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  Inherent differences exist between pediatric and adult patients.

  
  
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  Physicians have to treat both the parent and the child.

  
  
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  The older the child, the more reliable the clinical impression.

  
  
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  Disposition can be affected by unique family situations.

Infants, children, and adolescents constitute approximately a third of all visits to emergency departments (EDs) in the United States. Of these pediatric visits, more than half are for urgent/nonemergent problems such as otitis media, respiratory and gastrointestinal infections (often viral), asthma, fractures, sprains, soft tissue trauma, and minor head trauma. The challenge of pediatric emergency medicine is to prevent mortality or increased morbidity by catching the few cases that need hospital admission or emergent intervention and ensuring proper discharge of less ill patients.

Children are considered minors up to their 18th birthday. Although no consent is needed for life-saving interventions, minors require their parent’s or guardian’s consent for routine medical care and discharge. An exception to this rule is the emancipated minor. “Emancipated minor” status allows a person less than 18 years of age to consent for medical care without parental knowledge, consent, or liability. The exact legal terms of what makes a minor “emancipated” varies slightly from state to state, but generally includes one or more of the following: marriage (including becoming divorced, separated, or widowed), membership in the armed forces, becoming pregnant or having children, living separately from parent(s) or guardian(s), or, finally, demonstrating the ability to manage one’s own financial affairs. Of the preceding criteria, discovering a patient is pregnant is the most common situation the authors’ have encountered that leads to emancipated minor status.

Another important legal issue for clinicians working with children is our role as mandated reporters. We have a duty to protect vulnerable young patients. If there is reasonable cause to suspect that a child has been abused, neglected, or placed in imminent risk of serious harm, we are obligated to involve government agents such as child protective services, police, etc.

There are many aspects of clinical pediatric emergency medicine that differ from adult emergency medicine practice. Not only must you vary your approach to each patient based on their anatomic, physiologic, and developmental status, you also have to establish an effective relationship with the patient and his or her caregiver. In other words, physicians have to treat both the parent and the child. We review some of these differences later in this chapter.

History

Obtain as much information as possible from the child. Questions should be direct and stated in terms the child can understand. Further details and clarifications should be sought from the parents, guardians, or caregivers. The younger the child, the greater reliance on history obtained from the parents, and the more the history may be influenced by the parent(s)’ perception of symptoms. When taking the history, children can become anxious when separated from parents. Separate children from parents only when absolutely necessary (eg, in the case of an adolescent patient when a sexual and/or illicit drug history needs to be obtained) or in a younger patient when abuse or neglect is suspected. Unusual complaints such as weight loss, night sweats, headaches, or back pain in a small child should prompt concern for more indolent or life-threatening underlying pathology, particularly malignancy.

Important historical information needed in all pediatric patients includes birth history, immunizations, prior medical problems, medications, allergies, developmental milestones, usual activity, and oral intake. In particular, abnormal birth histories and immunization records can have a significant impact on the differential diagnosis for pediatric patients.

Normal oral intake for an infant depends on their age (Table 47-1). Any changes from baseline are important to discover and address. Solids are not generally initiated until the infant is approximately 6 months of age. When dehydration is a concern, you should ask about the patient’s activity level, oral intake, number of wet diapers, frequency of diarrhea or vomiting, and their ability to make tears.

Finally, a mismatch between the history and physical exam or an injury not explained by the historical mechanism provided should prompt the clinician to consider abuse as a cause of the patient’s complaint(s).

Physical Examination

Once the history is obtained, it is time to proceed to a physical examination of the child. Because many children are nervous and afraid of strangers, especially in the unfamiliar setting of an ED, a calm, gentle approach to the child during the examination can help a great deal. Having the parent hold the child on his or her lap or hug the child against his or her chest can help to both reassure the child and immobilize him or her during the exam. If the child does start to cry, repeated examinations may be necessary to ensure a thorough and accurate assessment.

As in adult emergency medicine, we use the ABCDE (airway, breathing, circulation, disability, and exposure) approach to management with a quick general assessment. Initial assessment includes obtaining the patient’s vital signs, which will help guide your management. Normal vital signs vary significantly according to patient age (Table 47-2). For example, the normal pulse in a 6-month-old is about 110 bpm, but this rate would be considered highly abnormal in an adolescent. You should also get an accurate weight on your pediatric patient, as your treatment and medical decision making will often be based on this weight.