Peds and Neonates Exam 1

US population of Pediatrics

316 million pediatrics total;

Total birth age to age 19 is 26%;

Children under 1 account for 1 percent of US population but ~13% of all hospital stays, Children (0-17) are 18% of all stays;

Children deteriorate more rapidly due to less physiologic reserve

Most Common cause for Pediatric hospital admissions

Number one reason is for the Respiratory System;

Many others will likely require respiratory therapy;

Top three admission reasons are respiratory disease by principle diagnosis for pediatrics (pneumonia, bronchitis, asthma);

Top three for adults are mood/skin related;

Very/extremely preterm neonate age definiton

Moderate preterm neonate age definiton

32-36 weeks gestational age

Late preterm neonate age definition

34 0/7 to 36 6/7 weeks gestational age;

Full-term neonate age definition

38-42 gestational age;

Baby labeled as neonate for first full month of life

Infant age definition

1-12 months

Toddler age definition

12-36 months

Preschool-age child age definition

4-5 1/2 years

School-age child age definition

5 1/2- 12 years

Adolescent age definition

12-18 years

Adult age definition

>18 years

Important Pediatric growth and development info

Growth and Development start in the womb;

Growth and development are a Continous processes from conception to death;

-Requires essential elements to reach full potential (Family involvement, support, interaction with child (bonding);

Growth and Development proceed in an orderly process

This is a big ass baby

Five dimensions of Growth and Devlopment

Social;

Emotional;

Cognitive;

Physical;

Language

Rate of predictable growth stages

Different children pass through predictable growth stages at different rates;

All body systems do not develop at the same rate;

Development is cephalocaudal (head to tail) and Proximodistal (center-out)

Newborn reflexes

Must be lost before development can proceed;

Sucking;

Rooting (turn head to find nip/ 2 months);

Stepping (2 months);

Asymmetric neck reflex (5-7 months);

Grasping (palmar 5-6/Plantar 9-12);

Moro (startle) (2 months);

Growth and Development of a baby 0-1

Motor: Largely reflex

Fine motor: Keeps hands fisted; able to follow object to midline

Socialization:

Play: Enjoys watching face of primary caregiver, listening to soothing sounds

Growth and Development of a 2 month old infant

Motor: Holds head up when prone

Fine motor: has social smile

Socialization: makes cooing sounds; differentiates cry

Play: Enjoys bright-colored mobiles;

Growth and development of a 3 month old infant

Motor: Holds head and chest up when prone

Fine motor: follows object past midline

Socialization: laughs out loud

Play: spends time looking at hands or uses them as toy during the month (hand regard)

Growth and development of a 4 month old

Motor: Grasp, stepping, tonic neck reflexes are fading

Fine motor:

Socialization:

Play: Needs space to turn

Growth and development of a 5 month old

Motor: Turns front to back; no longer has head lag when pulled upright; bears partial weight on feet when held upright

Fine motor:

Socialization:

Play: Handles rattles well

Growth and development of a 6 month old

Motor: Turns both ways; Moro reflex fading

Fine motor: Uses palmar grasp

Socialization: may say vowel sounds (oh-oh)

Play: enjoys bathtub toys, rubber ring for teething

Growth and development of a 7 month old infant

Motor: Reaches out in anticipation of being picked up; first tooth (central incisor) erupts; sits unsteadily (needs support)

Fine motor: Transfers objects from hand to hand

Socialization: Shows beginning fear of strangers

Play: Likes objects that are good size for transferring

Growth and development of a 8 month old infant

Motor: Sits securely without support

Fine motor:

Socialization: Has peak fear of stranger (ability to tell known from unknown people)

Play: enjoys manipulation, rattles and toys of different textures

Growth and development of a 9 month old

Motor: Creeps or crawls (abdomen off floor)

Fine motor:

Socialization: says first word (dada, easier to say, also cooler than mom)

Play: needs space for creeping

Growth and development of a 10 month old

Motor: Pulls self to standing

Fine motor: Uses pincer grasp (thumb and finger) to pick up small objects

Socialization:

Play: plays games like patty-cake and peek-a-boo

Growth and development of a 11 month old

Motor: cruises (walks with support)

Fine motor:

Socialization:

Play: cruises

Growth and development of a 12 month old

Motor: stands alone; some infants take first nap

Fine motor: holds cup and spoon well; helps to dress (pushes arm into sleeve)

Socialization: says two words plus ma-ma and da-da

Play: likes toys that fit inside each other (pots and pans); nursery rhymes; will like pull toys as soon as walking

Physical milestones of infant

Birth to 6 months of age:

-150-210 grams (5-7 ounces) per week in weight;

-1 inch in length per months;

6-12 months of age:

-90-150 grams (3-5 ounces) per week on weight;

-1/2 pound per month

Barriers to good nutritional status in infants

poor muscle control needed for coordination of suck, swallow, and breathing;

Problems with aspiraiotn;

failure to thrive;

chronic respiratory problems;

Typical feed schedule is every 3-4 horus

Safe sleep practices of infants

No co-sleeping;

Use of sleep sack;

positioned supine;

bed is free from toys, pillows

Deformational plagiocephaly

physical condition whereby soft bones of the head become flat on the back of the head as a result of frequently laying supine for prolonged periods of time;

treated with frequent body positioning, supervised tummy time and helmet therapy for severe conditions;

Tummy time is essential for proper growth and development beginning on day one

Cognitive, sensory and langauge growth of infancy

2 months: Development of oral skills, cooing;

4 months: drooling, gumming behavior;

6 months: teeth begin to erupt, solid food introduction, babbling;

9 months: sound repetition

Motor growth of infancy

3 months: head control

6 months: sitting independently;

9 months: crawling;

