Over the years I have learned to examine children almost exclusively in parents' arms. However, I have noticed that lots of colleagues put children down on a bed for examination.
I am a general practitioner but i have examined children some years ago. In my opinion , a physical exam must be done always on a bed.
@Manuel: thank you for your input!
Why physical exam must be done always on a bed?
Not that a physical exam should not done on a bed, but usually children cry, they are afraid. In their parents' arms is another story. Still they can cry of course, BUT they feel more secure.
To me examen a child in his parents' arm (or seated) is more a fair "imposed" contact rather than lay down in a bed, dominated by the " doctor".
Personally I examen children from 2 months to 5-6 years old (or above is afraid) in parents' arms.
The only point that I consider for the bed examination would be the abdominal exam, just to evaluate the liver and spleen! When needed I ask the child as last procedure to lay down in the bed only if presented with abdominal complains.
Again this is an advise. But consider it. I have done long time like you, like they told me, but ever since I give priority to examen a child in is parents' arms and see how different is the relationship, I am convinced that it should be "standard of care".
Hopefully we will receive other testimonials (:-)
As a pediatrician I always examine a child in the arms of the parent, if the child is small enough to fit there. This is less scary for the children, and even the parents feel at ease when they are able to be close to the child and provide comfort.
Examination of children should taken be serious to pick up signs as possible as you can.
In my opinion, I think it should be taken individualised...
Some children can be examined in both with same results, others can be examined with parent, the reset can be on bed.
All of above depend on:
1- Age of child.
2- Complain.
3- Degree of sickness.
4- Dr's skills.
5- Situation of clinic.
6- Others.
I do as much of the exam in the parents arms/lap as I can and then do what I must (ears/abdomen) on the table. It makes the child and everyone else in the room, much more comfortable that way.
For younger children, it is better to begin by examining them in their parents arms or on their parents laps (up to about 4 years old, depending on how attached they are to their parents). Once the children are more comfortable then they will engage with the doctor and may permit more detailed examination if the doctor is friendly and not rushed.More threatening aspects should be reserved for last e.g. measuring head circumference in younger children
Older children from about 5-6 years old will usually sit on the chair themselves and cooperate if the examiner is friendly and makes it a game.
Laying them on the bed helps to make the abdominal examination more accurate but may not be necessary for other aspects. As a paediatric neurologist much of the neurological examination can be done sitting on their parents' laps and by giving them toys to get them to walk around and interact with.
The exploration of children must be made according to the situation. When we have a child who is less than 6 months old and tolerates the presence of a stranger, I explore in bed. When the child is older and have fear, I explore in the arms of his mother, except abdominal exploration, which is the only time that I explore in the bed. Best Regards
@ALL: thanks for your inputs and consideration. I am happy to hear that many of you prioritize childrens'examination in parents' arms!
I think that this point should be emphasized whenever we teach students!
For sure, most people goes on examinating on a bed. When the child is afraid (usually aged 1-3), I try to do cardiopulmonary in parent's arms, even abdominal, sometimes ear, but we normally have to nake them all to examinate skin, what involves helping with a bed, and mouth and throat examination is usually really difficult to make properly in parent's arms.
@Alfredo: Thank you!
For nose and maouth/troath examination I ask parents to hold the child seated on their knee against them toward me. With 1 arm they hold the 2 arms' child and with the other hand they hold the front (this for mouth/throat examination)
For ear inspection: same procedure with 1 arm holfing the 2 arms' child and the other hand's parent hold the head laterally, exposing each ear to examination. The for the other ear parents exchange arms.
It works perfectly!
Regards.
From a dental therapy perspective, I only see children under the age of 18, for very young children ~4 and under I will often get them to be in their parents arms, or, if possible, sitting in their parents lap - facing towards them, then slowly lay back with their head on my knees - this has been very successful for intra-oral examination in the unusual dental setting for little ones, they still have the reassurance of their parents presence.
