17
The pre-school child
Introduction
More than 3 million children aged 0–16, the equivalent of 28 % of all children in England, attended Emergency Departments (EDs) in 2006/7 accounting for 25 % of all patients seen in EDs across the UK (Royal College of Paediatrics and Child Health and Royal College of Nursing 2010). As many as four out of five children attend with minor injuries, with one in five attendances resulting from parental concern about acute illness (Department of Health 2004). Findings from the Children’s National Service Framework 2004 (Department of Health 2004) indicate that 70 % of children attending rural EDs have accidental injuries and in inner city EDs 70 % of attendees are for acute medical illness. Recent figures suggest that children attending EDs often require an episode of care without an overnight stay, on average, an increase of 15%, highlighting the importance of community-based facilities competent in the assessment, treatment and observation of children (NHS Institute for Innovation and Improvement 2008). In the younger age group 1 child per 1000 of the population is in hospital with acute illness on any given day (Department of Health 2003a). Only a small percentage, less than 0.25 %, of all children attending the ED will require a paediatric intensive care bed.
Changing patterns of illness in children have shown a decrease in many of the acute presentations to the ED. This is felt to be due in part to the revision of immunization programmes, increased awareness of health promotion and the introduction of new technologies. Health promotion and early preventive measures have improved the management of some children’s conditions such as asthma. However, there is an increase in recognition of emotional/behavioural problems across childhood, including deliberate self-harm and harm to others (Department of Health 2003a).
Recent times have seen a shift in attitudes towards children and their needs and development, and considering the child as an individual in their own right rather than a ‘little adult’ is now more likely to be the norm. The concepts of children as people with rights are now also reflected in everyday policy and debate such as in the National Service Framework (Department of Health 2004), UNICEF (1990) and the UN Convention on the Rights of the Child (United Nations 1989). The Royal College of Paediatrics and Child Health and Royal College of Nursing (2010) have indicated the number of registered children’s nurses working within the ED setting is insufficient despite reports as far back as the 1950s stipulating that children in hospital must be cared for by staff trained in caring for children (Ministry of Health 1959); however, it is equally as important to recognize that emergency care skills are something conventional children’s nurse training does not offer (Royal College of Paediatrics and Child Health 2007a).
The visit to the ED is often a child’s first experience of hospital, thus making the whole incident doubly traumatic. Young children have insatiable curiosity about their surrounding environments, creating greater vulnerability by being generally unaware of the imposing dangers. Between 1 and 4 years a child’s physical and mental development is very rapid, with 50 % of the child’s mental capacity developed before the age of 5 years (Brain & Martin 1989). Coupled with substantial leaps in acquisition of language and multi-skills, such quick development can prove the danger for unsuspecting parents/carers. It can come as a surprise when the child is first able to scramble up the stairs and reach up to a work surface or has the strength to pull over a chair. Pre-school children usually arrive in accident and emergency as a result of accidental injury. The challenges of climbing furniture, stairs, the opening of all manner of containers, sampling even the most unpalatable of agents all increase the likelihood of a small child suffering falls, minor injury and poisoning (Mead & Sibert 1991).
Normal development
Pre-school children perceive the world differently from adults. The 2-year-old is egocentric and will perceive that he is the centre of his world, being unable to identify with anybody else’s point of view. The child may believe that it is he who is responsible for events that we know to be out of his control. Throughout this pre-operational phase of development, memory and imagination are developing rapidly. There is a tendency to mix fact with fantasy and a belief that the child’s thoughts can control events. There is an intuitive, magical quality to their thoughts (Hall & Elliman 2003).
The child under stress
The pre-school child is more vulnerable and traumatized when separated from his parents than at any other age. Bowlby (1953), in his famous study Child Care and the Growth of Love, shows how a child suffers maternal deprivation when separated from his significant carers, the male or female person who supplies love, care, protection and comfort.
Since then, many seminal reports have confirmed the importance of keeping parents and child together (Ministry of Health 1959, Department of Health 2004, Royal College of Paediatrics and Child Health and Royal College of Nursing 2010). This is particularly important in EDs where events leading to attendance will have caused some stress (Box 17.1). Injured/unwell children, despite their parents’ presence, may become clingy or dependent (regress) while in the hospital setting.
