advice for an M3 on handling crying kiddos

[artsydoc]

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I just started a family med rotation in a practice that's very heavily peds and am hoping for some general advice on avoiding tearful doctor visits in the toddler age group. I've had some kids in the first few days who start crying the second I walk through the door and it just gets worse from there. I know shots are awful and will cause some unhappiness but I just mean generally helping them be happy and not afraid for listening for heart and lungs, looking in ears, fairly innocuous stuff. I do know to keep them with their mom/dad for everything possible and have gotten a little better at smiling and joking with them over the just the past few days, but my attending gets very upset when the kids get upset and I'd like to get better with the little ones as quickly as I can! I'm not an awful person I promise, just not very natural with kids 🙁

 

[Socrates25]

I just started a family med rotation in a practice that's very heavily peds and am hoping for some general advice on avoiding tearful doctor visits in the toddler age group. I've had some kids in the first few days who start crying the second I walk through the door and it just gets worse from there. I know shots are awful and will cause some unhappiness but I just mean generally helping them be happy and not afraid for listening for heart and lungs, looking in ears, fairly innocuous stuff. I do know to keep them with their mom/dad for everything possible and have gotten a little better at smiling and joking with them over the just the past few days, but my attending gets very upset when the kids get upset and I'd like to get better with the little ones as quickly as I can! I'm not an awful person I promise, just not very natural with kids 🙁

1. Talk to the parents a long time before you actually go near the kids. Many/most kids will lighten up a little bit the longer you are in the room. You are a med student so you will have plenty of time to do this.

2. Buy a cute toy that attaches to your stethoscope, an animal or something with lights/flashes on it. Toddlers will be attracted to the toy and will ignore you listening to their heart or lungs.

3. Start with the least invasive part of the exam first, do the ears/mouth last. If the child starts crying during the exam, use that as a free opportunity to check out the throat, as many times you wont even need a tongue suppressor to see stuff on the palate.

4. Your attending is an idiot and shouldnt be treating kids. All of us deal with crying kids, it's the nature of the game. If your attending cant handle that then he needs to stick to adults.

 

[Lys Ile Glu Leu]

Now I'm not a medical student but I have tons of experience as a phlebotomist working with tons of kids and babies. Engaging the kids is important. Really talk to them and learn how to communicate in ways they understand. Let them check out your stethoscope out whatever else and tell them what these things do. I've found that some of the worst kids are a product of overly fearful parents, so comforting them (parents), sadly, is important as well. When all else fails, for some things, ya just gotta muscle it out, literally, e.g., hold em down for shots. Just remember why you're there and try not to feel bad.

 

[Perrotfish]

I just started a family med rotation in a practice that's very heavily peds and am hoping for some general advice on avoiding tearful doctor visits in the toddler age group. I've had some kids in the first few days who start crying the second I walk through the door and it just gets worse from there. I know shots are awful and will cause some unhappiness but I just mean generally helping them be happy and not afraid for listening for heart and lungs, looking in ears, fairly innocuous stuff. I do know to keep them with their mom/dad for everything possible and have gotten a little better at smiling and joking with them over the just the past few days, but my attending gets very upset when the kids get upset and I'd like to get better with the little ones as quickly as I can! I'm not an awful person I promise, just not very natural with kids 🙁

Babies get the 5 S treatment:
1) Suck (give them a bottle or a boob)
2) Sway (sway them back and forth, do not bounce!)
3) Side (lay them on their side)
4) Shush (make a shushing sound)
5) Swaddle (a tight swaddle where their arms are pinned calms them down amazingly well

For older toddlers
1) Distract. In pediatrics, like medical school, dignity is a liabitly. Dance for the child. Make funny faces at the child. Do robin Williams-esque voices at the child. If they laugh they won't cry.
2) Pretend play: Carry around a stuffed dog and introduce the toddler to it. Pet it and watch them imitate. Imaginative play is incredibly calming for toddlers.
3) Reciprocal exam: Let them examine you first. Once they use the stethoscope to listen to you they almost always seem to stop caring if you do it to them
4) Keep the patient in the mother's arms for as much of the exam as possible. In most clinic visits there is no particular reason the patient should ever get on the exam table if they're too young to be comfortable on it.