@Alfredo: (:-)! If you really mean it, I could send to you a conventional chair!
@Peta: Thanks for your input and sharing experience!
I use either method depending on the child's demeanor.
I usually examine preschool children in parents' lap but in the end the abdominal examination usually is done with the child supine on the examination bed. The point is that the examination is complete and that the least comfortable part of the examination is done at the end.
I do the lung auscultation with the child dressed - you can hear all the phenomena as long as the child is not crying. Also, throat exam can be done without the spatula or tongue depressor even in small children. If the child is instructed to open his/her mouth he/she gags a bit and then the tongue is depressed spontaneously and the pharynx can be visualised if good light is provided.
There is a lot of tricks that can be used but the bottom line is: the examination has to be thorough.
Pediatric dermatology is a very tough job, examining a child who is asleep is fine but asking a three year old to remain in one place is a hell of a job, fear is one of the biggest challenges that one needs to overcome when examining a child. Moles pigmentations, hemangiomas, all need some touching and scraping, i think the best position is again in the arms where the child feels safe
Alessandro and marko i like your input!. In my practice i use the same approach but most important try to respect child fear modesty. As you have put it " The point is that the examination is complete", but that point can sometime be very challenging to achieve. I always establish rapport and put them on their mothers lap.warm your hands, be gentle and explain to them to promote relaxation, regardless of whether on mothers lap or on the bed if these approach are not followed your examination room will be like a torture chamber!
For the infants you can request mother to breast feed while on her lap as this will make them feel safe.
@Mahfudh: I agree with you . Thank you.
I also say to children 18-24 months " Is something is wrong and you say STOP, I will stop my examination and explain you again".
i agree with Marko. Examining children on the parents' arms bring about reassurance, that way one do better examination. For the ones you examine on the bed usually the bigger children, you can explain to them before starting to gain both their confidence and co operation.
The cardiologic examinationin of the baby is much better in arm's parent. On the other hand, the abdominal examination is difficult. So the abdominal examination is on the table. I prepare a gauze compress soaked in water and sugar an the mother hold for the baby to suck. Is a very easy and effective procedure.
The position adopted for examination depends on the exams to be carried out, i do ocular exams on children on parents lap with the child facing me to avoid fear or panic. The younger ones is best on arms, but for chn from 3 most of the time sits, while i turn the examination procedure into games as if we are playing or having fun.
it really depends of case, i mean when examin patient whith urgent surgica desease - the body position will be one of the diagnostic criteria in some cases. When i examine planned surgical patients under 3- 4 years old on the bed.
Chidren below three year of age i examine on lap of mother/care taker..above 3 on examination table ...except the very apprehensive kids beyond 3year of age.Breast feeding helpful but all mothers are not comfortable..so many a times they bring bottle to feed while examining the kid in their lap..
Both. It depends on your own experience and individualized for each baby related to his (her) age and the behavior the kids show before the examination.
Thank you all for these last inputs.
Nice to hear that the approaches are towards skipping as much as possible panic & fear...
I even do sometimes even an echocardiogram in some infants in their motherslap or mother lying on the examination table besides her child and cuddling him. Thus I can frequently avoid sedation. But otherwise, as other colleagues mentioned it depends mainly on the age an attitudes of children and their parents. one has to use his/her best judgement.
As a rheumatologist with special interest in pediatric rheumatology, I have no choice but examine the child on the table, otherwise all the info I get from the examination is distorted. Having this rule imposed on me, I must find a way to examine the child on the table, with no other consideration except how to get this done, with the collaboration of parents and child. And I assure you that after 37 years of practice, it is feasable.
1. I get the child to understand that I am a friend, not a foe!
2. I let the mother stand close to the child on the opposite side of the exam table. She can talk to him/her, hold their hands (when I am done with the exam of the small joints there).
3. Discipline is mandatory, no matter how young the child is. Paternalistic medicine is in order here, if one wants things to be productive. Discipline is applied to parents and child. They must ACCEPT the routine. Otherwise how would they behave when a blood test is ordered? You don't sedate a child just for a blood test do you?