Effective nursing interventions at this early stage can do a lot towards developing a rapport with the child and family, and to alleviate stress and fear. Acknowledging the child’s suffering and putting it into context using toys or pictures can be helpful, as is prompt pain relief. Parental input from the outset is essential not only to reduce stress and induce normality in the child but also to reduce stress in the parents/carers themselves. Encouraging parents/carers to undress their child and to help them with the examination as well as to be there to give reassurance to their child reinforces the parents’ importance in the treatment and helps to allay their fears.
The environment in which a child is cared for has come under much scrutiny in recent years (Bentley 2004, National Audit Office 2004). Facilities for children are best provided in an environment away from adult patients. Children should have their separate waiting area geared towards their needs with appropriate toys, books, television, video and electronic games. Treatment areas should also be child-oriented not only in décor and furnishings but also in equipment so time is not wasted hunting for appropriate items such as child-size blood-pressure cuffs or pulse oxy-sensitivity probes.
Parental anxiety
Parents/carers frequently experience a lack of confidence in their judgement when their child is ill and often remain anxious and concerned, having to manage their sick child at home even after reassurance from a medical professional. In situations like this it has been shown that parents/carers do not know how to contact health services when their child has not improved (Neill 2000). It is easy in circumstances following an accident for the parents to feel inadequate or lose confidence in their own ability. This must be addressed in the ED constructively and without proportionate blame, to enable the parents to support their child. Reassurance, information and what the parents/carers can do to help their child should be clearly communicated. Poor handling of parents in the ED can have a long-term effect on both the child and the family’s recovery (Mead & Sibert 1991).
The term ‘family-centered care’ is frequently used in children’s nursing and aims to evoke the inclusion of parental participation in child health and shared care decisions ensuring both the needs of the child and family are paramount (Hughes & Lyte 2009). Working within the ED setting, this concept is no different. The ED nurse’s attitude should be family oriented when dealing with children. Parents are often under a great deal of stress, feel guilty and are very anxious. These negative emotions can have a profound effect on the child. The parents need reassurance and a chance to relay their fears and guilt to the nurse (Bentley 2004).
Communicating with the child and family
Effective communication is central to nursing any patient of any age. A key factor in reducing stress and relieving anxiety is the way by which we communicate with the child and family. The value of effective communication is not only dependent on the nursing staff but also on the multi-disciplinary team. Good communication is the basis of forming a trusting relationship with the child and family and Maguire & Pitceathly (2002) suggest that this aids the practitioner in identifying the child or family members’ problem resulting in greater patient/family satisfaction.
Understanding illness
To a young child, illness is remote and viewed as an external process. There is a tendency to believe this has something to do with magic or is a punishment. Pre-school children do not fully understand internal body processes. In this pre-operative phase (Piaget 1990), children are only just developing their thought processes in relation to internal body organs. They have little concept of where internal organs lie, other than the heart, which lies in the middle of their chest and is used for loving and caring. When talking with pre-school children they often describe tummy ache and at the same time point to their head or equally they will say they have headache and point to their tummy. A child of this younger age is concerned with external injury and very often frightened of seeing blood, small cuts and marks. The external aspect of his environment such as light, equipment, uniforms and noise will affect the child much more than an explanation of what is going on in his/her body.
Play is a very important aspect of the child’s care and is at the very centre of a healthy child’s life (Webster 2002). Children can express fear and anxiety through play, so a playful environment will help reduce stress and anxiety. Watching a child play gives a fair assessment of social and multi-skills. Playing with children during examination and assessment will help the child understand treatment and procedures. Play specialists in EDs often have little or no time to plan play or distraction therapies because of the unpredictability of the setting and speed at which interventions are required (Knight & Gregory 2009) and therefore must have the skills to adapt to this situation quickly. Dolls and teddy bears come in very useful when trying to demonstrate what is about to be done to a child. Through play children are able to learn both the sensory and concrete information they need in preparation for some clinical procedures.
Asthma
There are approximately 5.2 million people in the UK with asthma, nearly 1 million of whom are children (National Institute for Health and Clinical Excellence 2007). During the past two decades, many scientific advances have improved the understanding of asthma and ability to manage and control it effectively. Since the late 1990s admission rates have declined (Shabu et al. 2007). However, recommendations for asthma care need to be adapted to local conditions, resources and services (Bateman et al. 2008). Asthma is acknowledged to be the most common long-term childhood condition and although mortality as a result of asthma is rare, the condition can have a significant impact on the child’s quality of life. Regardless of medical advances and technological improvement in asthma management confidential enquiries into asthma deaths have often indicated that the fatality could have been avoided if there had been better preventive measures, better recognition and help in avoiding delay during the final attack and in receiving earlier emergency care. Younger children with asthma are particularly vulnerable because they rely on others to react to the severity of their condition and to act on their behalf. Children in the 0–4-year age range have the most frequent health consultations with GP and out-of-hours services for asthma conditions.
