PracticalDermatology

The aphorism “Children are not just little adults” is often repeated and sometimes challenged. Undoubtedly, however, it contains wisdom, and it is never more obvious than when entering an examination room to evaluate an anxious child. Although not often discussed in the dermatology literature, there is a fair amount of research on best practices and approaches when dealing with children and their families during a medical visit. Although not specific to dermatology, these practices and approaches are widely applicable to dermatologists seeing children.

Children visit doctors often and for many different reasons. According to the Centers for Disease Control and Prevention (CDC), 91% of the children in the US had a visit with a health care professional in 2021.¹ Such visits may involve check-ups, emergency visits, immunizations, or treatment of prolonged illnesses. The unfamiliar setting of an office visit may elicit behavioral and psychological manifestations of distress in children even when the visit does not involve a procedure.² Recollection of previous painful medical experiences may also lead to distress. Anxiety, stress, and fear may negatively affect how children recall medical encounters and amplify the perception of pain experienced during procedures. This perception not only affects how the present visit goes, but it also affects how they comprehend, cope with, and cooperate during visits and procedures later in life: ignoring distress may further influence medical encounters through adolescence and adulthood.^3,4 Therefore, clinicians should invest in age-appropriate preparation and pain management to help minimize health care-induced trauma and enhance their experience with positive medical memories whenever possible.

As infants become toddlers, school-aged children, and adolescents, they undergo developmental milestones that impact the best approaches. This review highlights techniques and maneuvers for clinicians who care for patients at all stages of childhood.

I. Dealing With Infants

During infancy, much of the patient interaction is with parents and guardians. However, directly addressing the child and establishing rapport during the physical exam not only helps to identify the infant’s needs but can help cement the relationship with the family as well.^5,6

Infant examinations are facilitated by the infant’s physical and cognitive immaturity. Since a full-body examination may be necessary, dermatologists should speak softly and use non-intrusive, warm, and gentle touch to help calm the infant.^5,6,7 Physicians should assure concerned parents that crying is normal when babies are undressed or placed on a cold examination table. If the baby is more comfortable in their parent’s lap, this may be preferable. If the distressed behavior persists, other techniques may provide distractions and comfort to the infant: non-nutritive sucking (eg, a pacifier or other sucking toys), engaging sounds (eg, age-appropriate rattle), or allowing parents to take a break from the consultation to quickly breastfeed or change the child’s diaper.⁵

As the infant gets older, they may develop stranger anxiety or separation anxiety. While these anxieties are completely normal, they may make patient-doctor interactions more challenging.^5,8 The unfamiliarity of the medical setting can be intimidating. In these cases, simple maneuver techniques may still be helpful. When interacting with a child who shows stranger anxiety or separation anxiety, the dermatologist should sit far from the infant, avoid eye contact, and slowly move closer to the infant.⁵ Another good strategy can be to allow infants to handle non-dangerous medical instruments that will be used during the examination while the clinician is talking to the parents.⁹ This is classically done with a stethoscope—in dermatology, it may be a dermatoscope or flashlight instead. It allows the infant to become familiar with the instruments and minimize anxiety.^5,9

The archaic belief that infants or toddlers cannot feel pain has long been disproven.¹⁰ Although distraction techniques are helpful during simple examinations, there are other approaches for pain control that are best used during procedures. Research has found that administering a sucrose solution before a procedure with or without a pacifier can successfully reduce discomfort in infants up to 12 months of age.^7,11 Topical anesthetics can help with the discomfort caused by injections.¹²

A study found that the use of vibration lessened the pain from a heel stick procedure. Ultimately, it may be most beneficial to use several techniques in conjunction with each other rather than just one.¹³

A dermatology visit may entail potentially painful procedures, such as administering local anesthesia, other injections, laser therapy, and skin biopsies. These procedures may not only make the child anxious, but the parents and guardians, too. Parental anxiety can make the infant’s anxiety worse, so open communication with the family may help assuage any potential concerns.^7,8,14 When explaining procedures, empathy toward their concerns and using jargon-free language may be helpful.

