For those of us who are parents or may become parents during a PSHTF time, a big issue for us is medical care for our children.  Most of us know what to do incase of a fever, or a tummy ache, but what if during a PSHTF time, you child begins to have seizures from a fever?  What if they develop a case of croup or epiglottitus?  Suppose they become lethargic and you don’t know why?  To better understand our children’s medical needs, we must know how children differ from adults, what the differences are in the behavior of a well child and a sick child, and to know and understand that children cannot be treated as miniature adults.  In this article we will discuss all the aspects of pediatrics, from normal development and vital signs to common childhood illnesses.   Hopefully at the end you will have a better understanding of how a child’s body differs from an adult.  DO NOT use this article as a replacement for current medical care.  Trust your child’s pediatrician and use that resource for medical care while it is available!

Children are very resilient.  They are able to withstand a moderate amount of rough and tumble without being seriously hurt.  Most of the time, a fall will result in bumps and bruises, rather than serious injury and most illnesses will be weathered without serious after affects.

The term pediatrics encompasses children from birth to eighteen years of age, though around adolescence, at age 12, they are treated as adults.  Most of the time everything in pediatrics is based on the child’s weight, and the weight is measured in kilograms.  There are 2.2 kilograms per pound.  The formula for figuring out how many kilos a child weighs is weight in pounds divided by 2.2.  So if you have an infant who weighs 15 pounds, if you divide 15 by 2.2 the infant’s weight in kilos is roughly, 6.8 kilos.  These measurements are used for figuring precise drug dosages, and other advanced techniques like, how many joules of electricity are used to defibrillate a child.

The various ages of pediatrics are broken down into six categories, because at different ages children respond differently to various stimuli.

Young infants, from birth to about six months (actually birth to one month is called neonate) are unable to voice complaints of pain or illness, therefore, relying on physical signs and history from the parents is important.  Also, much attention is paid to the parents, because as their emotional distress grows, the infant’s anxiety increases.  Keeping the parents calm and informed is very important.

Older infants, from 6 months to around one year, will be very wary of strangers.  They should be held by one of the parents while being treated or examined if possible.  They will withdraw from a strangers touch or attention.  If separated from the parents, they will experience separation anxiety and cry, which may worsen their illness or injury.

Toddlers are two and three year olds, and will in most cases be cautious but curious.  They will want to examine and touch any equipment you may have.  Allowing them to touch and “play with” the equipment insures them it will not harm them.  Speaking in a soft, animated voice and working slowly and confidently will win their trust.  In most cases allowing the parents to hold the child will help keep them at ease.

Preschoolers are four and five-year-olds and they perceive everything as evasive. It is best to get down on their eye level and not “tower” over them.  Speak softly and calmly and when asking questions and try to avoid questions that will elicit “yes” or “no” responses…try to get them to verbalize.  Instead of saying, “Does your tummy hurt?”  say, “Where do you hurt?”  Often children this age will answer yes to any question asked.  “Does your tummy hurt?” they say yes, “does your chest hurt?” they say yes, “does your hair hurt?” they say yes.  Explain everything you do in simple child-like terms and be honest.  A blood pressure cuff doesn’t hurt, it gives your arm a big hug.  When using the stethoscope, allow them to listen to their own heartbeat.  The look of fascination on their faces is amazing ?

School age children are from age six to eleven.  These children will want to have some control over what is happening to them. They are the most aware of needles and will anticipate them being used, which will heighten their anxiety.  They do better if they understand the “rules” of the situation.  Give them some independence in making certain choices.  “Will you choose the spoon we’ll use to give you your medicine?”  This sentence implies, they have the freedom to choose which utensil will be used, and they will take the medicine after choosing.  Be completely honest; do not tell them something won’t hurt if it will.

Adolescence is from 12 to 18 years of age.  The young adults are capable of abstract thinking and better reasoning.  They will “know everything”.  They are breaking away from their parents and are more peer oriented.  Some will be brave and put up a good front of not being scared or in pain.  Others will regress into a more childlike phase and cry or want their parents.  Allow them to regress and be very reassuring.  Treat them firmly, but with respect, and listen to what they say.  Gaining the trust of a teenager is talking WITH them and not down to them.