Assessment
The overall clinical picture is developed from the combination of history, physical assessment and clinical investigations. If the child has obvious breathing difficulty, oxygen and nebulized bronchial dilators should be commenced immediately, prior to detailed history-taking from the parents/carers. Children under the age of five cannot adequately use a peak flow meter so peak expiratory flow is not recommended for this age group. Questions which should be asked in establishing a history of the event and the child’s general health are given in Box 17.2.
Physical assessment
Initial observation of the child will allow the nurse to observe respiratory rate, rhythm and effort (Aylott 2007). The respiratory rate and depth should be established first as this correlates to the severity of asthma. Normal breathing is effortless and quiet. The use of accessory muscles such as those in the neck and shoulders is described as laboured and requires substantial effort (Brooker & Nicol 2003). Intercostal and sternal recession is an indication of moderate to severe respiratory difficulty. As the child’s ability to speak is an indication of respiratory function, the nurse should know if the child can speak in full sentences using more than a few words or not at all. Parents are invaluable in assessing difficulties in the child’s normal pattern of speech, as ability to converse varies with this age group.
Respiratory assessment should be conducted and interpreted in association with other clinical assessment; therefore a rise pulse rate may be indicative of increasing hypoxia, but must be considered within context (Aylott 2007) such as if the child is upset, pyrexial or on beta agonists such as salbutamol, a tachycardia would be expected. Although wheezing is a classic symptom of bronchospasm, it is unreliable in detecting the severity of an episode. At assessment, any audible wheeze or wheeze on auscultation should be recorded and used as baseline. It is important to remember that if air is not being moved effectively in and out of the lungs, no wheeze will be present. Signs of respiratory distress, e.g., nasal flaring, grunting, wheezing, recession, use of accessory and intercostal muscles, chest shape and movement should be noted by looking and listening (Royal College of Nursing 2007).
Peak flow measurement is considered an important indication of the severity of an asthma episode; however, Scullion (2005) notes that young children can also be confused by the exhalation method required to use a peak flow meter. Exercise testing, by getting a child to run around for about six minutes, may therefore be more suitable for younger children. Peak flow measurement should therefore only be attempted in children who have previously and regularly used a peak flow meter.
Management
In cases of life-threatening asthma (Box 17.3) these children need immediate high-flow oxygen via a non-rebreathing mask, and a nebulized beta agonist such as salbutamol. Preparation should be to establish i.v. access for the administration of medications. Children in this age group both deteriorate and respond to treatment rapidly. The nurse must be vigilant for any changes and equipment should be at hand for intubation and ventilation.
Rapid oxygen therapy and nebulized bronchial dilators should be commenced and in cases of severe asthma (Box 17.4) an oxygen saturation of at least 95 % should be the aim (British Thoracic Society and Scottish Intercollegiate Guidelines Network 2011). It is important not to distress the child unnecessarily as this significantly increases the work of breathing. Intravenous access should be considered particularly if the child does not respond rapidly to nebulizer therapy.
Compliance with treatment is crucial to the successful management of this group of children. It is important to be calm and to keep the parents/carers informed of treatment plans to enable them to assist in the care of their child. Initial management involves inhaled bronchial dilators (short-acting and long-acting) and cortical steroids are the drugs of choice. The administration of beta agonists such as salbutamol (dose dependent on age) is the first-line treatment for acute asthma and they can be given by a variety of devices. For the mild to moderate asthma a spacer with mask can be ideal for the younger age group. However, with severe asthma it is advisable to use a nebulizer. It is important that the nurse explains what is being done first and uses toys and play where appropriate. Alternative devices such as a mouthpiece nebulizer can be more successful. If the child is very upset it is sometimes better to get a parent to hold the nebulizer by the child’s mouth than to increase the level of distress by attaching the mask to the child. If the child responds well to nebulizer treatment, they should be observed in the ED as per local policy post-nebulizer, to ensure that the response is not transient – ideally 2–4 h (British Thoracic Society and Scottish Intercollegiate Guidelines Network 2011). If the response is not maintained, the child should be admitted for treatment and continued assessment.
