Care of the Pediatric Patient

Key Concepts

Patterns of illness and injury vary by age, and a number of anatomic and physiologic characteristics affect the presentation and management of pediatric emergencies.
A basic understanding of normal development will aid the emergency clinician in assessment of the pediatric patient.
The pediatric assessment triangle (PAT) can be used as a tool for rapid evaluation of the patient’s overall status.
Tachypnea in children should be evaluated relative to age norms and is often a sign of increased metabolic demands. A child with tachypnea despite normothermia should be evaluated for respiratory and nonrespiratory causes (e.g., hypoperfusion, acidemia).
Maintenance of a neutral thermal environment is necessary for critically ill infants.
Child abuse should be considered when injuries are inconsistent with history, when details of the history change, or with certain injury patterns.
A joint guideline of the American College of Emergency Physicians, American Academy of Pediatrics, and Emergency Nurses Association summarizes the role of pediatric emergency care coordinators, development of pediatric policies, and recommended equipment, supplies, and medications for emergency departments (EDs).
EDs that comply with the national guidelines for pediatric readiness have improved outcomes for care of critically ill children.
The family’s presence should be encouraged for pediatric procedures and resuscitations.
A variety of pharmacologic and nonpharmacologic techniques are available to decrease procedural pain and anxiety.

Foundations

Emergency clinicians assess and manage pediatric patients from newborns to adolescents. Of the 146 million annual US emergency department (ED) visits, 27.4 million (19%) are for children younger than 15 years. Twenty-two percent of children have at least one ED visit per year. Infants have higher per capita ED utilization than other age groups, with 98.7 visits/100 infants. More than 80% of pediatric patients are seen in general EDs, requiring all emergency clinicians to be skilled in the assessment, treatment, and stabilization of pediatric illnesses and injuries.

Children can present diagnostic and management challenges due to their anatomic, physiologic, and developmental differences from adult patients. Understanding these differences is crucial to the recognition and appropriate treatment of many pediatric emergencies. In addition, caring for the pediatric patient also involves active participation from caregivers.

Pathophysiology

Children exhibit different patterns of illness and injury because of their unique physiologic and anatomic characteristics. Illness and injury patterns not only differ between pediatric and adult patients, but also vary in children by age. In addition to changes in cognitive and behavioral development, temperature regulation, airway anatomy, cardiovascular physiology, immune function, and the musculoskeletal system all change as children grow. Furthermore, pediatric patients may present to the ED with previously undiagnosed congenital disorders. Drug dosing and choice of medications also depend on patient size and physiology.

Assessment should begin with a review of vital signs, evaluating for early signs of physiologic decompensation. Normal heart rate and respiratory rate vary by age ( Table 155.1 ). Normal blood pressure also varies by age, height, and gender ( Box 155.1 ; Table 155.2 ). Abnormal vital signs should be repeated and persistently abnormal vital signs quickly addressed.

TABLE 155.1

Normal Pediatric Vital Signs

From Dieckmann R, Brownstein D, Gausche-Hill M, eds. Pediatric Education for Prehospital Professionals . Sudbury, MA: Jones & Bartlett; 2013.

Age (Years)	Respiratory Rate (Breaths/Min)	Heart Rate (Beats/Min)
<1	30–60	100–160
1–2	24–40	90–150
2–5	22–34	80–140
6–12	18–30	70–120
>12	12–16	60–100

BOX 155.1

Hypotension in the Pediatric Population by Age

From American Heart Association: American Heart Association emergency cardiovascular care (ECC) guidelines, 2010. https://www.ahajournals.org/doi/10.1161/circ.102.suppl_1.I-291 .

0–28 days: 60 mm Hg
1–12 months: 70 mm Hg
1–10 years: 70 mm Hg + (2× age in years)

TABLE 155.2

Pediatric Blood Pressure by Age

Modified from The National High Blood Pressure Education Program Working Group on Children and Adolescents: The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4074640/ and https://www.nhlbi.nih.gov/files/docs/resources/heart/hbp_ped.pdf

Age (Years)	50th Percentile (mm Hg)		Hypertension–95th Percentile (mm Hg)
Age (Years)	Girls	Boys	Girls	Boys
1	86/40	85/37	104/58	103/56
5	93/54	95/53	110/72	112/72
10	102/60	102/61	119/78	119/80
15	110/65	113/64	127/83	131/83

^a For children at the 50th percentile for height.

Temperature Regulation

Infants and young children have a larger surface area–to–mass ratio, resulting in more heat loss to the environment than in adolescents and adults. Maintenance of a stable body temperature can be a significant metabolic demand for young infants, especially those stressed by injury or illness. Maintain a neutral thermal environment for children during the physical examination and while performing procedures. Patients exposed briefly for examinations and interventions should be covered as soon as possible to avoid excessive heat loss. Critically ill young infants should be placed under radiant warmers. Overhead warming lights are useful for older infants and children who require prolonged exposure for resuscitation and procedures.

Airway

The pediatric airway differs in a number of ways from an adult airway. ^, Compared to the adult airway, the pediatric larynx is more anterior and cephalad, and the epiglottis is composed of more flexible cartilage, making it floppy. The relatively larger occiput in infants and young children can cause neck flexion in the supine position, leading to potential airway obstruction. To open the airway, particularly during intubation attempts, a towel roll placed under the shoulders may be needed to align the laryngeal, pharyngeal, and oral airway axes ( Fig. 155.1 ). Infants and young children also have relatively large tongues, which may lead to airway obstruction during periods of changes in muscle tone, such as during a seizure. Use of a nasopharyngeal airway can alleviate the obstruction by allowing a clear passage of inhaled gases. In addition, airways in children are much smaller in diameter and much more easily obstructed with secretions. Because young infants preferentially breathe through their noses, respiratory distress can develop from copious nasal secretions. Thus, suctioning the nose and upper airway can dramatically diminish an infant’s work of breathing.