Shots: There is some good evidence based pain control guidance for shots:
1) Baby should be upright, not on their back
2) Insert the needle and push the injection as fast as you can.
3) The bigger the muscle the less painful it is.
4) EMLA (a topical anesthetic) applied at least 30 minutes before hand reduces pain
5) Sweeties (a super sweet thing you dip pacifiers in) appears to reduce pain for babies 6 months and younger

Ear exams:
1) You're f-cked
2) They're going to cry
3) Someone needs to invent a better way to do this.
4) If you have no reason to suspect an ear infection then don't look in the ears.

To some extent, kids cry no matter what, its just a matter of reducing the frequency with which it happens. From 9 months to about 2 years kids get 'stranger anxiety' (they scream at anyone who isn't momma and maybe Dad) and during that time even if you keep baby on Mom for the entire exam there's a better than even chance that the kid is going to wail. Do your best to get better, but at the same time don't feel bad when baby is still angry at you.

 

[Lys Ile Glu Leu]

Babies get the 5 S treatment:
1) Suck (give them a bottle or a boob)
2) Sway (sway them back and forth, do not bounce!)
3) Side (lay them on their side)
4) Shush (make a shushing sound)
5) Swaddle (a tight swaddle where their arms are pinned calms them down amazingly well

For older toddlers
1) Distract. In pediatrics, like medical school, dignity is a liabitly. Dance for the child. Make funny faces at the child. Do robin Williams-esque voices at the child. If they laugh they won't cry.
2) Pretend play: Carry around a stuffed dog and introduce the toddler to it. Pet it and watch them imitate. Imaginative play is incredibly calming for toddlers.
3) Reciprocal exam: Let them examine you first. Once they use the stethoscope to listen to you they almost always seem to stop caring if you do it to them
4) Keep the patient in the mother's arms for as much of the exam as possible. In most clinic visits there is no particular reason the patient should ever get on the exam table if they're too young to be comfortable on it.

Shots: There is some good evidence based pain control guidance for shots:
1) Baby should be upright, not on their back
2) Insert the needle and push the injection as fast as you can.
3) The bigger the muscle the less painful it is.
4) EMLA (a topical anesthetic) applied at least 30 minutes before hand reduces pain
5) Sweeties (a super sweet thing you dip pacifiers in) appears to reduce pain for babies 6 months and younger

Ear exams:
1) You're f-cked
2) They're going to cry
3) Someone needs to invent a better way to do this.
4) If you have no reason to suspect an ear infection then don't look in the ears.

To some extent, kids cry no matter what, its just a matter of reducing the frequency with which it happens. From 9 months to about 2 years kids get 'stranger anxiety' (they scream at anyone who isn't momma and maybe Dad) and during that time even if you keep baby on Mom for the entire exam there's a better than even chance that the kid is going to wail. Do your best to get better, but at the same time don't feel bad when baby is still angry at you.

Excellent advice! Since I'm considering peds on some level, I'll remember some of these points.

 

[artsydoc]

Thank you so much everyone for all the advice! I will incorporate it all and look forward to getting better at working with kids. I think they're totally adorable, just still a little clueless with what to do with them.

 

[michigangirl]

Perrotfish is on the mark. You really have to be ok with making a bit of a fool of yourself ;-) Saying silly things surprises the kids and makes them comfortable, making you less of an "authority figure" to be scared of. For the 5 to 6 year old, I'll say crazy stuff like-- so how old are you-- 52? For the 2-4 age group-- what kind of animals do you have in your ears? a frog? a giraffe?

Lots of goofy smiling, but not in a scary way. Talking to the parents for a while at first helps. Have em give you five at the beginning to start the process. Give them your stethoscope, reflex hammer, whatever, too look at and play with before you subject em to an exam with them. Give em an extra tongue depressor when you're taking one out to look in their mouth. A little goes a long way. You'll get the hang of it!

 

[dsoz]

I just started a family med rotation in a practice that's very heavily peds and am hoping for some general advice on avoiding tearful doctor visits in the toddler age group. I've had some kids in the first few days who start crying the second I walk through the door and it just gets worse from there. I know shots are awful and will cause some unhappiness but I just mean generally helping them be happy and not afraid for listening for heart and lungs, looking in ears, fairly innocuous stuff. I do know to keep them with their mom/dad for everything possible and have gotten a little better at smiling and joking with them over the just the past few days, but my attending gets very upset when the kids get upset and I'd like to get better with the little ones as quickly as I can! I'm not an awful person I promise, just not very natural with kids 🙁

Shouldn't your attending be helping you with some of these tips?