When planning the discharge of a young child from ED it is important that parents understand and are happy with ongoing treatment plans. Although a child may appear well after nebulizer therapy for an acute episode of asthma, the small airways obstruction can persist for several days. Parents must be able to administer supportive therapy at home. Many devices exist to assist young children in the inhalation of bronchial dilators. Spacers are commonly used for children under the age of five (British Thoracic Society and Scottish Intercollegiate Guidelines Network 2011). These create an enclosed space between an aerosol inhaler and the child’s mouth allowing him to work at his own pace without the need for hand-breathing coordination that an aerosol would demand.
The early use of steroids for acute asthma can reduce the need for hospital admission and prevent a relapse in symptoms after initial presentation. A short course of oral steroids can speed up the race for recovery from an acute episode of small airways obstruction. Prednisolone 1-2 mg/kg for three days or longer if necessary (Royal Pharmaceutical Society 2010) is recommended for children who have not responded to regular home treatment over a period of 24 hours or more prior to ED attendance. Children regularly on inhaled steroids may also benefit from this boost.
As well as advice on drug therapy, it is important that parents and carers are able to detect their child’s worsening condition and know when and where to seek help (Box 17.5). Parents/carers should be advised to return to the emergency department if:
• the respiratory rate increases
• the ability to speak deteriorates
• the positive response to inhaled bronchodilators reduces
• the child becomes agitated and is not behaving as normal for a child.
Follow-up should be arranged for all children discharged from ED; this can usually be done via children’s community nurse teams and/or the child’s own GP.
Acute laryngotracheobronchitis (viral croup)
Croup is a broad term used to describe an infection, usually viral in nature, of the upper airway and vocal chords. Croup is a common childhood illness, with the majority of children presenting with symptoms including acute onset of barking cough, low-grade fever and stridor. The stridor is made worse by crying, agitation and coughing. The most important thing to remember is to keep the child as happy as possible with as little or no intervention as possible (Bjornson & Johnson 2007). Croup is more common in boys than in girls, usually occurs between 6 and 36 months of age, and peaks during the second year of life (Zoorob et al. 2011). Croup most commonly occurs in damper weather of late autumn, winter and early spring. Typically the symptoms are worse between 18.00 and 06.00 and peak around the second or third night.
Pathophysiology
• inflammation of the subglottic area
• increased mucus production, which can affect the entire respiratory tract.
The increase in mucus together with the pharyngeal irritation results in the hoarse cough. Obstruction to airflow through the upper airway causes stridor and difficulty in breathing, and can progress to hypoxia. Hypoxia with mild obstruction indicates involvement of the lower airway, where obstruction causes ventilation perfusion mismatching. Later, hypercapnia occurs as hypoventilation progresses with obstruction (Dykes 2005). Less common symptoms of croup are highlighted in Box 17.6.
Assessment
Physical assessment
Assessment of the child in ED should focus on determining the degree of threat to the respiratory function. The work of breathing should be assessed in terms of the child’s colour, level of consciousness, respiratory rate, use of accessory muscles, nasal flaring and intercostal recessions. The degree of stridor is significant; the nurse should know whether the stridor is inspiratory, which usually indicates a supraglottic cause, or expiratory, which usually comes from the trachea. In severe cases inspiratory and expiratory stridor may be present. The loudness of the stridor is not an indication of its severity, but often influences the degree of anxiety. It is important to establish whether stridor is present at rest or only when the child becomes agitated or exerts him- or herself.
Having assessed the severity of the croup, the first line treatment is dexamethasone 0.15 mg/kg orally (Sparrow & Geelhooed 2006) if this is ineffective or if the child is assessed as having moderate to severe croup then the administration of an adrenaline (epinephrine) nebulizer 5 mL 1 in 1000 is the next step. This is best administered by a parent holding the nebulizer in front of the child, as face masks and mouthpieces can be frightening and considerably increase the child’s distress. Adrenaline acts both as a bronchodilator and suppresses histamine, thereby reducing mucous secretions and relieving airway obstructions. The effects of adrenaline nebulizers are relatively short-acting but often quick-acting. Should the child’s condition be deteriorating then a repeat adrenaline nebulizer 5 mL 1 in 1000 should be administered while preparations for intubation are underway with the support and presence of an anaesthetist. However, if the child is showing signs of improvement then further assessment should be taken 30 minutes post-nebulizer. Clinical investigations, such as blood tests and chest and neck X-rays, do little to alter the management plan but do much to increase the child’s distress and anxiety. For this reason investigations of this nature should not form part of the initial management (Box 17.7).
