GENERAL APPROACH TO CHILDREN
Clinicians who do not regularly care for children often are fearful of them, particularly because many are nonverbal and may not cooperate with an examination. While children are not just “little adults,” they will be much more willing to cooperate with the examination, and even procedures, if you spend a few minutes interacting with them, rather than interacting only with the parent. As much as possible, talk with children directly as if they were an adult patient. Also, tell children the truth. If a procedure is going to hurt, tell them. They may not like that it hurts, but they will trust that when you do something else and you tell them it will not hurt, you are telling the truth.1
Failure to progress through normal developmental milestones may indicate underlying medical problems, including malnutrition, anemia, human immunodeficiency virus (HIV), hearing loss, chronic infections, lung disorders, and chronic toxicity (e.g., lead poisoning).2 To determine how well children are progressing, remember the four important milestones listed below.
For more complex testing, use the developmental assessment provided in Table 37-1, which was initially created to assess children in rural India.
| Age | Test Type | Behavior |
|---|---|---|
| 3 months | T | Visually very alert, particularly interested in human faces. |
| T | Moves head deliberately to look around. | |
| T | Definite response to mother’s voice, either by becoming quiet or by smiling. | |
| 6 months | A, T | Can roll over from belly to back. |
| T | If placed face down (prone), will lift head and chest, supporting herself on extended arms. | |
| T | If held standing with feet touching a hard surface, the baby bears his weight on his feet and bounces up and down actively. | |
| A, T | Reaches for and grasps small objects. | |
| 9 months | A, T | Sits alone for 10-15 minutes on a firm surface. |
| A, T | Moves on the floor by rolling or squirming. | |
| A, T | Tries to crawl on hands and legs. | |
| T | If the baby is held standing, she steps on one foot then the other. | |
| A, T | Can distinguish strangers from known persons. May become distressed with strangers. | |
| 12 months | A, T | When lying down, can get into a sitting position. |
| A, T | Pulls himself to standing and lets himself down again, holding on to furniture. | |
| A, T | If the baby’s hands are held, she will walk, and may even walk without help. | |
| T | Gives objects to an adult on request. | |
| 15 months | T | Walks unevenly with feet wide apart and arms raised for balance. |
| A, T | Speaks two to six recognizable words. Understands more. | |
| T | Points to familiar persons, animals, toys when asked to do so. | |
| 18 months | T | Picks up a toy from the floor without falling. |
| T | Shows his own hair, nose, and eyes when asked to do so. | |
| A, T | Demands desired objects by pointing and making a noise. | |
| A, T | Explores her surroundings energetically. | |
| 2 years | T | Runs safely on whole feet, easily stopping and starting to avoid obstacles. |
| A, T | Puts two or more words together to form a simple sentence. | |
| A, T | Refers to himself by name. | |
| A, T | When asked, correctly shows her hair, hands, feet, nose, eyes, and mouth, and repeats their correct names. | |
| 2.5 years | T | Jumps with two feet together. |
| T | Can stand on tip-toe if shown how to do so. | |
| A, T | Uses the pronouns I, me, and you. | |
| 3 years | T | Stands for a short time on one foot when shown how to do so. |
| T | Can have simple conversations and talk about past experiences. | |
| A | Likes to help with adult activities. | |
| A | Plays with other children. | |
| 4 years | T | Hops on one foot. |
| A | Climbs ladders and trees. | |
| T | Gives a connected account of recent experiences. | |
| A | Needs other children to play with, and is alternatively cooperative and aggressive. | |
| 5 years | T | Runs lightly on his toes. |
| T | Can stand on one foot for 8 to 10 seconds. | |
| T | Can hop 2 to 3 meters forward on each foot. | |
| A | Undresses and dresses alone. |
HOSPITALIZED AND VERY ILL CHILDREN
In many cultures, a parent, usually the mother, traditionally helps to care for her own child in the hospital. While this should be encouraged in nearly all instances, in situations of scarcity, it has several advantages. It provides (a) low-cost bedside care, (b) continued breastfeeding, (c) emotional support from a known caregiver, (d) warmth for babies if mother and child sleep together, and (e) an opportunity to teach the mother important health care practices.
