Temperature Regulation

Infants and young children have a large surface area–to–mass ratio and lose more heat to the environment than adolescents and adults. Maintenance of a stable body temperature can be a significant metabolic demand in young infants, especially those stressed by injury or illness. Every effort should be made to maintain a neutral thermal environment. Patients can be exposed briefly for interventions and examinations but 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 can be useful for older infants and children requiring prolonged exposure for resuscitation and procedures.

Airway

The pediatric airway differs in a number of ways from an adult airway.⁵ Numerous characteristics of the pediatric airway predispose to obstruction. Infants and young children have relatively large tongues, which may lead to airway obstruction during seizures or periods of altered mental status. Use of nasopharyngeal airways can be helpful in bypassing obstruction due to a relatively large tongue. The small airways of children are more easily obstructed with secretions. In addition, young infants preferentially breathe through their noses and can have significant respiratory distress from nasal secretions. For these reasons, airway suctioning can dramatically diminish an infant’s work of breathing. Infants and young children also have large occiputs, causing neck flexion and potential airway obstruction in the supine position. A shoulder roll can be used to properly position young patients; it may significantly decrease respiratory distress and improve intubating conditions (Fig. 166-1).

Cardiovascular

Healthy children have compensatory mechanisms that can support blood pressure even when cardiac output is decreasing. Children have the ability to increase their heart rate and peripherally vasoconstrict to shunt blood centrally. Hypotension is a late finding of shock in previously healthy children, and intervention should 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. Unexplained tachycardia in a calm or sleeping child is concerning. The quality of the pulse is also helpful in assessing patients. A thready pulse associated with tachycardia should be considered to be shock until it is proved otherwise. Bradycardia in ill children is especially ominous and may signal impending cardiac arrest.

Musculoskeletal

Growing children have musculoskeletal injury patterns different from those of adults. The weakest part of a growing child’s bone is the physis, or growth plate, leading to a propensity to fracture. Physeal injuries should be considered in children even with normal radiographs. Treatment of fractures in children takes future growth potential into consideration. Certain physeal injuries can lead to long-term growth disturbance if not treated appropriately. At the same time, growing children have more potential for bone remodeling and greater degrees of angulation can be accepted for certain fractures. Ligaments are strong relative to the immature bone, so children have an increased propensity to fracture bones rather than to sprain ligaments.

Immunologic

Young infants are at increased risk of serious bacterial infections because of their immature immune system. Febrile infants younger than 1 month are an especially high-risk group and have an approximately 10% rate of serious bacterial infection.⁶ For this reason, the evaluation of infants with fever differs from the evaluation of older children and adults, and the workup varies by the age and vaccination status of the infant.

Pharmacologic

Pediatric patients are particularly prone to medication errors for multiple reasons, including the fact that medications for children are calculated using weight-based dosing with attention to the adult maximum medication dose.⁷ Most calculation-based dosing errors occur in pediatric patients.⁷ Suggested safeguards include pharmacy review of medication orders, computerized order entry and use of templated order forms, resuscitation calculators, and length-based resuscitation tapes. 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. For this reason, emergency department scales should be programmed to report weight in kilograms, not pounds, and weight in pounds should not be written in the medical chart.

In addition to potential dosing errors, certain frequently used medications should not be given to young children. For example, ceftriaxone is not recommended in the first month of life because it may cause bilirubin encephalopathy. Use of pediatric-specific drug references can help providers avoid medication errors.

Young Infants

Infants younger than 2 months are especially challenging to assess because they have limited behavioral cues. They may not make eye contact or 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 be the early sign of serious disease and should be investigated.

Infants (<12 months of age)

By 2 months of age, infants develop a social smile and track objects held near their faces. Lack of interaction with the parents is concerning. After 6 months, infants may develop significant stranger anxiety, which can make the physical examination challenging. Whenever possible, examination of the infant in the parent’s lap will lead to less anxiety of the patient and may facilitate the physical examination. Brightly colored toys or toys with lights or sounds serve to distract the infant and may be useful in keeping the patient calm.

Toddlers (1- to 2-year-olds)

Toddlers have limited expressive language skills but will be aware of and react to parental anxiety. A toddler may be able to participate in the history in a limited way, such as pointing to the location of pain. Toddlers vary in their response to physical examination. Some toddlers are fearful and unable to cooperate, whereas others are curious and cooperate more easily with the examination. When the patient is stable, it can be helpful to begin the encounter standing or sitting at a distance from the child while taking the history. Speaking in a soothing voice and distracting the child with toys or other interesting objects can facilitate the examination.