These are the norms of how most children in those age groups behave.  As always, there are exceptions.  Knowing how a child would normally respond can clue you in on problems if they are acting differently.  When a three year old is listless and doesn’t care that a stranger has picked him or her up, when mom or dad is standing right there, should cause warning bells to go off.  This is a sick kid.  A child this age who doesn’t care about their surroundings is concentrating on sickness or pain or on breathing and staying alive.  Another thing to be aware of is parental anxiety.  A hysterical parent can worsen a child’s condition, therefore in certain situations it may be best to separate the parents from the child.  This is no easy task, and can be heartbreaking to watch a parent agonize over their child.  Explaining calmly and professionally that the child is being well taken care of and the medics need space to work will help, but only to a point.  Have someone stay with the parents and be the shoulder to cry on and the voice of reassurance for the parents.

When assessing a child, don’t start with obviously injured areas, in a non-critical patient.  Work your way to them.  A critically ill or injured child won’t care, but a child who is fully alert and aware will perceive it as a threat of trying to make the problem worse.  Before touching the child observe the signs and symptoms that are apparent.  Observe the environment the child is in and the relationship between the parent and child.  Does the child cling to the parent or are they despondent? Do they seem afraid, or cower when the parent approaches or makes a sudden movement?  Is the child guarding a particular area of their body?  Guarding is holding and “protecting” that area from being moved or touched.   Is the skin pink and rosy, or flushed?  Cyanotic, mottled, bruised?  Looking at hydration, if the child is crying are tears present?  Is he drooling or is saliva noticeably absent?  If it is an infant, are the fontanels (soft spots on the head) sunken?  If tears or saliva are absent it could be an indication of dehydration.  If the fontanels are sunken, it is an indication of severe dehydration.    What is his mental status?  Age appropriate?  Alert, curious, quiet, uninterested, or unresponsive?  Look at muscle tone, does he have spontaneous, purposeful movement or are the extremities limp?  Is everything symmetrical?  Lastly, what are the respirations like?  Quiet, noisy, using accessory muscles in the neck, nasal flaring, sternal or intracostal retractions?  Is his head bobbing back and forth?  If the muscles on the sides of the neck are pronounced during inspiration, this is called using the accessory muscles to breathe.  Nasal flaring is the nostrils flaring in and out while breathing.  If the muscles around the sternum or between the ribs are moving in and out during respiration, it is called sternal or intracostal retractions.  Head bobbing is the child’s head moving back and forth during inspiration.  All of these things are signs of respiratory distress and should be addressed immediately.

On the physical exam, work head to toe.  The assessment is basically the same for kids as with adults, so reading the article on adult assessment will help. Starting with the head, gently touch the fontanels.  Are they soft, bulging or sunken?  Bulging fontanels are indicative of a closed head injury.  Look at the shape of the head, is it round or misshapen, any depressed spots or soft spots where there shouldn’t be?  Now look at the eyes.   Are the pupils equal and reactive to light?  Is the sclera (the whites of the eye) jaundiced or red?   Is the conjunctiva (the inner eyelids) pale?  This could be an indication of anemia.  Bruising around or under both eyes, called raccoon’s eyes, may indicate a basilar skull fracture.  Are the orbits around the eyes intact?  Any swelling or deformity present?  Is there any drainage from the eyes?  Yellow, pus-like drainage from the eyes indicates conjunctivitis.  Now move to the ears.  Is there any drainage?  Clear or bloody drainage may indicate a skull fracture.  Another indication of a skull fracture would be bruising behind the ears, called battle signs.    Looking at the nose, check the septum, is it straight or deviated?  Is there swelling?  Any nasal drainage?  Check the mouth for foreign objects.  If the lips are blue, there is an oxygenation problem.  If there is no saliva, it indicates possible dehydration, if there is excessive drooling it could indicate respiratory distress like epiglottitus, or perhaps poisoning.  Now move to the chest.  Does the breathing seem normal?  Is the chest rising and falling symmetrically?  Any use of accessory muscles or retractions?  Listen to the breath sounds?  Anything abnormal?  Listen to the heart rate?  Is it within normal limits?  Does it sound regular or does the rhythm sound irregular?  Move to the abdomen.  Is it soft or firm?  Does it appear distended?  When feeling each quadrant, does the child withdraw or cry out in pain?  Next examine the extremities.  Are they symmetrical?  Any deformity or swelling?  Any obvious trauma or bleeding?  Does the child have good movement in all extremities?  Good sensation and distal pulses?  This is the basic assessment of children, and the differences to look for from adults.  Though both processes are essentially the same, things to look for can vary greatly.

