PARA 1000

Introduction to Paediatrics

Dr John Craven

2015

• The Normal Child

– Ages

– Anatomical and physiological differences

– Stages of development

• The Sick Child

– Presentations

– SIDS

Session outcomes

2

References

The Normal Child

• Newborn

• Neonate (0 - ~6weeks)

• Infant (~6 weeks - ~12 months)

• Toddler (~12months - ~24 months)

• Child (2 yrs ~ 12yrs)

• Adolescent (~12yrs - ~29 yrs)

Ages of Childhood

Newborn

• Transition of fetus to a baby

• Physiological & environmental changes:

– Circulation (placental/umbilical flow, shunting of blood through

heart and through ductus arteriosis)

– Respiration (oxygenation from lungs rather than placenta)

– Exposure to environmental microbes

– Exposure to cold

• Oxygenation and drying of child

• Initiation of feeding

Newborn

• Talk to the parents

– Often new experience for them

– Parental anxiety and expectations

• Look at the child

– Does the child look okay?

• Does the child ‘handle’ well?

Approach to the Newborn

• Establishment of feeding

• Colonisation with commensal bacterial

• Poor immune function

• Poor thermoregulation

• Immobility

Neonate (0-6 weeks)

• Feeding/sleeping/irritability issues

• High risk of bacterial infection

• Sudden Unexplained Death in Infancy (SUDI)

– (previously Sudden Infant Death Syndrome (SIDS)

Neonate (0-6 weeks)

• Develops from minimal movement to rolling,

sitting, crawling, and walking

• Remains highly dependant on environment

Infant (6 weeks – 12months)

• Mobile child 12-24mths

• Exploring, inquisitive, exploring

• Development of language and

communication

Toddler

• High rate of infection (hand to mouth,

infectious contacts)

• Immune system still developing fully

Toddler

• 2 yrs – puberty (~12yrs)

• Further language and social development

• Increased size and physical activity

• Less dependence on the family environment

• Through to beginning of pubertal

development

Child

• Adult size

• Establishment of adult (or pseudo adult)

behaviours

• Pushing of boundaries

– Risk taking (physical activities, drug use)

– Sexual exploration

• Mental health

– Depression

– Eating disorders

– Schizophrenia

Adolescent

Adolescent

Differences between small children

and large children (adults)

Physiological differences

Different body proportions

through & across ages

Smaller children have:

• Larger skin surface

• Higher water volume/kg

• Less total blood volume

• Mature at different rates

• Hyper-metabolic

• Poor heat regulation

• Age related body issues

Childhood growth and development (Ref 74: Children and clinical studies)

Weight variation across an age (Ref62: essential Baby 2011)

Physiological differences

Anatomical differences - head

• Head size

– 25% of body at birth

• Brain

– Size doubles in 1st 6 months of life, reaches 80%

adult size by age 2

– Smaller subarachnoid space (less cushioning)

Anatomical differences - head

• Fontanelles and Sutures

– Anterior closes <18mths

– Posterior closes <3 mths

– Sutures may be palpable

Anatomical differences • Spine

– Hypermobile and incompletely ossified

– Large head + weak neck muscles

• Vision – Pupillary light reflex from 28 wks gestation

– Fix and follow at term

– Visual acuity development • 6/45 at term

• 6/18 at 4mths age

• 6/6 at 6-8 mths

– Colour vision normal from birth

Anatomical differences – Airway

Paediatric and adult airway differences (Ref37: New York State Health)

Anatomical differences – Airway

Paediatric and adult airway differences (Ref37: New York State Health)

• Large tongue

• Soft compressible sub glottic area

• Soft palate

• Initially obligate nasal breather

• High anterior floppy larynx

• Narrowest at the cricoid

Anatomical differences - Chest

• Chest wall more compliant – Blunt chest trauma fracture ribs infant and young child, due to the

increased elasticity and compliance of the chest wall.

– The force may be transmitted through to the underlying structures,

which may sustain significant internal injuries.

• Increased mobility of the mediastinal

structures – The increased mobility of the mediastinum increases the likelihood

that the injured child may develop a tension pneumothorax from a

simple pneumothorax, or transect a small mediastinal vessel as the

mediastinum shifts.

Anatomical differences - Abdomen

• Relatively thin abdominal

wall – Provides less protection to abdominal

organs.

• Abdominal organ proportions

and placement – Flatter diaphragm pushes the liver and

spleen further below the rib cage.

– Liver and spleen are more abdominal and

they are more likely to be injured.

– The infant bladder is an intra-abdominal

organ, increasing the risk of bladder

damage in abdominal trauma.

Anatomical differences - Musculoskeletal

Growth plates not fused

• Epiphyseal plate does not fuse until after the pubertal growth

spurt

Cartilaginous bones

• The bones of children are more cartilaginous and flexible but also

more likely to break than ligaments or tendons

– Green stick fractures are common

– Sprains (ligament or tendon injuries) are less common

– Flexible ribs will transmit force to underlying organs

Child Development

Child Development

Development - Gross motor

Development - Fine motor

Development - Speech & language

Development - Cognitive and social

• Pick up genetic/congenital/environmental

issues

• Target therapy

• Allows tailoring of the therapeutic approach to

the child

Why child development?