Some of the rest of these tips are great. You will get better. Not having any pride helps.

🙂

 

[BigRedBeta]

Babies get the 5 S treatment:
1) Suck (give them a bottle or a boob)
2) Sway (sway them back and forth, do not bounce!)
3) Side (lay them on their side)
4) Shush (make a shushing sound)
5) Swaddle (a tight swaddle where their arms are pinned calms them down amazingly well

For older toddlers
3) Reciprocal exam: Let them examine you first. Once they use the stethoscope to listen to you they almost always seem to stop caring if you do it to them
4) Keep the patient in the mother's arms for as much of the exam as possible. In most clinic visits there is no particular reason the patient should ever get on the exam table if they're too young to be comfortable on it.

Ear exams:
1) You're f-cked
2) They're going to cry
3) Someone needs to invent a better way to do this.
4) If you have no reason to suspect an ear infection then don't look in the ears.

In my general peds days, I developed a method for ears that I'd say got me through about 80% of exams with no crying. Not even joking.

Here's what I did:
Obviously building trust is important, and you have the whole exam prior to looking in the ears to build that. For the prime screamers (8 months to 2 years old) when I came in the room, I'd usually try to engage them first, give them something to make it seem like I'm okay. Little ones got a tongue depressor which I drew a smiley face on (important because it can go right in there mouth with no worries). Bigger toddlers got a inflated exam glove or I'd play with their toys with them. Patty cake, high fives and peek a boo are also super important.

During the exam, everything I used I let them touch and handle first. If I'm going to listen to heart and lungs, then I hold out my stethoscope and ask if they want to hold it - kids are curious and if they get to handle something on their terms, it goes much better. After they got a chance to check it out, I'd ask if they could give it back, and then would "listen" to less threatening areas first - their hand, their leg, the top of their head - before getting all up in their personal space and doing my real exam.

For ears, the routine was somewhat similar. First I'd show them that the otoscope had a light by shining it on my hand, then on mom/dad's hand, and then on the kiddo's hand - again, demonstrating that it's not threatening. This is followed by me showing how the light can make my fingertip glow, again with mom or dad, and then hopefully with the child. You never force the child to touch anything they don't want to, and it simply works better if they end up being the ones reaching to try it out. Then add on the speculum, show them that it's still the same thing and can make their finger glow, and then start talking to them about looking in their ears. It doesn't always work, but I had so many parents tell me that I was the first doctor who'd gotten their child through an ear exam without tears that I figure I must have been doing something right.

The other key for a good ear exam is having the parents hold. For kids that are going to scream and squirm, you have to have the parents help or you'll never see anything ever. Here's the way parents need to hold:

1) child is on lap, facing one direction - everything pointed the same way. That means both feet, knees, shoulders, belly button and head are the same way to your right or left. Kids should not be straddling parent.
2) Parent is going to take their arm that's touching the child's back and use that to hug the child tight and take control of the arms.
3) Parent's other arm is then used to hold the child's head to parent's chest.
4) Looking in the other ear, requires flipping the child around in block and repeating the hugging steps but with the arms in opposite positions.

This is the best way to get through an ear exam with a squirmer.



Mouth and throat exams, biggest thing is being quick and accepting you're not going to get a great exam no matter what. As a medical student, you should just do this with you attending, not on your own.

Again the hold for smaller kids is important. My strategy was to sit knee to knee to the parents and then lay the child across our laps, with me taking the legs and mom/dad arms and head. The best way for parents to accomplish that was to take the child's hands and hold them to the child's ears so that they could then keep the head midline at the same time. Then it's up to the doctor to be quick - I usually just gagged them so that they opened up quick, took my 1/2 second look and called it a day. Most kids, once my hands were off them and I was saying "all done, all done", calmed pretty quickly.


Thankfully, my gen peds days are over and I don't have to do these exams on quite as routine basis.

 

[JRjcu08]

The other key for a good ear exam is having the parents hold. For kids that are going to scream and squirm, you have to have the parents help or you'll never see anything ever. Here's the way parents need to hold:

1) child is on lap, facing one direction - everything pointed the same way. That means both feet, knees, shoulders, belly button and head are the same way to your right or left. Kids should not be straddling parent.
2) Parent is going to take their arm that's touching the child's back and use that to hug the child tight and take control of the arms.
3) Parent's other arm is then used to hold the child's head to parent's chest.
4) Looking in the other ear, requires flipping the child around in block and repeating the hugging steps but with the arms in opposite positions.