In remote areas or in situations with scarce resources, it is important to know which children you must immediately refer to a hospital for admission or, possibly in a less urgent manner, to specialists. The following rules (Table 37-2) were developed for practitioners in Papua-New Guinea, which has a chronic scarcity of health resources.3 However, the rules can be applied to all scarce-resource circumstances.
| • Born with an imperforate anus | • <4 weeks old with meningitis, severe jaundice, or sepsis who are not improving after 2 days of treatment | • Neonates with any sign of infection, including fever in infants <28 days old |
| • Moderate to severe dehydration | • Fever and not sucking | • Babies with bile-stained vomit |
| • Intercostal retractions | • Newborns with frequent vomiting and marked salivation in the first few hours of life | • <6 months old with whooping cough |
| • Stridor | • Suspicious injuries that do not fit the history | • Edema |
| • Continued abdominal pain and vomiting | • Convulsion with fever (tropical setting with concern for TB, malaria, HIV) | • Sudden onset of paralysis |
| • Weight <60% of predicted for age, and flat or falling weight curve | • Mid-upper-arm circumference <12.5 cm | • Snakebite with evidence of envenomations (edema, ecchymosis, hematologic or systemic signs) |
| • Poison ingestion | • Child in coma | • Distended, tender abdomen |
| • Suspected meningitis who are not improving after 2 days of treatment | • Hematuria, with or without edema, who do not improve after 2 days of treatment | • Hematochezia |
| • History of unconsciousness after head injury and not back to normal when seen | • Fever, tenderness, and swelling of a limb or a joint that does not improve after 2 days of treatment | • Suspected diabetes mellitus |
| • aMalnourished children not responding to treatment | • aNot responding to standard medical/surgical treatment | • aBabies with ambiguous genitalia |
| • aSlow development | • aPoorly responsive w/umbilical hernia | • aPersistent heart murmur |
NEONATES/INFANTS
Knowing the normal neonatal vital signs for preterm infants (Table 37-3) helps to determine whether a neonate needs resuscitation (assuming that the resources to do this are available) and whether you have successfully resuscitated the infant.
| Preterm | Term | 6 months | 1 year | 3 years | 6 years | |
|---|---|---|---|---|---|---|
| Weight (lb) | 3 | 7.5 | 15 | 22 | 33 | 44 |
| Weight (kg) | 1.5 | 3.5 | 7 | 10 | 15 | 20 |
| Heart beats/min | 140 | 125 | 120 | 120 | 110 | 100 |
| Respirations/min | 40-60 | 40-60 | 24-26 | 22-30 | 20-26 | 20-24 |
| Systolic BP (mm Hg) | 50-60 | 70 | 90 ± 30 | 95 ± 30 | 100 ± 25 | 100 ± 15 |
| Fluid challenge (mL) | 30 | 70 | 140 | 200 | 300 | 400 |
| 8 years | 10 years | 11 years | 12 years | 14 years | ||
| Weight (lb) | 55 | 66 | 77 | 88 | 99 | |
| Weight (kg) | 25 | 30 | 35 | 40 | 45 | |
| Heart beats/min | 90 | 90 | 85 | 85 | 80 | |
| Respirations/min | 18-22 | 18-22 | 16-22 | 16-22 | 14-20 | |
| Systolic BP (mm Hg) | 105 ± 15 | 110 ± 20 | 110 ± 20 | 115 ± 20 | 115 ± 20 | |
| Fluid challenge (mL) | 500 | 500 | 500 | 500 | 500 | |
As soon as an infant is delivered, evaluate the baby’s condition condition to determine if additional intervention is needed. To do this, I devised the simple mnemonic, “BoTToM,” which stands for the status of the normal newborn: Breathing spontaneously (Bo), Term infant (T), normal muscle Tone (T), and no Meconium staining (oM). If the baby does not meet the BoTToM criteria, have other practitioners (preferably two) take the child to a heated area of the room for further evaluation and, if necessary, resuscitation. If the baby meets all these criteria, dry the child and put him or her on the mother’s chest for “kangaroo care.” (See below for an explanation of kangaroo care.)
In infants <12 months old, clinicians’ first-attempt success rate for lumbar punctures is higher with the sitting-flexed position (odds ratio: 2.74), rather than with the lateral-flexed position. Their ultimate success in obtaining cerebrospinal fluid (CSF) for culture, cell count, and in obtaining non-traumatic CSF is the same in both positions.6
In most cases, neonates begin breathing without any stimulation. If not, drying and suctioning them is sufficient stimulation.
