Examining children

Examining a small child can be hard enough; it’s even more difficult when it’s your own

Clare Quigley

Posted: Thursday, April 1, 2021

“You need to have him sitting on your lap, his back against your chest. One arm around him, incorporating his arms, and one hand on his forehead, keeping his head back. And clamp his feet between your knees.”

Standard instructions to give to a parent when examining a small child, ones that I had given many times before. But it felt more severe, delivering the instructions to my husband. Michael was squirming on his lap, bouncing with curiosity about the odd hat on his mother’s head, wriggling and squealing.

He was amused until I focused the indirect’s beam on his fundus, when he got upset.

His Dad held him more firmly, and I worked quickly, checking one eye and then the other.

“Nerves normal, fundi normal.” I sighed in relief.

The idea of examining Michael came up after talking with a paediatrician family friend. I had spoken to her about our visit with the public health nurse, when Michael’s head circumference had come out as above normal on routine checks. Next thing, we were awaiting a visit to hospital to have him checked over, pondering differential diagnoses. Hydrocephalus seemed very unlikely, given he was well otherwise, but I wanted to minimise the chance that he would need any neuro-imaging to rule out a problem. Normal nerves, despite the large head, was reassuring. Hopefully the paediatrician would agree with me.

At the moment I am making an effort to study more, as exams loom again. Our training includes exams that mark the progression from senior house officer to registrar, giving membership status, and final exit exams, granting fellow status. Coming up for us now are the European Board of Ophthalmology exams, mandatory to complete before we can sit our national exit exam. Compared to other exams we do, there is one distinct positive aspect: the exam normally takes place in Paris. There were registrars working in different cities around Ireland who were all planning to sit the exam, and we formed a WhatsApp group, excited about the upcoming trip.

The group was named “Paris in Maytime”, evoking mental images of suitably French scenes – walking to a boulangerie for breakfast croissants, reading over exam notes while sitting outside a café enjoying the early summer light, and an evening celebration after finishing the exam, meeting up in a bar, enjoying some wine… That was until the exam was cancelled and postponed last year. We have since found out that it is rescheduled to take place in the summer, virtually. Our WhatsApp group was aptly renamed by one of the registrars; “A Desk at Home in June.” Another COVID casualty.

Studying now is both easier and harder than when I was younger. It is more interesting, as I can read up on any new developments in clinical problems that I see regularly. Even for rare diseases or problems, studying them, reading about them, makes it more likely that I’ll know what to do when I do see a patient presenting with them one day. I have motivation, as I know it will make me a better clinician. But the harder aspect is etching out time to get study done. The day-to-day job is busy, and the evenings and weekends feel like time to relax and spend with family. My solution is to do a little most days, especially at work in the morning before the clinics start, after a coffee to get me going. Question banks are easy to dip in and out of. Playing an ophthalmology podcast is handy when driving, or out grocery shopping. Somehow, I will ramp up my reading as the exam gets closer…

By the time we made it to the hospital appointment with Michael, we had started to get anxious again. The paediatrician examined him, and then turned to me. The measuring tape was out, this time for my head. He looked up the adult female head circumference centiles – it turned out that my head measures pretty big too. I had an inkling about this, from hats often not fitting me well. Then the paediatrician took out some old centile charts, that are out of production, specific for children in Ireland and Britain. On these more localised charts, Michael’s head was trending along a more acceptable centile. It turns out that inhabitants of these islands tend to have larger heads, and it can be inherited in an autosomal dominant pattern. The new WHO charts, including a global population, can place healthy Irish babies off the scales in head circumference.

Next time I was looking after a child in distress was in the emergency department, after a mild chemical injury. I found myself sympathising more with both parent and child at their shared discomfort of the examination, and sharing in their joy when I could discharge them.

Clare Quigley is a resident at the Royal Victoria Eye and Ear Hospital, Dublin, Ireland