Fig. 155.1, Infant With Neck in Flexed Position (A) and After Placement of a Shoulder Roll (B).

Cardiovascular System

Healthy children have compensatory mechanisms to maintain blood pressure, even when cardiac output is decreasing. Children have the ability to increase their heart rate and vasoconstrict peripherally to shunt blood centrally, while very young children have limited ability to increase their cardiac contractility. Hypotension is a late finding of shock in previously healthy children, and interventions should ideally occur before the onset of hypotension. The earliest sign of cardiovascular compromise in most patients is tachycardia. Unfortunately, tachycardia is nonspecific and may be due to fever, pain, or anxiety. Repeated assessment of the heart rate can be helpful. In a crying child, a true resting heart rate can be obtained by leaving the pulse oximeter on until the child is calm. Unexplained tachycardia in a calm or sleeping child should be investigated for the cause of the tachycardia. The quality of the pulse is also helpful. A thready peripheral pulse associated with tachycardia should be considered a sign of shock. Bradycardia in ill children is especially ominous and may signal impending cardiopulmonary failure.

Musculoskeletal System

Growing children have musculoskeletal injury patterns different from those of adults. Ligaments are stronger relative to the immature bone, so children are more likely to fracture bones than sprain ligaments. The weakest part of a growing child’s bone is the physis, or growth plate. If tenderness is present on examination, physeal injuries should be considered in children with normal radiographs. Treatment of fractures in children should consider future growth potential. For example, certain physeal injuries can lead to long-term growth disturbances, whereas greater degrees of angulation are acceptable in many fractures due to the increased potential for bone remodeling.

Immunologic System

Due to their immature immune system, young infants are at increased risk of serious bacterial infections. Febrile infants younger than 1 month are a particularly high-risk group and have a 10% or higher rate of serious bacterial infection. For this reason, the evaluation of infants with fever differs from the evaluation of older children and adults; the evaluation varies by age and vaccination status (see Chapter 161 ).

Pharmacologic Considerations

Medications for children are calculated using weight-based dosing, with attention to the maximum medication dose. Suggested safeguards to prevent calculation-based dosing errors in children include pharmacy review of medication orders, computerized order entry, use of templated order forms, and length-based resuscitation tapes to reduce calculation errors. One easily remedied potential error is the inadvertent calculation of a drug dose on the basis of weight in pounds, not kilograms, leading to a more than twofold overdose. Therefore, ED scales and electronic charts should be programmed to report weight only in kilograms.

In addition to potential dosing errors, certain frequently used medications in older children and adolescents should not be given to young infants. For example, ceftriaxone is not recommended for infants younger than 28 days because it can displace bilirubin from albumin, leading to kernicterus or bilirubin-induced neurologic dysfunction (BIND). Although not well studied, the use of ibuprofen in infants younger than 6 months has not been approved by the US Food and Drug Administration because of the theoretical risk of kidney and liver injury.

Developmental Considerations

Assessment of pediatric patients requires an understanding of normal developmental milestones. Table 155.3 lists basic developmental milestones in the first 2 years of life. Variation in the rate at which children develop can be normal or may signal neurodevelopmental delays. Therefore, the parent’s report of the child’s developmental history and normal behavior is extremely important. Injuries identified should also fit the developmental milestones of a child. Injuries that fall outside of the normal developmental patterns should raise the consideration of non-accidental trauma/child abuse.

TABLE 155.3

Developmental Milestones in Typically Developing Children Up To 2 Years of Age

Adapted from Engorn B, Flerlage J. The Harriet Lane Handbook . 20th ed. Philadelphia: Elsevier Saunders; 2015.

Age (Months)	Gross Motor	Visual-Motor, Social, and Language
1	Raises head from prone position	Visually follows to midline, alerts to sound, regards face
2	Lifts chest off table	Smiles socially, recognizes parent, follows object past midline
4	Rolls over	Laughs, orients to voice
6	Sits unsupported	Babbles
9	Pulls to stand, cruises	Says “mama” and “dada” indiscriminately, plays games such as pat-a-cake
12	Walks alone	Two words other than “mama” and “dada”
15	Creeps upstairs, walks backward	Uses 4–6 words
18	Runs	Uses 7–10 words, knows five body parts
24	Walks up and down stairs independently	50-word vocabulary, two-word sentences

Young Infants

Infants younger than 2 months are especially challenging to assess because they have a limited behavioral repertoire. They may not make eye contact nor have a social smile. Normal behavior includes sleeping, crying, quiet alert time, feeding, and stooling. A change in any of these activities may indicate serious disease. Increased sleeping or crying or decreased interest in feeding may herald a serious illness, such as sepsis or an underlying cardiac or metabolic disorder.

Infants (<12 Months)

Infants typically develop a social smile and track close objects by 2 to 3 months of age. After 6 months, infants may develop significant stranger anxiety, making the physical examination challenging. Whenever possible, examining the infant in the parent’s lap, with the infant initially facing away from the examiner, can mitigate anxiety and facilitate physical examination. Bubbles or interactive toys can distract infants and may help keep them calm.

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