This is the best way to get through an ear exam with a squirmer.

This is on the money.
I've sat on the floor before to listen to a kid's heart/lungs while he sat under the chair. Whatever works. Something else I've done as an ice-breaker is to let them listen to their own heartbeat with the stethoscope.
Another trick I picked up to look at babies' eyes when they won't open up is to turn the whole room light off first so that there is complete darkness.

 

[Giic]

1. Talk to the parents a long time before you actually go near the kids. Many/most kids will lighten up a little bit the longer you are in the room. You are a med student so you will have plenty of time to do this.

2. Buy a cute toy that attaches to your stethoscope, an animal or something with lights/flashes on it. Toddlers will be attracted to the toy and will ignore you listening to their heart or lungs.

3. Start with the least invasive part of the exam first, do the ears/mouth last. If the child starts crying during the exam, use that as a free opportunity to check out the throat, as many times you wont even need a tongue suppressor to see stuff on the palate.

4. Your attending is an idiot and shouldnt be treating kids. All of us deal with crying kids, it's the nature of the game. If your attending cant handle that then he needs to stick to adults.

LMAO at your #4. I agree completely.

 

[Giic]

Babies get the 5 S treatment:
1) Suck (give them a bottle or a boob)
2) Sway (sway them back and forth, do not bounce!)
3) Side (lay them on their side)
4) Shush (make a shushing sound)
5) Swaddle (a tight swaddle where their arms are pinned calms them down amazingly well

For older toddlers
1) Distract. In pediatrics, like medical school, dignity is a liabitly. Dance for the child. Make funny faces at the child. Do robin Williams-esque voices at the child. If they laugh they won't cry.
2) Pretend play: Carry around a stuffed dog and introduce the toddler to it. Pet it and watch them imitate. Imaginative play is incredibly calming for toddlers.
3) Reciprocal exam: Let them examine you first. Once they use the stethoscope to listen to you they almost always seem to stop caring if you do it to them
4) Keep the patient in the mother's arms for as much of the exam as possible. In most clinic visits there is no particular reason the patient should ever get on the exam table if they're too young to be comfortable on it.

Shots: There is some good evidence based pain control guidance for shots:
1) Baby should be upright, not on their back
2) Insert the needle and push the injection as fast as you can.
3) The bigger the muscle the less painful it is.
4) EMLA (a topical anesthetic) applied at least 30 minutes before hand reduces pain
5) Sweeties (a super sweet thing you dip pacifiers in) appears to reduce pain for babies 6 months and younger

Ear exams:
1) You're f-cked
2) They're going to cry
3) Someone needs to invent a better way to do this.
4) If you have no reason to suspect an ear infection then don't look in the ears.

To some extent, kids cry no matter what, its just a matter of reducing the frequency with which it happens. From 9 months to about 2 years kids get 'stranger anxiety' (they scream at anyone who isn't momma and maybe Dad) and during that time even if you keep baby on Mom for the entire exam there's a better than even chance that the kid is going to wail. Do your best to get better, but at the same time don't feel bad when baby is still angry at you.

I DISAGREE. YOU SHOULD ALWAYS LOOK IN THE EARS NO MATTER WHAT.
Kids crying should not be a reason to circumvent a thorough pediatric exam.

 

[Perrotfish]

I DISAGREE. YOU SHOULD ALWAYS LOOK IN THE EARS NO MATTER WHAT.
Kids crying should not be a reason to circumvent a thorough pediatric exam.

I see your point but I disagree. I think any exam maneuver that makes your patient uncomfortable should avoided unless you have some reasonable index of suspicion for a pathologic process, and you're suspicious for something that might cause to alter your management based on the exam findings. Boys, for example, don't get a rectal exam unless they have GI/anemia/motor neuron concerns. Similarly I don't think toddlers should get an ear exam unless they have ear pain/hearing/ID concerns.

I can't think of any congenital anomalies I would be looking for. Is there anything else on a screening ear exam has altered your management of a patient who presented to clinic for a well child exam?

 

[BigRedBeta]

I see your point but I disagree.