The Sick Child

• Wide range of disorders

that can chronically or

intermittently affect a

child or raise risk of

certain illness developing

• Most parents are experts

in their child’s condition

Congenital/Genetic Problems

• FMC ~18 500 presentations per year

• WCH ~42 000 presentations per year

• Children represent ~2-5% of SAAS transfers

Presentations to hospitals

Patterns of presentation to the Australian and New Zealand Paediatric Emergency

Research Network

Emergency Medicine Australasia

Volume 21, Issue 1, pages 59-66, 17 FEB 2009 DOI: 10.1111/j.1742-6723.2009.01154.x

http://onlinelibrary.wiley.com/doi/10.1111/j.1742-6723.2009.01154.x/full#f1

Patterns of presentation to the Australian and New Zealand Paediatric Emergency

Research Network

Emergency Medicine Australasia

Volume 21, Issue 1, pages 59-66, 17 FEB 2009 DOI: 10.1111/j.1742-6723.2009.01154.x

http://onlinelibrary.wiley.com/doi/10.1111/j.1742-6723.2009.01154.x/full#f2

Age (years) Diagnosis Count Proportion of ED presentations by age

group (%)

<1 yr

(n = 51 753)

1. Bronchiolitis, acute 6214 12.0

2. Gastroenteritis, acute 4610 8.9

3. URTI, acute 4484 8.7

4. Viral illness, acute 3966 7.7

5. Fever without identifiable source 1639 3.2

1–4 yr

(n = 119 610)

1. Gastroenteritis, acute 9393 7.9

2. Viral illness, acute 8405 7.0

3. URTI, acute 8077 6.8

4. Asthma, acute 6148 5.1

5. Croup, acute 5524 4.6

5–9 yr

(n = 59 657)

1. Gastroenteritis, acute 2785 4.7

2. Viral illness, acute 2580 4.3

3. Abdominal pain, non-specific 2489 4.2

4. Asthma, acute 2304 3.9

5. Fractured forearm (radius and/or ulna) 2158 3.6

10–14 yr

(n = 42 596)

1. Abdominal pain, non-specific 2360 5.5

2. Fractured forearm (radius and/or ulna) 1857 4.4

3. Gastroenteritis, acute 1090 2.6

4. Asthma, acute 934 2.2

5. Viral illness, acute 832 2.0

15–18 yr

(n = 10 711)

1. Abdominal pain, non-specific 541 5.1

2. Toxic effect of substance (including alcohol) 308 2.9

3. Psychiatric or behavioural problems 233 2.2

4. Gastroenteritis, acute 216 2.0

5. Asthma, acute 212 2.0

Acworth et al. Patterns of presentation to the Australian and New Zealand Paediatric

Emergency Research Network. Emerg Med Australas. 2009 Feb;21(1):59-66.

• Most paediatric presentations can be divided

into 3 groups:

– Obviously well child

– Obviously sick child

– Potentially sick child

• Severe form of a usually benign illness

• Early subtle signs of a serious illness

• Appear unwell but need investigation to rule out serious

illness

Identification of the sick child

Assessing a sick child -

observation

• Does this child look sick?

• What is it that makes you reach this

opinion?

Summary: Assessment Assessment of the unwell child

Airway and Breathing

• Effort •Respiratory rate •Accessory muscle use •Flaring of the nostrils, head

bobbing, tracheal tug •Child's position

• Efficacy •Chest expansion •Air entry •Pulse oximetry

• Effects of Inadequacy •Respiratory rate •Skin (colour/temperature) •Mental status

Circulation

• Signs: • Heart rate • Capillary refill time • Blood pressure • Skin temperature

• Effects of Inadequacy • Respiratory rate • Skin

(colour/temperature) • Mental status

Disability

• Conscious level

• Posture

• Pupils

• Sudden death of an infant that is not predicted by

medical history and remains unexplained after a

thorough forensic autopsy and detailed death scene

investigation.

• Infants are at the highest risk for SIDS during sleep.

• Typically the infant is found dead after having been

put to bed, and exhibits no signs of having struggled.

Sudden Infant Death Syndrome (SIDS)

Sudden Unexplained Death in Infants

(SUDI)

Sudden Infant Death Syndrome (SIDS)

Sudden Unexplained Death in Infants (SUDI)

• Gaining rapport with the child and the confidence of the

parents is the key to assessing the child

• Address the concerns of the parents/carers – they know

what the child is normally like

• A child needs to be approached according to

chronological and developmental age

• Observation is a vital diagnostic tool

• It is often more important to exclude serious illnesses

than make a definitive diagnosis

• A child should be considered sick until it can be

concluded they are well following a thorough assessment

Paediatrics Tips

John.Craven@health.sa.gov.au