Introduction: A Familiar Scene
As I walk into the exam room, I see the parent sitting with their pride and joy on their lap. It is a familiar scene. A toddler looking up at me as I open the door with penetrating eyes, flushed cheeks, and a nose dripping with clear mucous. The child looks at me sideways and I can clearly feel them messaging me like a scene from the 1971 Clint Eastwood movie, Dirty Harry, “Do you feel lucky? Well, do ya, punk?”
As I proceed to obtain the history of the illness from the parent, I can see their fatigue and desperation from lack of sleep for the last few days. It is a common theme. The child gets sick and doesn’t eat or sleep well. Subsequently, the parents don’t eat or sleep well. The whole family is exhausted. The ultimate reason for the visit is to get their child well again as well as help the family regain the normalcy they so desperately need.
Once the interview is done, I move to examine the patient. As I roll myself on the stool toward the child sitting on their parent’s lap, there is an instant flood of tears and wailing. This is expected for this age, but it is still shocking to see the instantaneous transformation from complete silence to a volume of “10” from such a small child!
The Challenge of Examining a Toddler
The examination begins with the easy parts, listening to the heart and lungs, looking at the skin for rashes, etc. However, the transition to the more invasive part of the exam, looking in the ears and mouth, is the trickiest and most often distressing period. Needing a tongue depressor to open the mouth and get a brief look at the back of the throat requires restraining the child by the parent and can often result in the child vomiting. But, looking in the ears is the most challenging part of the exam, as to which many a pediatrician can attest.
So, moving to inspect the ears is usually met with the toddler squirming in their parent's arms, turning their head to the side, covering their ears with their hands, and any other move that makes visualizing the ears difficult if not impossible. Regardless, the need to look in the ears is crucial to rule out an ear infection because young kids with “cold” symptoms are a set-up for ear infections.
Looking into the Ears
To give you an idea of the challenge of viewing a toddler’s ear drum (tympanic membrane) to identify an ear infection or not, imagine trying to insert the hard, plastic speculum of the otoscope into the small ear canal of a moving toddler. The tip of the speculum is about 2.5 millimeters in diameter. So, you’re inserting a tiny object into a tiny space and trying to visualize the tiny tympanic membrane. Sometimes, you only have a few seconds to get a good view of the tympanic membrane and surrounding ear canal in a child who is frantically trying to not let you put anything in their ears.
Then, imagine seeing wax or cerumen in the ear canal that obscures your view. The amount of wax may be the size of the tip of a pencil. But, that may just be enough cerumen to completely obscure your view of the ear drum. So, not only do you have to look in the ear canal again with the otoscope, but you must insert a curette to scoop out the wax. Both tasks are trying to be accomplished in a child who’s moving, and both tasks can result in trauma to the ear canal that will cause bleeding which makes the task that much more stressful for the child and the family as well as obscures the tympanic membrane view with blood.
Positioning the Child for Success
The whole process of looking into the ears of a toddler is challenging on so many levels. This highlights the importance of positioning the child in a manner that limits their movement to prevent trauma to the ear canal and optimize the chances of getting the best view of the tympanic membrane to make the most accurate diagnosis.
Ultimately, positioning the child is the key to success. While there is often an initial attempt to examine the ears while the child is sitting in their parent’s arms, it is often not as successful. Once that attempt fails, we move to lay the child on the exam table. This usually entails the parent lying the toddler on their back and holding their arms and body still while I control the head to investigate each ear canal. Even with this method, I am surprised at how kids can still thwart our attempts to restrain them for the exam.
The Escape Artist Toddler
As the child is on their back and being restrained from head to toe, they still find a way to wriggle free of our hold. There is arching of the neck and back, kicking of the legs, and twisting of the torso. And, at some point during the exam, I realize that the toddler has rolled themselves over to their stomach and found a new way to hinder our attempts to examine their ears. It is like they’ve been trained by the master escape artist himself, Harry Houdini. So, when I see a toddler staring at me sideways when I enter the exam room like they are saying, “Do you feel lucky? Well, do ya, punk?”, I think for a moment to myself and pray that this is indeed my lucky day.
Have you ever had to deal with a child who was so resistant to a medical exam that it was impossible to complete? How did you handle the situation?
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