Chapter 116 Vital communication issues

the child

Louise E. Allen

Good rapport and a trusting relationship with children are vital in order to encourage their cooperation and aid compliance. Your style of communication should be tailored to the age and maturity of the child; they are the center of the consultation.¹

Infants

To ensure a good examination, babies should be rested and fed. If the baby comes into the consultation sleeping, take the opportunity to perform the ocular examination − visual assessment and eye movement testing can wait until the child is awake. If the baby is crying and the ocular examination is difficult, bottle- or breastfeeding will settle the infant and enable a good examination. Generally, it is unnecessary to use a speculum in term infants unless there is concern about peripheral retinal pathology. If a speculum is necessary, topical anesthetic, swaddling, and oral sugar solution can be helpful.

Toddlers are the most difficult age group to examine (Box 116.1). They don’t understand why you are examining them and can rarely be reasoned with. The combination of a tired, hungry toddler and stressed parent can make a full examination impossible. Call the family into the consulting room yourself so that the child can appraise you; give the child lots of smiling, playful banter, and compliments. If the history is complicated, let the child explore and play until you are ready to examine them. If you sense your examination may be limited, do the essential things first and complete other aspects of the examination on a return visit. I very rarely restrain children to examine them – I try all other inducements – drinks, raisins, cookies, etc. first. If I feel that a fundus check is vital to exclude serious pathology, I will ask the child’s parents to briefly hold them in their arms while I take a quick look. If I can’t get a good look, I explain this to the parents (who are usually understanding) and arrange another visit. Often an earlier appointment time or having the pupils predilated at home can make a big difference. Many hospitals have play therapists who can help those children who find the examination or procedures like contact lens insertion very frightening.

Box 116.1

Tips for communicating with toddlers pre-school children

• Call the child into the consultation room yourself

• Call the child by their usual name/nickname

• Crouch down to their level – SMILE!

• Use simple language and familiar words

• Talk at their pace, use short sentences

• Examine the child on the parent’s lap

• Explain to the parent and child what you are going to do

• Demonstrate the examination on their parent, sibling or doll

School-age children

Even children who appear very sophisticated may find understanding visual and eye problems and their treatment difficult (Box 116.2). Video analysis of doctor−parent−child consultations have shown that school-aged children are left out of the conversation in 90% of consultations.²

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