And what about an intra-articular injection? I sedate the child (mild sedative) for that procedure, but I never call for anesthesia for that. Soon, the child gets to accept this procedure, even somewhat reluctantly, after he/she feels the benefits.
I have heard about a peadiatrician who has a mirror placed on the roof of the examination table, so the children keep watching their own image and the actions happening and thus the doctor gets the co-operation
I feel it is best to be a friend to the child, keep their apprehensions away, most examinations will need some clothings to be removed which will make the child apprehensive, making sure that you dont mean any harm is important.
I do nearly all infants and young children exam on lap of parents.Communication with child is so important before starting exam.You should aware to some key points:
1-children can concentrate to only one things(flash light,sound.moving things,...)
2- If bigger sister or brother is with him It is better to start with them.
3-Its not necessary to remove the cloth of child
4-.....
For young patients who seemed anxious I will let the parent holding them to examine. For older ones we let them lay on exam table or bed. But, I also consider what the problem the patients have. If the concern is a lump in the abdomen I will try to exam the patient on a bed.
To add to Dr Jagat Ram's comment, slip lamp exam is often needed in pediatric rheumatology (routine screening in JIA). The child is more cooperative that one thinks. Doctors are more apprehensive.
True, If you are not comfortable or apprehensive when handling a child then it will be difficult to examine or continue to work as a paediatrician. Babies and young children do have built in instinct that identify danger or threat. There is no hard and fast rule how to examine a child and where the child must be (mothers lap, on mothers chest or on the couch) but must be comfortable and not distressed.
Majority of illness in children can be diagnosed by listening to mothers because they know their child better than any doctors on earth. If any one reads this, please spend more time listening to mothers and spend less time trying to examine a distressed child. Remember, our duty is to help alleviate pain and suffering and not make fellow human (two not one) suffer.
You are all right. For many questions, it is fine to examine the child on the parents arms (auscultation etc.) However, if you realy want to palpate the abdomen thoroughly, you should do it twice, first on the parents lap and then, lying still on the bed, afterwards. If you succeed you will get a better palpation on the bed, but if the child starts crying, you still have the impression from the first examination on the parents lap. Thus, my recommendation to my students is to take time and to do it twice...
@ALL: thank you for all your input! I am really happy to hear that most of us give privilege to exam young children on parent's lap.
I still wonder if we teach this issue to young Doctor.-Often a shoch to me when rather i hear or see Doctor putting down children on the table and asking help (nurses...) to hold them tightly....
from the first time i read this question i am giving big importanceand attention on how our pediatricians examining kids. I more and more assure that it really depends on a case that u're going to exam...
only children with gross abnormal vital signs and obvious respiratory failure or shock that need rapid control of airway or rapid vascular access should be placed initially on the examination/resuscitation table.
Young infants below age of 6 months that have incomplete control of paraspinal muscles [or head/neck control] can be placed gently on the table. In my opinion a gentle approach, a smiling/friendly face and a low voice can ease the approach to a small child.
Do not forget hands temperature [wash hands with warm water to decrease abdominal garding in infants!].
I usually play with the infants/toddlers for 30-60 seconds before the "real thing" [abdominal evaluation, genital/rectal exam, etc]. If needed and procedure painfull a mild procedural sedation can be performed.
Depends on what specific examination you want to perform. It is better to examine the child with the parents
In ambulatory setting, almost complete examination including neurological assessment can be done while the infant is in the mothers lap. Keep some manipulations like eliciting tendon reflexes and other frightening parts of the examination towards the end. This is true for less than 2-3 year old young children.
I examine them while they are with their parents, sitting on their lap or in their arms
Children feel safe close to the parents, ideally on their parents lap or arms, depend of the age. Abdominal examination the child laying on the bed.
Thank you all for considering childrens examinination on parents' lap (:-)!!!