As clinicians address parental concerns, they reinforce the idea that the whole family is the patient. Often, anxious parents do not immediately absorb and process all of the information given to them, so patience, repetition, written information, and plans may enhance understanding and strengthen the desired medical outcome. Give the parents the opportunity to lead the conversation. Ultimately, this may improve the experience for both the infant and the parents.^9,14 (Table 1.)

II. Dealing With Toddlers and Preschool-Aged Children

Approaching examinations with toddlers can be different from infants and poses new challenges. Toddlers are capable of great cooperation during a doctor visit, but visits may still trigger stranger anxiety and separation anxiety because of the unfamiliarity of the environment, equipment used, and a lack of control.^2,5 Anxious behavior may range from aggressiveness, to clinginess to a parent, to indifference to direction during an examination.²

As with infants, it is important to get to know toddlers slowly. Physicians can engage the patient in simple conversation before history taking.^2,4,5,8 They can ask about their likes, their family, their favorite color, and other personal things. Writing these answers down and bringing them up in the future can make patients and their family members feel valued.⁸ Physicians can appear less intimidating and more approachable by positioning themselves at the same level as the toddler or below.¹⁵

Initiating play can help build a positive relationship with the child, and it can aid during physical examinations.^7,11 The American Academy of Pediatrics has found that play reduces unwanted, stress-induced behavior during medical visits. “Play” can be as simple as any activity that engages the child.¹⁶ Thus, child-friendly spaces with developmentally appropriate games, toys, magazines, or posters are encouraged in the examination room.⁷ Games such as “I spy,” “peek-a-boo,” or “this little piggy” offer comfort to toddlers, because they can foresee what will happen.^7,16 Older toddlers should be given a hand-held mirror so they can observe while their skin is being examined.⁹ Such approaches benefit the child as their stress is eased, but also the physician as they encourage cooperation and aid in efficiency.

Parental attachment can benefit the physician during an office visit.^14,5,7,8 As with infants, toddlers can be put in their parent’s lap during a physical consultation. Parents can model as a patient (eg, “Watch Mommy sit on the examining table while I take a look at her arm”).⁵ Parents can help with positioning the child, undressing, providing emotional support, and helping distract the toddler during painful procedures.^5,8

Parental guidance before a procedure is essential. Parents or caregivers can be very anxious for their child; thus, telling them what to expect, how to distract, and how to communicate with their child can lessen anxiety on both the child’s and parent’s part. Often, parents want to ease their child’s pain by giving false or premature reassurance such as “This won’t hurt,” or “It’s all over.” This can create an unrealistic expectation for the child and can backfire. Advise against the use of “I’m sorry” as it may do more harm than good.⁷

Proper preparation before each procedure will help reduce patient anxiety. For procedures like a skin biopsy, it can be beneficial to keep intimidating materials, such as needles and surgical instruments, covered. While not always feasible, it’s helpful when the physician who performed the first consultation performs the surgery, as they are more familiar with the family.^15,17

It is crucial to be attentive to how one describes the type of pain or distress that the child will undergo. When an injection is necessary, instead of using the word “shot,” a more neutral word like “pinch” or “pressure” is preferred.^5,7,8,14 The actual injection does not hurt for long; children fear the expectation of pain almost as much as the pain itself.¹⁵ Words matter for children, and language that has the potential to ease their anxiety should be used when possible.

Physicians should provide careful and age-appropriate explanations to toddlers, ideally just prior to the procedure.¹⁸ For a toddler of 1 to 2 years old, parents are great allies to ease any distress through distraction or emotional support. Older children–between 3 and 5 years old–benefit from words of affirmation and constant conversation as a method of distraction. They receive information based on sense,¹⁸ so it is essential to describe to the pre-school-aged child what he or she might feel or smell during the procedure. To encourage cooperation, aim to explain in simple language what is going to happen and what their part in the procedure is, before it happens.^4,5,7,8,14

Keeping the child engaged during the consultation can be an excellent distraction mechanism during the consultation. It can be useful to give the patient choices.⁴ For example, toddlers may choose an activity like drawing or listening to music. That will make them feel more in control during a procedure.^7,17 Allowing the child to bring a favorite toy can help them feel more comfortable, as well. Praise is an excellent way to keep them engaged. Even if the patient is not behaving well during the visit, praise them to keep them focused, make them feel empowered, and improve their overall behavior.^4,5,8 At the end of the medical encounter, a reward of stickers or little treats can make the experience fun and help create a fond memory.^7,8,17,18 (Table 2.)

