Fractious screaming toddler
A look at one of general practice's most stressful situations
by Dr Neil Brownlee
Your first screaming toddler accompanied by a harassed mother can be a challenging consultation. How on earth are you going to examine it? What if you miss meningitis? What are the patients listening in the waiting room going to think?
It is easy to feel hopeless.
Some partners write 'too upset to examine' in the notes. However, is this
really justifiable? It certainly would not look very good in court.
Examine your own feelings
Sit back, relax and examine how you are feeling. There will be frustration, perhaps mild anger and certainly a degree of anxiety. Now look at the mother. You both probably both feel the same.
She will be tired and frustrated. She will be embarrassed about the noise caused in the waiting room. She will probably be sleep deprived.
Think about her health beliefs. She may have read that irritability is a sign of meningitis; leaflets in fever strip thermometers tell mothers to call a doctor immediately if the temperature reaches 40 degrees.
She might have had a slight argument with the receptionist on her way in.
You are frustrated because of an inability to perform a proper examination. The constant screaming is preventing a proper history. The normal consultation rules have flown out of the window. Does this really matter?
A screaming toddler pulling at his mother's arm and trying to escape the room is very unlikely to be seriously ill. The objective of the consultation is mainly to reassure the tired, stressed mother that her child is unlikely to come to any harm. You also want to show the mother you are professional and unflappable.
If all is lost, I often let them run away and play with the toys or back to a grandparent in the waiting room. I then record this in the notes as a good clinical sign. This also allows a proper history, which is usually the most important part of the consultation. I then try to re-examine them later.
Another trick is to play for time by taking a long history until the patient settles down.
Try the old chestnut of examining their toy first. I once found an incisional hernia in an old teddy bear. Our practice nurse uses brightly-coloured finger puppets as she chats to the toddler.
If the toddler is starting to settle then the examination can be performed with minimal upset but this has to be in the right order.
Listen to the chest first. I usually listen through the vest if they are at risk of crying again. A quick look in their ears can almost go unnoticed. Examination of the abdomen can be done gently on their mother's knee (remember to look for hernias if they are unusually distressed)
Gently blanch any rashes. The mother will be waiting for this one.
Lastly look in their throat. This nearly always causes all hell to break out but by then you are nearly finished. I have a frog torch which lights up when the frog opens its mouth.
If the toddler refuses to settle
This is when clinical judgment comes in. If you are certain the child is not seriously unwell but want to reassure both yourself and the mother, then an examination can still be performed. Inspiratory breath sounds can be clearly heard between cries. The abdomen will usually become soft between sobs. Ears can still be examined effectively.
It is important not to miss a urinary tract infection. If there is no obvious cause for the pyrexia then urinalysis must be done. I usually ask the practice nurse to explain u-bags or pads to the parent.
If examination remains very difficult you can always examine them later at home. They may well have settled down in an hour or so.
A patient, relaxed examination will reassure and please the mother. You may even be in the toddler's good books and become their favourite doctor.
Tips and tricks
They tell us prevention is better than cure:
· Ask your receptionists to advise paracetamol suspension be given to a hot child before setting off for the appointment
· Keep their waiting time short try to fit them in fairly soon
· Have your room toddler friendly; toys and current posters
are a good idea; 'Bob the Builder' is still in fashion and
'Finding Nemo' is the in thing
· Try to make the mother laugh as this may well reassure
· Call the toddler by their first name as soon as they enter
this sometimes stops them in their tracks!
· If younger children attend with older siblings, I sometimes
do a quick fun examination on the younger one and pronounce their jumper poorly this may well put them
at ease when they attend for real