Vital Signs in Children
Children’s vital signs can fluctuate greatly depending on the amount of duress they are under.  A very important thing to remember with children is with their physiology; their bodies will compensate dramatically when under heavy stress of illness or trauma.  But they can only compensate for so long, and when the decompensation begins, they crash and crash hard.  Usually by then it is very difficult to get them back.  The key is to recognize the overcompensation and treat it aggressively before they begin to fall.

Average Vital Signs

Age                Pulse                    Respirations             Blood Pressure (Systolic)

Birth               140                      40                           60 – 80
Six months      110                     30                            90
One year         100                     28                           90
3 to 4 years     95                       25                           100
5 to 10 years   90                       24                           100
11 to 18 years 60-100               12-24                      110-120

These are averages for the vital signs.  A few points in either direction isn’t crucial, but more than 10 points in either direction could indicate a problem.  When assessing vital signs on an infant from birth to one year of age, the pulse rate should be listened to apically, meaning, using a stethoscope and listening to the heart for a full minute, counting the beats and listening for regularity.  For age two to ten, take the pulse at the brachial artery located on the inside part of the upper arm (a technique that should have been learned during your CPR classes).  Blood pressure and respirations are counted the same as adults.
 

Common Childhood Illnesses and Diseases
The most common childhood illness is fever.  Usually fever is a sign of infection, but infants can spike a fever for just about any reason including teething, constipation, allergies, diet, etc.  Infection induced fevers in adults may be considered a low grade fever, under 100 deg F, but in children will be much higher, usually over 101.5 deg F.  If the child’s temperature spikes above 104 deg F, febrile seizures will usually follow.  A febrile seizure is the brains response to being too hot and the child will experience a grand mal seizure which is usually characterized by full body shaking, or rigidity of the extremities, eyes deviated to one side, excessive drooling, incontinence to the bladder or bowel.  The child may also bite their tongue or lip.  If a child or anyone begins to seize, DO NOT attempt to place anything in their mouth.  They will NOT swallow their tongue…that is a myth.  A person cannot swallow their tongue…the tongue may occlude the airway, but it cannot be swallowed.  Place the child in safe place, off of furniture where they could fall and away from objects or furniture they could hit and injure themselves.  Allow them to have the seizure and do not try to hold them down.  Protect the head as much as possible.  Most seizures last anywhere from 30 seconds to two minutes.  Once the seizure has finished the child will be in what is called the post-ictal phase.  During this phase, the child will be unresponsive to stimuli, may appear very lethargic, eyes glazed, extremities flaccid.  It is not uncommon for a person to become apneic for a few seconds after a seizure.  Watch them closely…unless their airway is occluded, they will begin breathing again.  The respirations will be a deep snoring like sound.  The post ictal phase can last from a few minutes to thirty minutes.  Use of Oxygen may help them come around more quickly.  For febrile seizures, it is imperative that the fever be reduced.  The infant’s brain is essentially baking inside the skull and the seizure is the body’s warning that things aren’t right.  Most children who have febrile seizures do not have long term problems later in life unless there was an underlying illness or disease, or anoxia to the brain that causes damage.  The way to avoid this problem is to be diligent about monitoring a sick child’s temperature.  If a child is sick, at the first sign of a fever, begin giving the child infant or children’s strength acetaminophen or ibuprofen (Tylenol or Advil).  These two medications may be used together, with the Tylenol being given every four hours and the Advil given every six to eight.  NEVER give a pediatric patient under the age of 19 Aspirin!!  Aspirin can cause Reyes Syndrome in children and adolescence and is a fatal disease!   After giving the initial dose of the meds, check the child’s temp in an hour.  There should be at least a one-degree difference.  Check the temp again before repeating the second dose of medication and again an hour after giving it.  Continue to give the medication until the child’s temperature is normal.  After discontinuing the meds, continue to monitor the child’s temp every four hours for 24 hours.  If it begins to rise again, begin using the meds again.  Other methods to reduce a fever are bathing the child in a tepid bath (NOT COLD), placing cool clothes on top of the child’s head, under the armpits and in the groin area (they will cry…they don’t like that one very much ?).  If the fever isn’t reduced in 24 hours with the Tylenol or Advil, and there are other symptoms present that indicate infection, antibiotic therapy may be indicated.