Preschoolers (3- to 5-year-olds)

Preschool-age children have increasing language skills. Like toddlers, their receptive language skills exceed their expressive language skills, and they often understand more than is realized. Preschoolers should be included in the conversation when possible. Providers should be cautious about talking to parents about procedures or diagnoses in front of the preschool child even if the child seems not to be paying attention or not to understand. Like toddlers, preschool children vary greatly in their cooperation with the physical examination. Providing limited options, such as sitting with the parent or on the gurney or choosing which ear should be examined first, may improve cooperation. Distraction with questions or stories can facilitate the physical examination. Simple, concrete explanations of procedures are appropriate immediately before and during the procedure. Preschool children may perceive illness or painful procedures as punishment for their actions, making simple explanations of what is occurring and why even more important.

School-Age Children

At least some questions during the history should be directed at the school-age child. Some older school-age children will be able to provide much of the history themselves. School-age children are often cooperative with the examination but may regress when they are frightened or in pain. School-age children become increasingly modest, and attempts should be made to provide privacy.

School-age children may attempt to negotiate or stall when painful or unpleasant examinations or procedures are planned. Honest and firm but reassuring explanations of what will happen are important. Appropriate concrete explanations include the sequence of events and what physical sensations the patient will experience. Preparation for procedures will give children some sense of control. Timing the explanation shortly before the procedure may decrease anxiety. School-age children may perseverate and become extremely anxious if there is a long delay between the explanation and the procedure.

Adolescents

Adolescents increasingly want independence from their parents but may regress in times of stress. Adolescents will be able to provide much if not all of the history. However, it is important to elicit the concerns of both the adolescent and the parent and to ensure that both understand the diagnosis and plan. The adolescent should be given a chance to speak to the provider without the parent in the room. Any sensitive questions, such as drug use and sexual activity, should be asked privately. Adolescents can generally be examined in a manner similar to adults. They are often extremely modest, and attempts should be made to preserve privacy with private rooms when possible and exposure of only the body part being examined. Adolescents may want the parent present during the physical examination or may prefer that the parent stay outside of the room.

Triage

Triage serves to identify patients requiring immediate care, to prioritize patients waiting to be seen, and to ensure that patients are treated in the most appropriate area of the emergency department. Pediatric-specific triage systems are important to avoid overtriage and undertriage of children. Application of adult-specific vital signs to children may lead to inappropriate triage level classification. In addition, signs and symptoms of serious illness may be subtle in infants and very young children.

Triage systems with pediatric modifications include the Emergency Severity Index, the pediatric Canadian Triage and Acuity Scale, the Manchester Triage System, and the Australasian Triage Scale.⁸ All of these systems are five-level triage systems. In five-level triage systems, level 1 patients require immediate intervention. Level 2 patients are emergent and should be seen within 10 to 15 minutes. Level 3 patients are considered urgent and should be seen within 30 to 60 minutes, depending on the triage system. Level 4 and level 5 are thought to be stable patients. The Emergency Severity Index classifies patients by acuity and number of resources expected to be required.⁹ A flowchart specific to pediatric patients with fever has been added. In the Canadian Triage and Acuity Scale, specific criteria for various presenting complaints are used to assign triage levels.¹⁰ The pediatric modification includes pediatric-specific presenting complaints and determination of acuity by use of pediatric-specific vital signs. The Manchester Triage System contains flowcharts based on presenting complaint, with some pediatric-specific flowcharts.¹¹ The Australasian Triage Scale is mostly a general triage scale but has several pediatric-specific criteria.¹²

No triage system is clearly demonstrated to be superior, and data on reliability and validity are limited for all triage systems. The Emergency Severity Index, the Manchester Triage System, and the pediatric Canadian Triage and Acuity Scale have been demonstrated to be valid in pediatric patients.8,13,14 Reliability is good for the Manchester Triage System and moderate for the Emergency Severity Index and pediatric Canadian Triage and Acuity Scale.^8,14 The Australasian Triage Scale appears to have lower reliability than the other triage systems.⁸

History

In critically ill or injured patients, the SAMPLE history can be used as a way to quickly obtain a focused history (Box 166-1). The SAMPLE history reminds providers to ask for Signs and symptoms, Allergies, Medications, Past medical history, Last meal, and Events surrounding the illness or injury.

A more detailed history will be guided by the patient’s complaint. In infants and very young children, the entire history will be obtained from the parent. Although the parent’s concerns should be seriously considered, the history provided by the parent may be unreliable in cases of abuse and neglect. Furthermore, in cases of injury, the event may not have been witnessed, and details may not be available. In preverbal children, symptoms will be inferred by the parent on the basis of the child’s behavior. Parents are often very perceptive and may notice subtle changes that are not immediately obvious to the provider performing a relatively brief assessment. Therefore, parental report of symptoms should not be disregarded.

Additional questions may be indicated in children of different ages. In neonates, pregnancy and birth history are important. In infants and toddlers, urine output, quantified in number of wet diapers, can be helpful in determining the hydration status. This can be especially helpful in breast-feeding newborns, whose intake is difficult to quantify. Vaccination status is important in infants and children presenting with symptoms such as fever and rash. Drug and alcohol use as well as sexual history become important in adolescents who have increased risk-taking behaviors.