For neonates, sucking the mucous and meconium may require mouth suction. The easiest way to make a mouth-operated suction device is to punch two holes in the top of a sealed container, insert two rubber tubes through these holes, and begin sucking on one of the tubes (Fig. 37-1). The suction pressure is easily controlled by how hard the clinician sucks. Once common, use of these devices has decreased due to the risk of infection posed to health care workers. Yet mouth-operated suction devices have many advantages: They are easy to make, inexpensive, disposable, and portable; need only one hand to operate; and do not require a power source other than the clinician. Some studies found that using these devices is a relatively safe procedure, although others have found that they occasionally can transmit pathogens.7,8
In some regions, mothers of older children, in what is a type of reverse mouth-to-mouth procedure, suck the mucus out of their babies’ noses with their mouths.9 The danger of passing pathogens from baby to mother is probably a moot point.
Hypothermia can be devastating to neonates, especially those who are premature or small-for-dates. In fact, all infants <12 months old are highly susceptible to hypothermia, as are any children with marasmus (previously termed “protein-energy malnutrition”), with large areas of damaged skin, or who have serious infections. Hypothermia is defined as a rectal temperature <35.5°C (95.9°F) or an axillary temperature <35.0°C (95.0°F). Also, treat all hypothermic children for hypoglycemia and for serious systemic infection.
The “warm chain” for infants (as opposed to the “cold chain” for vaccine preservation) is a set of interlocking procedures designed to minimize the likelihood of hypothermia around the time of birth.11 These include ensuring that the place of delivery is draft-free and is stocked with the appropriate materials to immediately dry and wrap the infant, including a warm cap for the head. In addition, cover the mother and baby together, and start early breastfeeding.
“Kangaroo care” means keeping mothers and their small or premature infants together, skin-to-skin, over the first days and weeks of life.12 Developed for resource-poor areas, kangaroo care provides an appropriate heat source (mother) that helps maintain neonates’ temperatures, improves survival rates, and spurs weight gain.13
It allows low-birth-weight (<1500 g) babies, some as small as 700 g, to be safely fed, warmed, and bonded to their mothers. The technique is to breastfeed the infant with skin-to-skin contact. Place the child on the mother’s bare chest or abdomen (skin-to-skin) and cover both of them. Alternatively, clothe the child well, including the head, cover with a warmed blanket, and place him or her in an incubator with an incandescent lamp over, but not touching, his or her body. Even in a public setting, mothers can continue such care under a loose dress. After the infant is discharged home, they should continue to use kangaroo care.14,15
Kangaroo care reduces the risk of reflux and aspiration, reduces apnea and infection, and shortens the hospital stay. It also encourages bonding between mother and baby, improves lactation, decreases the amount of time health care workers must spend with the family, and apparently improves the infant’s psychological adjustment.16,17
A simple way to maintain the neonatal warm chain is to swathe the child in a plastic “baby bag” immediately upon birth.
Make “baby bags” by loosely swaddling the infant in polyethylene doubled over on itself, with one thickness above and two below the infant. This retains the neonate’s body temperature and moisture. Dry the head, but do not cover the baby’s head with plastic wrap! This material, often used as household plastic wrap and industrial packing, is inexpensive (<5¢ US) and lightweight (<20 g for a piece to cover an infant). Optimally, use it in conjunction with a radiant warmer. Similarly, a thermal blanket laid over an infant helps preserve heat and moisture. Covering the baby’s large head with a hat might further maintain heat.18,19,20
Commercial incubators often do not work in developing countries, usually because they lack proper maintenance. Consider making improvised incubators rather than using one incubator for several infants, which only serves to facilitate cross-infections, or electric heating pads, which tend to overheat them, may produce burns, and has led to deaths19 (see the “Equipment” section below in this chapter). Use homemade incubator covers to reduce light by completely covering the incubator. Closed-weave quilted and flannel covers perform similarly to commercial covers. Crocheted covers and receiving blankets are markedly inferior.21
Without equipment, successfully resuscitate neonates using mouth-to-mouth breathing. The best way is to run an oxygen tube into the corner of the child’s mouth, with oxygen flowing at 3 to 4 L/min. The clinician uses his or her cheeks as bellows and “puffs” into the neonate’s mouth. Observe chest rise to determine if the ventilation is adequate.22
The ventilation technique, known as “frog breathing” is suitable only for temporary use in babies weighing under about 5 kg.23 However, this is true ventilation, not apneic oxygenation.
Insert an 8- or 10-Fr nasogastric (NG) tube through one nostril into the stomach. Drain it to gravity to prevent the stomach from overinflating.
Give nasopharyngeal oxygen at 2 L/min. Insert the oxygen cannula to a depth equal to the distance between the side of the baby’s nose and the tragus (front of the ear). Do not insert it farther than this, or it may go into the esophagus.
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