I can't think of any congenital anomalies I would be looking for. Is there anything else on a screening ear exam has altered your management of a patient who presented to clinic for a well child exam?

I've found foreign bodies that no one knew about. Also sent 2 different kids to ENT for non-healing TM perforations - one of which was after PE Tubes (something that is in my own PMH) and it expedited their previously scheduled follow up. Given the frequency of AOM in the toddler years, you could make the argument that you're always providing surveillance for OM with an effusion...

 

[Giic]

I've found foreign bodies that no one knew about. Also sent 2 different kids to ENT for non-healing TM perforations - one of which was after PE Tubes (something that is in my own PMH) and it expedited their previously scheduled follow up. Given the frequency of AOM in the toddler years, you could make the argument that you're always providing surveillance for OM with an effusion...

Agree completely. I was trained as a resident to ALWAYS check.

 

[BabyDoc86]

Babies get the 5 S treatment:
1) Suck (give them a bottle or a boob)
2) Sway (sway them back and forth, do not bounce!)
3) Side (lay them on their side)
4) Shush (make a shushing sound)
5) Swaddle (a tight swaddle where their arms are pinned calms them down amazingly well

For older toddlers
1) Distract. In pediatrics, like medical school, dignity is a liabitly. Dance for the child. Make funny faces at the child. Do robin Williams-esque voices at the child. If they laugh they won't cry.
2) Pretend play: Carry around a stuffed dog and introduce the toddler to it. Pet it and watch them imitate. Imaginative play is incredibly calming for toddlers.
3) Reciprocal exam: Let them examine you first. Once they use the stethoscope to listen to you they almost always seem to stop caring if you do it to them
4) Keep the patient in the mother's arms for as much of the exam as possible. In most clinic visits there is no particular reason the patient should ever get on the exam table if they're too young to be comfortable on it.

Shots: There is some good evidence based pain control guidance for shots:
1) Baby should be upright, not on their back
2) Insert the needle and push the injection as fast as you can.
3) The bigger the muscle the less painful it is.
4) EMLA (a topical anesthetic) applied at least 30 minutes before hand reduces pain
5) Sweeties (a super sweet thing you dip pacifiers in) appears to reduce pain for babies 6 months and younger

Ear exams:
1) You're f-cked
2) They're going to cry
3) Someone needs to invent a better way to do this.
4) If you have no reason to suspect an ear infection then don't look in the ears.

To some extent, kids cry no matter what, its just a matter of reducing the frequency with which it happens. From 9 months to about 2 years kids get 'stranger anxiety' (they scream at anyone who isn't momma and maybe Dad) and during that time even if you keep baby on Mom for the entire exam there's a better than even chance that the kid is going to wail. Do your best to get better, but at the same time don't feel bad when baby is still angry at you.

This is awesome! 👍 Thank you~

 

[Spinock]

Agree with all of Perottfish's advice.

Also...don't be scared! Kids get uncomfortable when you're uncomfortable. Best of luck!

 

[Sweet Tea]

BRB's exam technique is spot-on.

Mouth and ears are the last thing I do. I talk to the parents, and leave the kid with mom and dad. I use this time to feel out the kid...are they a "song and dance" kind of kid who will open up if you put on a show and sing a silly song, or are they a quieter kid who will work with you if you slowly and quietly build their trust? Once I figure out my approach, my exam is pretty much the same: start with the non-threatening stuff, do silly stuff like put my stethoscope on their knees and ask them if I'm doing it right, and then save the ears and mouth for last. The advantage to screaming during the ear exam is that you can use it as an opportunity to get a good look at the palate, and I tell the parents that I am looking at the palate so that they don't try to shush the kid.

Other things to make looking in ears easier...don't hold the otoscope like a hammer. For the love of pete, it's not a hammer. You have much less control and much greater chance of a painful exam if you hold it like a hammer. Hold it to the side, and on younger kids, gently tug the pinna down and back. This will help straighten out the canal and make it easier to see the TM without abusing the ear canal. Like others, I look in just about every kid's ear, and I have 2 reasons for doing this. 1) It's like a treasure chest and you never know what kids are storing in there (beads! bugs! pieces of lunch!) and 2) parents pretty much expect that you're going to do it and it helps build trust that you're doing all the doctor stuff right. Seriously-- I've had parents call me out when I haven't looked in their kid's ears, even when they've been hospitalized for a butt abscess.