III. Dealing With School-Aged Children

Generally, school-aged children between the ages of 6 and 12 years are eager to cooperate during medical encounters.¹⁹

Although maneuvers presented for toddlers and preschool-aged children are still applicable, clinicians can now regularly address the patient directly for history taking or discussing treatment plans, though parental assistance may be necessary.^5,8 Physicians should be aware of the child’s demeanor and be empathetic toward their needs. Making eye-contact and engaging the patient in casual conversation can help gain the patient’s trust and help the child open up and share their thoughts, feelings, and concerns.^5,8 Physicians can ask: “What bothers you about your skin?” or “Which part of your skin do you want to improve most? or “Has this affected your time at school or with friends?”^5,8,9 In this age range, patients can usually disclose what part of their body has issues, and they can identify what alleviates or exacerbates the pain.

Children fear losing autonomy, so allowing them to set boundaries may help them feel more secure. As they develop, they may feel insecure about their bodies. When appropriate, it may be beneficial to offer a gown as one would for an adult before examination.^5,8 School-aged children can fully comprehend what is happening during an office visit; therefore, honesty is essential to respecting their sense of autonomy and keeping their trust.^5,7,8,14 The physician should aim to disclose the agenda to the patient and their family members. The agenda incorporates the details of what will happen, when it will happen, what the child should expect to feel, and what is expected from the child. Communicating these details encourages the patient to feel more in control and may help to reduce fear.⁴

Preparing the patient will likely ease their stress. School-aged children benefit from sufficient time to assimilate new information and ask questions as they arise. Patient-centered education¹⁷ is beneficial in diminishing patient anxiety. A verbal explanation of the procedure, along with written information, perhaps even with cartoons or illustrations that the child can take home, can be effective.¹⁷ Other methods to provide information may involve medical videos, medical play, or therapeutic play.^18,20,21

Research has shown that as children learn more about the procedure and become more familiar with the medical setting, the less stress they experience during the actual procedure.^14,17,21

Distraction techniques during the procedures should still be used for this age group to improve overall experience. Activities can be a great distraction during any type of medical encounter.¹⁴ Activities could include age-appropriate video games (such as on a tablet device or smart phone), television, drawing, or even friendly conversation.^5,7,8,15,18 Music can be used to distract, as research has shown that it is effective in lessening children’s distress and pain during procedures.^9,22 Communicating to the patient that they will receive a reward after a procedure—in the form of a written note, a sticker, or a small toy—can also be useful.^8,17 Such techniques help the patient feel in control, ease their distress, and encourage their cooperation. (Table 3)

IV. Dealing With Adolescents

Adolescence is a time of many changes. Patients between the ages of 10 and 19 years experience physical, hormonal, behavioral, and many other changes that make treating them different from those in other age groups. This stage is characterized by their efforts to feel independent while also being accepted by family and peers.^5,8,23,24 The physiological changes occurring during this period lead to alterations in their skin’s complexion, texture, and even sweat and sebaceous glands. They can lead to acne, scarring, body odor as well as axillary and facial hair. These drastic changes in appearance are directly linked to their self-esteem, so it is essential that physicians have adequate knowledge of these changes to provide sensitive and comprehensive care for their teen patients.^23,24

As always, building a strong interpersonal relationship with an adolescent patient is important to providing the best care. Respecting the adolescent’s opinions and concerns and positioning oneself as an advocate rather than in a paternalistic or friend-like position is ideal.²⁴ Physicians should provide the option to have at least a part of the consultation either in private or in the presence of the parent or guardian when appropriate. By providing this option, the physician shows respect to the adolescent’s wishes and has the teen’s best interest in mind. Barring information that puts the adolescent or other individuals at risk, the physician and adolescent can discuss what information or treatment plans may be shared with parents in a post-consultation session.^5,8,23,24