@Swaroop: of course you have to put these children under sedation...this is also part pf taking care of their comfort and keeping them far as possible from useless fear.
Neonates : Excluding abdomen / perineum, rest can be examined on the parents' lap.
Infants: If child is playful, examination on the couch, otherwise, parents' lap.
Toddler: Until child smiles back / responds to simple tasks (accepting a toy or object) child is best not examined
Older Child: Until the child engages in conversation, examination is postponed.
Another trick is to "palpate" the abdomen through the child or Mom's hand such that your hand doesn't touch the child. This along with the warm hands, smile, and not rushing, and most of hints already given. Another trick is to examine the partent's abdomen first. Kids are often fascinated by this and will then allow themselves to be examined, lying along side the parent [CAREFUL, TABLES ARE NARROW, BE ON SIDE OF CHILD SO THEY CAN'T FALL OFF].
it is depended. for example ; for chest examination at arms` PARENTS, but for abdomin examination at bed and else.
Children should be examined in the position they prephare which is most likely in the arm of their parents
There is no hard and fast rule in examining the child other than using ones initiative-examine in the best position the child is comfortable in! This could range from the child laying on the bed to sitting on the lap. Would depend on the age of the child though.
It is depended. Some time i exam the baby on arms` parents and sometimes on the bed.
I'm always willing to go to the child - maybe sitting on the floor, or standing, or in parent's arms, and thereby gain a little trust, only repeating a few things on the table if they are really scared of it.
Great answers above . I teach my students to make good eye contact and use the child's name a little during the history so that they warm up to them . As a rule of thumb before school age I suggest on the parents lap. I use a teddy bear or mom and dad to show what I am doing first then proceed to the child. I let them help and even have a look in my ears ...... with me helping them . For the abdomen I was taught years ago at Bart's Hospital that you can lay the infant over the parents shoulder and palpate between parent and infant ... great to feel a lump such at fro Pyloric stenosis .
it is depended, overall , I do physical examination after take a history. the baby and her or his parents be relax. the room air should be suitable(no hot and or no cold).
Let's keep teaching all these (right) issues whenever we coach medical students!
I am amazed - sometimes literally shocked- how often I see young doctors exam children in a technical way: on the bed, without explaining /adressing what they are willing to do to children...and without be concerned/be really aware of what they are doing!
As much as possible the best bed for child examination is parent's arms.
Kindly, it is depended. For more physical examination the best bed is parent`s arms such as: respiratory exam, nose and ear. But for abdominal examination the best bed is bed exam. Thanks
Alexandro Diana, Children bellow 3 years of age needs to be laid on bed to tecnically examine the oropharynx..
Gen exam / auscult :
best in parents lap
Abdomen :
Best in a couch. Before examining a child, it may be better to strike some conversation / eye contact in a toddler, so that the child will co-operate better.
In neonates / most infants, some kind of diversion like a toy with attractive colours would be suffice to take through the entire examination. Cellphones / glove balloons come in handy when no toys are closeby.
Yes, a child with good co-operation we could exame on parent`s arm but a child without co-0peration he/she exame on bed.
it is not depended to age`s patients. but I think more depended to patient`s illness. sometimes we exame on arm`s parents and or on bed.
As a pediatrician, one should examine the child in the arms of the mother or caregiver. This allays apprehension. Once you get friendly with the child you may examine the child while sitting or lying on the bed. However, for detecting tumors in the abdomen it is better to have the child lay on the bed or perhaps when the child is sleeping.
Examine the child in the parent's arms initially if the child is apprehensive. I often will "examine" parent first and then compare "if you sound/look/feel like mommy/daddy." I have also used a lollipop instead of a tongue depressor then will lie them down briefly while they have the lollipop and get a good "tummy tickle." This has worked very well (benefit vs low risk of choking hazard). Every visit I palpate a child's abdomen - twice during visits for other concerns - (well visit and fall in bath) - Wilm's tumors have been found.
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