Dehydration is common when a child runs a fever and is vomiting and has diarrhea.  A small child can dehydrate overnight.  Vigilant care must be taken to insure the child is drinking enough fluids, something like Pedilyte, and that they have adequate urinary output.  Acceptable urinary output for a child 30 kg (66lbs) or less is 1cc/kg/hr.  So if a child weighs 20 kg, they should be putting out 20 cc of urine per hour.  For a child over 30 kg, the acceptable U/O is the same as an adult, ½ cc/kg/hr.  If the child weighs 45 kg, they should be putting out 22.5 cc of urine per hour.  If oral rehydration isn’t possible, IV rehydration will be necessary, and should only be preformed by trained individuals.

Another common problem with infants is diaper rash.  This occurs when the sensitive skin in the diaper area becomes red and inflamed from contact with wet and soiled diapers.  Some babies are more prone to it than others.  Frequent diaper changes and use of a diaper rash ointment such as Desitin or Balmex will help dry up the rash.  Also letting the child go without diapers for several hours a day and allowing the area to get air circulation will aid in healing. Using the ointments during each diaper change prophylactically will help prevent diaper rash from occurring.

Croup is a viral infection of the respiratory tract that usually affects children between the ages of three months and three years of age.  This infection causes swelling just below the epiglottis and will cause mild to moderate respiratory distress.  The child will have inspiratory stridor, which is a high pitched squeaking sound when they breathe in, and they will have the “seal-bark” cough.  Wheezing in the lungs may or may not be present depending on how much of the lower respiratory tract is involved.  The child will also have a slow onset, low-grade fever, below 101 deg F.  This infection can be treated with a cool mist humidifier or by taking the child into a steamy bathroom.  The object is to get some moisture into the air they’re breathing.  Viral infections are usually not helped with antibiotics, but in some cases croup may be treated with steroids such as Decadron.

Epiglottitus is sometimes called bacterial croup and is a life threatening childhood illness.  It usually affects children from ages three to seven, but can happen at any age, even adulthood.  The onset of epiglottitus is acute, happening over an hour or two.  The epiglottis is a leaf shaped flap that covers the opening of the trachea in the throat.  When it becomes inflamed, it can cause airway occlusion and respiratory arrest.  The child will spike a high fever, 103 or higher, over a very brief period of time.  They will have excessive drooling because they cannot swallow.  They will develop moderate to severe respiratory distress, including inspiratory stridor, intracostal and/or sternal retractions, and nasal flaring.  They will appear listless and uninterested in anything;  their main focus is on breathing.  Any stimulation of this child can trigger what are called laryngospasms.  This is where the vocal cords begins to spasm and clamp shut.  This will lead to respiratory arrest and the need for emergency airway interventions such as a tracheotomy.  Once a good, patent airway has been established, an IV should be started so IV antibiotics, such as Ampicillan can be administered.

Conjunctivitis, commonly called pink eye is another common childhood illness, mainly because it is highly contagious.  Pink eye will present as redness of the sclera (the white of the eye) and a thick yellowish, green drainage from the eye.  Itching is another common symptom, and everytime the child rubs the infected eye, the infection can spread to the opposite eye or to other people.    Irrigating the eyes with sterile saline solution to rinse out the drainage and treating with antibiotic eyedrops, such as Polymixin are necessary.

Otitus Media, or the common earache, is usually a viral infection of the middle ear and causes intense pain, fever, chills, possible hearing loss, and a feeling of fullness or pressure in the ear.  Use of antibiotics is controversial with Otitus Media, because as stated before, antibiotics do not help viral infections.  If the ear ache is accompanied by a cold, flu, sinus problems, etc, that is bacterial, the antibiotics will clear up that infection, and take with it the earache, because the earache is a symptom of the initial problem.  Tylenol and Ibuprofen will help with the pain and must be given on a scheduled basis to prevent the pain from recurring.  Often heat, from a heating pad or hot water bottle will help alleviate pain also, but must be used carefully so as not to burn the child.  Decongestants can also be used to help clear the sinus passages, and keep the Eustachian tubes open.  If there is any sign of nasal allergy or if the child is prone to nasal allergies, an antihistamine may be used also.  Treating the cause of the infection, whether it’s cold, sinus problems etc, is the key to stopping the earache.

