Paediatrics for beginners

Its been a while since I last taught anybody anything, being busy preparing for exam and working. Thus I think it is appropriate to just share something during my rare free time, just for the benefit of medical students.......Okay I admit I'm bored.

Its a common perception : Paediatric cases in exam has high mortality rate. Here are some tips for medical students in dealing with those freaking squealing things called a child. Following this steps may reduce mortality rate in exams.

Why do medical students "die" in Paeds?
1)They thought children are "small adults" and treat them as such
2) they cannot tolerate crying babies and child
3)They panicked once they think they fail to follow so called "steps" when examining the child
4) They are too focused on the child, not realising that the caretaker(most of the time, the mother) is the Mouth of the child.

Prepare the following before your exam : A good pair of eyes, a calm and clear mind, playful character, selectively deaf ears, gentle pair of hands, flexible skill(with no hard and fast "steps" but complete) and small TOYS(after all, all the toys in the world are created for kids except for sex toys.)

There is a term in psychiatry called anticipatory anxiety(AA). Anticipation is a must in planning anything, but add the other A and it becomes pathological. Thus, in dealing with paediatrics (as well as other fields of medicine) anticipation is a must, but never be anxious in dealing with them, as they can sense you and make your life more miserable.

Things to anticipate with paediatric patients

1) CRY- This is the thing that you must be able to bear and handle before succeeding in any paediatric cases. Most students returning from the exam will tell their fellow students "Shit la, get paeds case, that child cry cry cry I also dunno what I'm doing."
Please be aware that a Crying Child is a good thing, it means the child is still alive. I personally would be very afraid if a mother come and tell me that the child had not cried for the past 1 week! Or if the labour room called and inform me that the newborn is not crying. Cry is the only means of communication for younger infants, a way to convey the message that they are unwell but still able to "talk".
So don't get panic when a child start crying when they see you. You can even comment on the cry and earn some extra points for good observation. The reason they cry:

I) You look big and formidable in your white coats!(trust me I know this all too well, standing at 1.90meters)
Solution:a) Ask for permission to remove white coat, and squat down, kneel down, sit down, whatever it is to make yourself look smaller and non threatening. A smile won't hurt either.
b) Have a lil bit of developmental regression, start playing with the child. Bring some small toys.Act cute, whatever. After all, the child won't remember that "when i was 2 years old a trainee doctor pretended to be cute in front of me". Perhaps the mother and examiner will laugh, let them. After all, laughter is the best medicine.

II) They are anxious of strangers.If you don't know what stranger anxiety means, its time to read up on Developmental paediatrics. Normally it appears at around 7 months of age.
Solution: a)They are anxious, you don't be anxious la. I know that there is this formidable Consultant Paediatric so-and-so watching your every step, let her/him! Have this in mind: Paediatricians are people who love kids and dedicate their life to take care of sick children, how bad and evil can they be? If they are then they might as well be paedophiles instead of paediatrician.
2) Anxious of strangers, so if you turn yourself into :non stranger then everything will be fine. Sometimes its hard to do in 10 minutes but try doing so. At the end if you failed its okay, just comment "the child is having stranger anxiety, thus he must be at least 7 months in terms of development" Extra points!

III) They are unwell. Fretful is the term. A fretful child sometimes cannot be consoled even by the caretakers. This is one of the most common reasons for visit to hospital (and most common reason medical students thought they already failed the exam): "Don't know why this few days he cry non stop" Can it be colic? Can it be some CNS infection? Can it be UTI? It is our job to find out what is causing the child so much distress.
Solution : If a child is fretful and you are unable to control, ask for help! Obvious help is right in front of you(No, not from Prof Madya SO and SO). Ask help from the caretaker! You don't need a Professor to pacify a child. If even the caretakers can't pacify the child, how can the examiner assume you can?
So if you came across a fretful child, do all you can, ask help from the mother, if still fretful, just say the magic word The child is FRETFUL. (saying this before attempting to pacify the child will invite weird questions like "so, what are you going to do?") ATTEMPT is important.

2) Unexpected behavior
A child is not a smaller version of adult (small size adult is called a dwarf, achondroplasia). In adult patients(normal one) we can anticipate that they will listen to our instructions -that make life easier. How do you instruct a child to breath in breath out while auscultating? Which is why, a pair of sharp eyes and a clear mind is essential. Be opportunistic. Do whatever you can. The small bugger wont listen to you anyway, just do what he allows you to do.

3) Questions on growth and development
Is the child's development appropriate for his age? Is he thriving? After all, if there is one thing that differentiates paediatric patients from adults, its growth and development. A child who can't grow(failure to thrive) or develop(developmental delay)  may have some serious biological, psychological or social problems. Which is why a knowledge on Developmental paediatrics is very essential. We may miss lots of things(sometimes lethal) by not knowing inside out about the two terms highlighted above. So, if you don't have time to "read finish" your Sunflower, read on this 2 things.
After all, when you come to think of it, failure to thrive and developmental delay are the complications of almost all  chronic diseases in paediatrics.

4) Questions on Genetics
Some of the most common questions in exams like thalassaemia, muscular dystrophy, Down's syndrome are all genetic diseases. It is easy to see why genetic is so important in paediatrics, most of them manifest either at birth or early childhood. You don't need to know how to interpret Fluorescen in situ hybridisation, just know the common ones (as listed earlier) and how to diagnose, what are the complications.

5) Scary Examiners
As I had said earlier, you may meet a Senior Paediatrician who had wrote 30 books and published 12 papers. Thus it is considered normal to be apprehensive when facing such people. So change your mindset "In 10 years I will be like him too". Some examiners are well known to fail people but I'm sure the number of people they passed is far greater than those he failed. Why are you so sure you will fail?
(the same applies to exams in other fields such as O&G)

The hardest thing is to comment on something you see. Sometimes we tend to haveBroca aphasia in exam, we know what we are looking at but we could say it out! We can practice this actually. Saw that fat lady in that awful dress at the supermarket? Describe what you see!
(while staying at A-19-7 in Prima Setapak, I used to describe what I saw from the balcony--> Petronas twin tower (Giant Japanese metal  chopsticks), the KL tower and all other wonderful things I saw from up there)

Have fun dealing with kids. Its very satisfying. :)

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