Clinical Tip: Bubbles and the art of medicine

A number of years ago, while wandering through a gift shop, I spied a small bottle that looked like a perfume bottle on a string. It turned out to be one of those bottles containing bubble liquid and a small bubble wand that have since become so popular with children. I didn't realize at the time what a useful tool bubbles would become in my medical practice.

All children love bubbles, of course, unless they are very ill. In fact, I have used the "bubble test" in the outpatient clinic as a quick assessment of how ill a patient is feeling: The child who cries and turns away from the bubbles is likely quite sick; the one who stops crying and starts to smile is less so.

Blowing bubbles is also a useful test for hand-eye coordination in infants, and dysmetria in older children. I have found that most children can't seem to track the bubbles until about 7 months of age, and they don't reach for the bubbles until about 9 months of age.

Bubbles have also helped me assess younger children for meningismus. I know that a child who can move his or her head up and down and side to side to watch the bubbles probably doesn't have meningitis.

One of the most satisfying ways I use bubbles is to interact with a terrified youngster who is in the hospital for the first time, especially if he or she has stranger or white-coat anxiety. If the child clings to mom or dad when I enter the room, as if I'm the enemy, I begin to blow bubbles as I walk toward them. Somehow the bubbles make the white coat disappear in the child's eyes. As I approach the child, I get down on my knees to his or her level and we blow bubbles together.

[Editor's note: Also see "Bubbles that break the ice," in the January 2006 online issue, accessible at http://www.contemporarypediatrics.com/]

These days, I hang two bubblers around my neck, my old standby "perfume bottle" and my Barney bubbler. I often use the "perfume bottle" when examining a child with the stethoscope because I can blow bubbles with my left hand while holding the stethoscope with my right hand. I ask the parent to turn the child facing away from me, then blow bubbles just as I place the diaphragm of the stethoscope on the child's back. I can often hear breath sounds without the child ever knowing I touched him or her-as long as the stethoscope is prewarmed, of course.

Many 2- and 3-year-olds don't understand the concept of "take a deep breath," but they do seem to understand, "OK, blow the bubbles... oh, much harder! Big breath and blow the bubbles across the room." I'm amazed at how many times I've diagnosed asthma or pneumonia in a child with a negative radiograph by this method.

In the Child Life program at our hospital, I often request that a hypoxic patient admitted with pneumonia or an exacerbation of asthma receive "bubble therapy"-basically, a variation on incentive spirometry. I ask the parents and Child Life staff to have the child blow bubbles, trying to hit the wall in front of them, for 15 minutes tid. I haven't studied whether this technique shortens the child's hospital stay, but it certainly delights the child.

Bubbles have made my job much easier and more enjoyable in many ways. If you find other ways to use bubbles, pass them along. There will never be too many bubbles in the world!

Elizabeth A. Weltman, MD, Pediatric Hospitalist, All Children's Hospital,St. Petersburg, Fla.