14 General Approach to the Pediatric Patient
Key Points• Each stage of childhood development brings particular anatomic, physiologic, and developmental features that affect assessment and management.
• The emergency department must have the resources immediately available for stabilization of critically ill children. Written transfer agreements for specialized care are imperative.
• Parents or caregivers must be considered during every interaction with a child, especially if the child is seriously injured or ill. A child’s anxiety and fear often reflect what the child feels or sees in the caregivers.
• Family presence during invasive procedures and resuscitation can be a positive experience for some caregivers, especially those treating children with chronic illnesses.
Acknowledgment and thanks to Dr. Antonio E. Muniz for his work on the first edition.
General Approach
Children account for about 30% of all emergency department (ED) visits; of these, 80% are initially evaluated in a general rather than a pediatric ED.1,2 Therefore, it is imperative that the general ED environment be not only child friendly but also child safe.
Children are triaged according to the same general guidelines as adults:
The pediatric assessment triangle (PAT), which consists of a 15- to 20-second evaluation of the patient’s appearance, mental status, work of breathing, and circulation of the skin, should be performed before the physical examination. The PAT provides a rapid assessment of the child’s oxygenation, ventilation, and perfusion and can help categorize the patient into a triage level. Normal vital signs by age are listed in Table 14.1. The PALS formula for blood pressure is 70 + (2 × age in years). It is important to note that this formula defines the 5th percentile for systolic blood pressure in children. Therefore, the preferred formula is 90 + (2 × age in years) because this is the 50th percentile for blood pressure. In the newborn period, normal systolic blood pressure is 60 mm Hg.
Table 14.1 Normal Vital Signs by Age
| AGE | RESPIRATORY RATE (BREATHS PER MINUTE) | HEART RATE (BEATS PER MINUTE) |
|---|---|---|
| <1 yr | 30-60 | 100-160 |
| 1-2 yr | 25-40 | 90-150 |
| 2-5 yr | 20-30 | 80-140 |
| 6-12 yr | 18-30 | 70-120 |
| >12 yr | 12-16 | 60-100 |
The following suggestions constitute a general approach to a child in the ED:
• Allow the parent or caregiver to stay with the child whenever possible.
• Ask what name to use for the child, and then address the child by name.
• Use nonmedical terminology when talking with the family, especially when discussing planned interventions, findings, and treatments. Use language that children will comprehend.
• Always provide privacy no matter how young the child.
• Observe the patient’s level of consciousness, activity level, interaction with the environment and caregiver, position of comfort, skin color, respiratory rate and effort, and level of discomfort before touching the child. Compare the findings on evaluation with the parents’ or caregivers’ description of the child’s normal behavior, such as eating and sleeping habits, activity level, and level of consciousness.
• Be honest with the child and parent or caregiver. Parents or caregivers require reassurance about and explanations of the situation and the anticipated plan of treatment.
• Acknowledge and compliment good behavior, and encourage and praise the child. Provide rewards such as stickers or books.
• Allow the child to make simple age-appropriate choices and to participate in the treatment plan. For example, ask the child which arm to use for measuring blood pressure.
• Encourage play during the examination and any procedures. Use diversion and distraction techniques, such as encouraging the child to blow bubbles and blow the hurt away. Ask the child to sing a favorite song, and sing along or have the parents or caregivers do so. Have the child picture a favorite place and describe it in detail with all five senses.
• Give the child permission to voice any feelings. Tell the child that it is okay to cry. Sympathy is essential.
• Assess for pain with age-appropriate assessment tools. Elicit from the parents or caregivers the child’s typical response to pain.
• Be cautious about what you say in the presence of an awake or presumed unconscious child.
Growth and Development
Although growth and development occur simultaneously, they are discrete and separate processes. Growth refers to an increase in the number of cells and leads to an increase in physical size. Development is the gradual and successive increase in ability or performance skills along a predetermined path, often referred to as developmental milestones or tasks (Table 14.2). Development is predominantly age specific and reflects neurologic, emotional, and social maturation. Although there is cross-cultural similarity in the sequence and timing of developmental milestones, cultures exert an all-pervasive influence on developing children.
Table 14.2 Developmental Milestones