Conducting a private consultation can lead to more accurate information-gathering and diminish chances of misdiagnosis or mismanagement. Physicians should ask about hobbies, interests, school, sports, or friends to build trust and ease anxiety. They should be careful of their tone during history taking, so as not to appear to be “going through the motions.” After breaking the ice, they can transition to questions regarding the medical reason for the patient’s visit or the history related to the medical concern.^5,8,23,24

Before the start of physical examination, it is crucial to know whether the patient understands their condition and understand what their expectations are for the medical visit. A treatment plan can be formed as insight is gained on the purpose of the visit.²⁴ Is the patient genuinely concerned about the condition, or is the medical visit due to an overzealous parent? An adolescent patient might not adhere to the treatment if they are indifferent toward the issue.⁸ Consider their condition along with their daily activities when suggesting appropriate procedures or medications. It is important to enact a regimen that will be effective and improve outcomes for all stakeholders.^23,24 Lastly, a clear discussion of the anticipated duration and time frame of treatment and response helps to minimize unrealistic expectations.²⁴

An adolescent patient may feel anxious and self-conscious during the physical examination, so clinicians can examine these patients and take advantage of the same techniques used with adults.^18,23,24 Prepare the patient by summarizing the steps of examination (especially if disrobing is necessary).^4,24 To preserve the privacy of the adolescent patient, offer appropriate gowns.^8,24 Lack of autonomy may also increase the adolescent’s anxiety during physical examination. Physicians may enhance the feeling of control by having the patient uncover the area needed to be examined. To keep the patient comfortable while examining them, the physician should keep talking to them and share findings and possible conclusions expressed in jargon-free language.^8,14,23,24 Lastly, while it is important to focus on the chief complaint brought up by the patient, physicians should be attentive to other possible conditions.²⁴

Conclusion

Office visits and procedures with children can be more complex and more challenging than with adults. Even when the patient is cooperative, the presence of parents or guardians—and often siblings—can add layers of unpredictability. However, there is also tremendous satisfaction that comes from connecting with a child and their family and helping to manage a skin condition. While these visits may never be easy, with some of these techniques and foreknowledge, it is our hope that they won’t be quite so difficult.

1. National Center for Health Statistics. Percentage of having a doctor visit for any reason in the past 12 months for children under age 18 years, United States, 2019-2021. wwwn.cdc.gov. https://wwwn.cdc.gov/NHISDataQueryTool/SHS_child/index.html

2. Rodriguez CM, Clough V, Gowda AS, Tucker MC. Multimethod Assessment of Children’s Distress During Noninvasive Outpatient Medical Procedures: Child and Parent Attitudes and Factors. J Ped Psychol. 2012;37(5):557-566. doi:10.1093/jpepsy/jss005.

3. Von Baeyer CL, Marche TA, Rocha EM, Salmon K. Children’s memory for pain: Overview and implications for practice. J Pain. 2004;5(5):241-249. doi:10.1016/j.jpain.2004.05.001.

4. Lerwick JL. Minimizing pediatric healthcare-induced anxiety and trauma. World J of Clin Pediatr. 2016;5(2):143. doi:10.5409/wjcp.v5.i2.143.

5. Algranati PS. Effect of developmental status on the approach to physical examination. Ped Clinics North Am. 1998;45(1):1-23. doi:10.1016/s0031-3955(05)70580-0.

6. Hanson SG, Nigro JF. Pediatric Dermatology. Med Clinics North Am. 1998;82(6):1381-1403. doi:10.1016/s0025-7125(05)70420-x.

7. Trottier E, Doré-Bergeron MJ, Chauvin-Kimoff L, Baerg K, Ali S. Managing pain and distress in children undergoing brief diagnostic and therapeutic procedures. Paed Child Health. 2019;24(8):509-521. doi:10.1093/pch/pxz026.

8. Mallin K, Lazarus MC. Treating Children Is Different. Dermatol Clinics. 2005;23(2):171-180. doi:10.1016/j.det.2004.09.002.

