Am I Going to Get A Shot:
Navigating the perils of the pediatric exam.
By Jeff Bennett, DO
I thought I was done with small talk about 12 years ago when I got married. However, when you are a pediatrician it is literally small talk that gets you through an exam.
First meetings between adults are most often cordial. With kids, this is not always the case. Once children younger than 2 have seen you, waterworks and screaming often begin and listening to their heart and lungs is difficult. This is a learned, Skinnerian behavioral model. Simply put, kids go to two-, four-, six-, nine-, 12- and 15-month exams and get their immunizations. Mixed with an age of strong anxiety and there you have it; even a toddler knows (or suspects) what will happen. Once they are 3- to 4-years-old they ask the important question . . . “Am I gonna get a shot?!?” or, as my daughter asked when she was that age, “Am I gonna get a shock?!?” Once the dreaded shot was given she questioned, “You cut me?!?”
The ability to examine kids is certainly an art often aided by knowledge and experience. A pediatric residency and the training that pediatric nurse practitioners go through are vigorous. It involves seeing thousands of kids from well children to those in emergency rooms to the sickest children in the oncology clinics, neonatal and pediatric intensive care units. Fortunately, most of the children who come into KidMed, pediatricians’ offices and pediatric emergency rooms do not have dreaded or scary illnesses, but believe me ... we are always on the lookout.
When the parents bring their child in for illness there are two agendas – the parents’ and the child’s. The parents want to know what is going on and what needs to be done to diagnose and treat. The child, on the other hand, just wants to go home. At KidMed we have set up some distractions that help somewhat, including the TV and the promise of popsicles, lollipops and stickers to those who are “good” (SPOILER ALERT – they all are). A lot of parents are using iPads and phones to play games or songs that are really helpful also.
The exam and level of cooperation vary with each child and especially with the age of the child. While each child is different, there are some general guidelines we use:
- Know who is in charge. Generally it is the child. He/she will allow the exam in his/her timeline, not yours.
- Examine heart and lungs while the child is asleep or distracted. Smaller kids are usually being held by parents and a lung exam can often be accomplished before they know it. Heart exams are a little more difficult as kids see the stethoscope as you bring it around.
- Distraction. Infants usually love mouth-popping noises. Toddlers and small kids love TV and games. Know your “Dora” and “Teenage Mutant Ninja Turtles.” For example, if a little kid is wearing “Dora” shoes, you can often comment on the attire. “You look super cute in your ‘Dora’ shoes.” It also gives the examiner the opportunity to continue with the motif and find Boots and Bennie the Bull in the child’s ear.
- Get the question “Am I going to get a shot?” out of the way. If you don’t need blood work or medicine by injection, let them know early. If they need it, tell them “I don’t know yet.” Shorten the “fret” time as much as possible. We get everything set up first. Then, only when you are ready to do the injection, let them know what you are doing and why you are doing it. I always let them know that “I would not do this if I didn’t know it was going to make you better.”
- Young kids are poor historians with responses that can be misleading. A 2-year-old will answer a leading question. For instance, a child is brought in and a parent asks “Does your belly hurt?” and the child nods and says “yeah.” The parents will often turn to me and say “See.” So I ask the child “Are there dragons in your nose?” The child often nods and says “yeah.” Like I said, poor historian.
- Five to 8 is the age of “kinda” or “sorta.” Most kids that age just want to make you happy and they will give that unequivocal answer almost every time.
- Teenagers often just answer questions with an eye roll or are too busy texting (fortunately we have learned to speak eye roll at KidMed). Sometimes I think it would be easier to find out what is bothering them through their Facebook page or Twitter account.
- Positive reinforcement, verbally and with treats, usually does the trick. Part of the beauty of the promise of a sticker, Popsicle or lollipop is the autonomy of getting a choice of what they want after a lot of lack of choice. Ask “what color would you like?” and the crying stops almost immediately in most cases. Although, redirection may be needed when they pick rainbow or chocolate Popsicles. We don’t have either of these flavors . . . which disappoints us both.
- Make the environment as comfortable as possible. Some kids are not amenable to any exam in the patient room, despite all of our efforts. One child cried every time I cracked the door. This went on for a half-hour. I finally had to go outside and watch how the child interacted with the parents through the window (hiding behind an air conditioning unit). Once I saw him playing I knew he wasn’t too sick. Desperate times do require desperate measures. I had to watch another child who had a head injury play outside in the mulch bed behind the building to see if he was OK as he had cried 30 straight minutes in the room!
- Last resort – bring back the late ’60s: DRUGS are a very important part of KidMed’s arsenal. While some kids only need topical anesthesia, with a lot of talk and reassurance, others need injectable meds for pain relief in laceration repairs, imbedded fish hooks and other foreign bodies. When reassurance does not work or the procedure is too painful or prolonged, we often use intranasal medications for mild sedation. We will also use intravenous medication for certain procedures such as reducing shoulder dislocations, straightening the bones that are broken (with cooperation with Tuckahoe Pediatric Orthopedics) and other involved procedures.
Finally, there are subtle things about taking histories from parents and examining kids that are really important and take a keen eye and ear to make an accurate diagnosis. Not every pediatric fever requires the all too common, cookie-cutter approach of blood work and chest X-ray that is commonly seen in adult-based urgent care and ER settings. It is also why the American Academy of Pediatrics has urged parents to stop bringing their children to retail clinics. It is important to see board-certified pediatricians and staff, geared toward infants, toddlers, children and teenagers. The marketing I have seen is very misleading at some of these clinics. If there is not a board-certified pediatrician there, they are not experts in pediatrics.
KidMed offers after-hours care to ill and injured children and young adults, newborn through age 21. Its offices, in Midlothian, Glen Allen and Mechanicsville, are open evenings, weekends and holidays, 365 days a year. No appointment is necessary.
Dr. Jeff Bennett had 13 years of pediatric and adult emergency medicine experience prior to co-founding KidMed in 2009. He is a Fellow of the American Academy of Pediatrics and is board certified in pediatrics.