalized and subjected to repeated invasive tests, for example), you may need to delve deeper. One 2-year-old acted in precisely this manner, and after I diagnosed him with a minor viral upper respiratory infection, I asked his mother if he often behaved in this manner. After some discussion, it came out that he had witnessed numerous instances of domestic violence between her and his father, whom they still lived with. Given their lack of insurance and the fact that the mother didn't have a regular healthcare provider, the child's behavior was the only clue that led to his mother being referred to a women's shelter.

Finally, these tips won't necessarily work in every situation or with every child. Sometimes they won't work at all. Rather than focusing on the specifics, however, think about the overall philosophy behind these techniques. A cooperative child makes for a rewarding and fun interaction, and let's face it -- sick adults are usually far more whiny than most children, healthy or sick. Parents will also appreciate that you're making the effort to make the visit easier for their child. And, of course, children will look forward to seeing "that funny doctor." It's a win-win situation for everyone.