Teething pain is another issue all parents deal with.  Some children teethe and have no problems at all while other children will have pain, low-grade fevers, gum swelling, and maybe even vomiting.  Since teething is a natural process and can’t be prevented, we can only deal with the symptoms as best we can.  Give the child Tylenol or Ibuprofen as indicated for the pain and something soft to chew on….commercial teething rings, a wet wash cloth, teething cookies are all examples.  WARNING!!!  DO NOT give children small objects to teethe, objects small than the child’s fist are choke hazards.  Once the tooth erupts through the gums, the pain and other symptoms usually lessen dramatically if not disappear completely.

On from teething, are older children losing their baby teeth.  Again, this is a natural process that can’t be prevented.  When a child has a loose tooth, they are usually delighted and will wiggle it until if comes out.  Occasionally there are some children (Tiny Chick is one of them) who fear losing their teeth and won’t wiggle the tooth to loosen it and it takes longer for it to come out.  The problem with this is, as the permanent teeth are coming down, they are pushing into the roots of the baby teeth, and these roots can abscess.  Usually this abscess can be seen on the gum line and will drain on its own.  If they don’t drain, they can cause damage to the permanent tooth above.  The solution is one no parent likes…I know I didn’t.  That is to wiggle the child’s tooth for them, everyday, until it is loose enough to pull.  Once a tooth comes out, it will bleed for a few minutes, and usually stops on it’s own.  Having the child rinse with tepid water will help rinse their mouth.  Do not allow them to swallow the blood.  This will cause nausea and possibly vomiting.  Once the tooth is out, save it until bedtime and put it under the child’s pillow and await a visit from the Tooth Fairy ?

Chicken Pox is a childhood illness that most children get between the ages of one year and 10 years old.  There is currently a vaccination available for chicken pox, called the Varicella Vaccine.  In many states it is becoming part of the regular immunization schedule for kids.  Chicken pox, while rarely fatal, is extemely miserable.  The child will first develop small blister-like bumps on their chest and back, and they will quickly spread to the arms, legs, face, head.  In severe cases, they can be in the child’s mouth, covering the groin area, around or in the eyes, etc.  These little blisters itch severely and scratching will spread them.   These blisters usually dry up and the scabs fall off in one to three weeks.  The child should have limited contact with those who have never been exposed or vaccinated against Varicella until all of the blisters have drained and completely scabbed over.  Fever and runny nose may also be present, and should be treated accordingly.  Antihistimines may be given to help alleviate itching.  Maintain fluid intake, and practice good hygeine, handwashing before and after touching the child and routine bathing of the patient.

Minor injuries in children are treated, for the most part just as you would an adult.  Remember the normal behaviors for each age bracket and treat the child accordingly.  Wash all small cuts and scrapes with soap and water.  With small injuries and small children, remember, a band-aid can make the world of difference! ?

For bigger injuries, be aggressive with the care, stop bleeding quickly.  A child who weighs less than 20 kg can go into shock from bleeding out only 12 ounces….that’s the amount of a can of Diet Coke!!  If a child is seriously wounded get him or her to the medic immediately!  Aggressive advanced care will be necessary to keep the child from crashing.  Remember, children differ from adults in how they compesate during shock.  An adult will not compensate at all, and it is very obvious they are in shock.  A child will compensate up until the very end.  Their vital signs will be elevated, but not drastically so, they may feel poorly and become listless, but that’s the extent of the warning you’ll get.  If the mechanism of injury is great and the chances of trauma are increased, treat this child as if they are in shock.  Monitor their vital signs every three minutes and constantly reevaluate their condition.  When a child begins to decompensate and the signs of shock are apparent, it is extremely difficult to stabilize them.  Aggressive advanced care is necessary to save the child’s life.

Pediatrics is a complex topic to cover and I hope I’ve touched on many of the common childhood illnesses and problems that we as parents may encounter.  Remember when dealing with children, include the parents.  A parent’s trauma is just as great as the childs, and sometimes, on an emotional scale, worse.  Be calm, rational and compassionate when dealing with parents.  If you are a parent, put yourself in their place and imagine for a split second the heartbreak they are experiencing.  Dealing with the parents is sometimes more traumatic for the medics than actually caring for the child.  If you don’t have children, be empathetic.  Never minimize a parent’s fears or sadness.  Assure them the child is getting the best care and keep them aprised of the situation.

I hope this article was informative and helpful for those who are parents, or may become parents, or for any group who have members with children.  Our children are our future, so let’s take care of them, teach them, and keep them healthy, because oneday they’ll be caring for us.

Palehorse