Secrets of the impossible exam

The Pediatric Insider

© 2011 Roy Benaroch, MD

From Linda: “A question I’ve had for years….how can you hear the heart or lung sounds when the child is crying? Thanks!”

I’m pretty good, at least most of the time—but sometimes my Jedi Mind Tricks fail, and Junior gets worked up. I’ll keep trying for a little while, maybe pop in a pacifier if he’s younger, or make funny faces, or count toes. But once a kiddo is really squalling, you just have to plunge ahead and get what you can get.

So can a pediatrician really hear lung and heart sounds in a crying child?

No, not really. I can usually tell the that heart is actually beating (note: I already knew that, having observed that the child is moving and upright and quite clearly alive), and I can tell that air is moving in and out of the lungs (again, we all already knew that, even the nurses in the hallway and the family next door). Maybe I could discern that the breath sounds are more-or-less symmetric from side to side, and maybe I could even tell that the heart beat is regular. But really, once there’s a lot of yelling the stethoscope is more decorative than functional.

I’ll tell you something else: getting a good ear look is nearly impossible once Junior’s over the edge. You can hold ‘em down, but without general anesthesia squirming is inevitable. And those eardrums turn quite pink from the yelling, so it’s easy to “over-call” an infection that really isn’t there. Using a little bulb to blow air into the ear canal can help, but with the kicking and yelling (especially in a toddler) it’s hard to get a good stable look. Besides, the most-upset kids also tend to be the kids with the most earwax, and the hardest kids to scrape out cleanly and painlessly.

The best way to avoid this problem is to bring Junior to all of the ordinary scheduled well checks. That way he stays used to the routine, and hopefully recognizes me. It also gives me a chance to repeat the exam over and over, so hopefully at least sometimes I’ll get a decent look and listen.

Some kids have a more-anxious personality than others. That doesn’t mean that mom or dad has done anything wrong. But there are some things that parents can do that might make it more likely to get through a visit without tears:

  • Be calm and confident. Say “The doctor’s going to look in your ears now.”
  • Don’t apologize or fret. Don’t say “Oooo baby I’m so sorry.”
  • Don’t wave toys frantically in her face. That ratchets up the worry.
  • Do bring a few favorite lovies to hold (for your child to hold, I mean. Not you.)
  • Avoid using the worst word ever said at the doctor’s office: “Hurt.” Do NOT say “this isn’t going to hurt,” because all your child hears is “HURT HURT HURT HURT.” Trust me on this. Don’t say it.
  • Don’t remind the child that she doesn’t like the physical exam. I already know that. As soon as you say, “She doesn’t like it when people look at her ears,” she’ll get teary and upset.
  • If things are getting tense, ask the doc “How can I help?”

It’s not all up to the parents, of course. The doc needs to turn on the calming mojo:

  • Take things slow. Don’t rush.
  • Don’t jump to the “most invasive” parts of the exam first. Counting toes is rarely offensive to babies, and it does help confirm that there are in fact 5 or so toes on each foot.
  • Don’t immediately try to hold down the child—give her a chance to hold still herself.
  • Let Junior look in your ears first. Then in mom’s ears. Then in her stuffed bunny’s ears. Then let the stuffed bunny count her toes (in kids older than 3 or 4, there can be six or seven toes on each foot. Cracks ‘em up.) Then the bunny can look in her ears. Etc.

For long term issues—the toddler who always freaks at the doctor’s—a few other tricks can help. Get a doctor kit to practice with at home (if you’re really ambitious, get a chrome-plated kit that looks like my toys instead of the plastic ones.) Stop by the doctor’s waiting room every once in a while to say hello (bring beignets!). Read books like Elmo’s appendix and Spongebob goes to the endodontist, or watch the video hit “Why do they have The Wiggles? A trip to the neurologist”.

Not every exam is going to go well, and even with every trick some kids will not be calmed. You can increase the odds of success, but sometimes the pediatrician will just be unable to get a great exam. Keep calm, try again, and try again next time. We’ll get through it together.

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One Comment on “Secrets of the impossible exam”

  1. Holly Misirly Says:

    One thing that has worked for my twins is the lollipop treat at the end of the visit. And I don’t just bring one for each – I bring one of every color from the DumDum bag. The time it takes to discuss the merits of each color and make a decision on which one to choose has often bought enough time to get the business done. Now that they are world-wise 5-year-olds, the distraction may lose some effectiveness, but you can bet that when we show up for flu shots this week, the bag of DumDums will be there as well. 🙂


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