9. Ahmed S, Miller J, Burrows JF, Bertha BK, Rosen P. Evaluation of patient satisfaction in pediatric dermatology. Ped Dermatol. 2017;34(6):668-672. doi:10.1111/pde.13294.

10. Morton NS. The pain-free ward: myth or reality. Ped Anesthesia. 2012;22(6):527-529. doi:10.1111/j.1460-9592.2012.03881.x.

11. Stevens B, Yamada J, Ohlsson A, Haliburton S, Shorkey A. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database System Rev. 2016;7(7). doi:10.1002/14651858.cd001069.pub5.

12. Lio PA, McQueen AA, eds. Pain-free Dermatology: Minimizing discomfort in procedures for children and adults. Practl Dermatol. Published April 2016. https://practicaldermatology.com/articles/2016-apr/pain-free-dermatology-minimizing-discomfort-in-procedures-for-children-and-adults?c4src=issue:feed

13. Baba LR, McGrath JM, Liu J. The efficacy of mechanical vibration analgesia for relief of heel stick pain in neonates. J Perinatal Neonatal Nurs. 2010;24(3):274-283. doi:10.1097/jpn.0b013e3181ea7350.

14. Baba LR, McGrath JM, Liu J. The efficacy of mechanical vibration analgesia for relief of heel stick pain in neonates. J Perinatal Neonatal Nurs. 2010;24(3):274-283. doi:10.1097/jpn.0b013e3181ea7350.

15. Todres I. Communication between physician, patient, and family in the pediatric intensive care unit. Critical Care Med. 1993;21 (Supplement):S383-S385. doi:10.1097/00003246-199309001-00053.

16. Metz BJ. Procedural Pediatric Dermatology. Dermatolc Clinics. 2013;31(2):337-346. doi:10.1016/j.det.2012.12.011.

17. Yogman M, Garner A, Hutchinson J, Hirsh-Pasek K, Golinkoff RM. The power of play: A pediatric role in enhancing development in young children. Pediatrics. 2018;142(3). doi:10.1542/peds.2018-2058.

18. El Hachem M, Carnevale C, Diociaiuti A, et al. Local anesthesia in pediatric dermatologic surgery: Evaluation of a patient-centered approach. Pediatric Dermatology. 2017;35(1):112-116. doi:10.1111/pde.13347

19. Smith ML. “Interventions to minimize distress during pediatric primary care visits: A systematic Literature Review.” Student Works. 2014;4. doi:https://scholarsarchive.byu.edu/studentpub/4

20. CHOC. Growth & Development: 6 to 12 Years (School Age) | CHOC. CHOC Children’s. Published May 2021. https://www.choc.org/primary-care/ages-stages/6-to-12-years/

21. Burns-Nader S, Hernandez-Reif M, Thoma SJ. Play and video effects on mood and procedure behaviors in school-aged children visiting the pediatrician. Clinical Pediatrics. 2013;52(10):929-935. doi:10.1177/0009922813492882.

22. Li HCW, Lopez V. Effectiveness and Appropriateness of Therapeutic Play Intervention in Preparing Children for Surgery: A Randomized Controlled Trial Study. J Specialists Pediatric Nurs. 2008;13(2):63-73. doi:10.1111/j.1744-6155.2008.00138.x.

23. Klassen JA, Liang Y, Tjosvold L, Klassen TP, Hartling L. Music for pain and anxiety in children undergoing medical procedures: A systematic review of randomized controlled trials. Ambul Pediatr. 2008;8(2):117-128. doi:10.1016/j.ambp.2007.12.005.

24. Walker H, Hall W, Hurst J, eds. Clinical Methods: The History, Physical and Laboratory Examinations. 3rd ed. Boston: Butterworths; 1990. https://pubmed.ncbi.nlm.nih.gov/21250045/

25. Das G. The art of addressing adolescents in dermatology & aesthetic practice. In: Ashwini P, Kishor M, eds. Essentials of Psychiatry for Dermatology and Aesthetic Practice. Apsara Prakashana; 2021. https://www.researchgate.net/publication/351304819_Essentials_of_Psychiatry_for_Dermatology_and_Aesthetic_Practice