12 months: walking

Growth and development of a 15 month toddler

Fine motor: Puts small pellets into small bottles. scribbles voluntarily with pencil or crayon, holds a spoon well but might still turn

Gross motor: walks alone well, can seat in chair, creep upstairs

Language: 4-6 words

Play: can stack 2 blocks, enjoys being read to; drops toys for adult to recover (exploring sense of permanence)

Growth and development of a 18 month toddler

Fine motor: no longer rotates spoon to bring it to mouth

Gross motor: can run and jump in place; can walk up and down stairs holding onto a person's hand or railing, typically places both feet on one step before advancing

Language: 7-20 words, uses jargoing names

Play: imitates house hold chores, dusting. parallel play (playing next but not with another child)

Growth and development of a 2 year old toddler

Fine motor: can open doors by turning door knobs, unscrew lids

Gross motor: walks up stairs alone still using both feet on same step at same time

Language: 50 words, 2 word sentences (noun-pronoun and verb) such as "daddy go, me come"

Play: parallel play evident

Growth and development of a 3 year old toddler

Fine motor: makes simple lines or strokes for crosses with pencil;

Gross motor: can jump down the stairs;

Language: verbal language increasing steadily. Knows full name. can name 1 color and hold up fingers to show age;

Play: spends time playing house. imitating parents actions; play is 'rough-housing' or active

Physical development of a toddler

Weight: 0.8 to 2.7 kg (4-6 pounds) per year;

Height:

-7.5 cm per year;

-Growth occurs in spurts;

-More growth in legs and trunk;

Growth cart is used to document growth so that a step-like pattern of growth can be seen

Independent walking of a toddler

1 year toddler can walk independent;

18 months attempt running, fall frequently;

2 years are walking well, mastering going up and down stairs, kicking a ball, run with fewer falls;

2.5 years can stand on one foot for a few seconds, and take a few steps on tip toe;

3 years of age: all of the mentioned skills are well-developed and smoothly completed

Cognitive, sensory, and language growth of a toddler

From 18 months to roughly 5 years of age children learn approx. 9 words a day; (63 words a week, 3,285 a year);

Exploration of environment can be hazardous:

-Choking hazards (pencils, crayons, lollipops shouldn't be in mouth while walking/playing)

Drowning in toddlers

Drowning is the leading cause of injury and death for toddlers; supervision is required around water, including bathtubs, pools, ponds, lakes, whirlpools, or the ocean;

-Swimming and water safety lessons started as early as possible

Developmental milestones of toddlers

2 years:

Fine: builds tower of 6-7 blocks;

Gross: runs well, kicks ball forward, goes up stairs one at time

3 years:

Fine: copies in a circle with crayon, can work with toys and moving parts;

Gross: climbs well, runs easily, uses stairs with one foot on each step

Growth and development of a 4 year old

Fine: Can do simple buttons

Gross: constantly in motion, jumps skips

Language: vocab of 1,500 words

Play: pretend is a major activity

Growth and development of a 5 year old

Fine: draws 6 part man, ties shoes;

Gross: throws overhand;

Vocab of 2,100 words;

Play: likes games with numbers/letters

Physical growth of a preschooler (3-5)

2-3 kg/year;

Height:

-Slower than toddler years;

-Occurs in spurts;

-Growth concentrated on long bones of the legs

Cognitive, sensory, and language growth of a preschooler

Inquisitive and interested in learning about individuals outside of the frailly (gender roles, norms);

Injury risk associated with exploring their environment:

-(accidental trauma);

Complex language and learning skills (1800 words in vocab);

Social growth of pre-schooler

Mastery and control of their environment;

Develops self-control behaviors;

Empathetic;

More fearful (view illness as punishment);

Engage in coop, imaginative, and symbolic play

Development of a 6 year old

Physical: A year of constant motion: skipping is a new skill, first molars erupt

Psychological: first-grade teacher becomes authority: adjustment to all day school may be difficult and lead to nervous manifestations of fingernail biting. Defines words by their use is to unlock a door, not a metal object;

Development of a 7 year old

Physical: Central incisors erupt: difference between sexes is apparent (video games vs dolls): spends time in quiet play;

Psychological: A quiet year, striving for perfection leads to this being an eraser year. Conservation (water from tall glass same as short wide glasses) is learned. Can tell time, make change

Development of a 8 year old

Physical: Coordination definitely improved; playing with gang becomes important; eyes become fully developed;

Psychosocial: "best friends" develop; whispering and giggling begin; can write as well as print; understands concepts of past, present, and future

Development of a 9 year old

Physical: all activities done with gang

Psychological: gang age; 9-year old club is formed to spit someone, secret codes; all boy or all girl; gangs disband and reform quickly;

Development of a 10 year old

Physical: coordination improves

Psychological: ready for camp away from home, collecting age; likes competition

Development of 11 year old

Physical: active but awkward and ungainly

Psychological: insecure with members of opposite sex, repeats off color jokes

Development of 12 year old

Physical: coordination improves even more

Psychological: a sense of humor is present, is social and cooperative

Development of Secondary Sex characteristics in Boys

9-11: Prepubertal weight gain occurs;

11-12:

-Sparse growth of straight downy, slightly pigmented hair at base of penis;

-Scrotum becoming textured, growth of penis and testis begin;

-Sebaceous gland secretion increases (incr. perspiration);

12-13:

-Pubic hair across pubis;

-Penis lengthens;

-Dramatic linear growth spurt;

-Breast enlargement occurs

Development of secondary sex characteristics in girls

9-11: Breasts: elevation of papilla with breast bud formation; areolar diameter enlarges;

11-12:

-Straight hair along the labia, vaginal epithelium becomes confines;

-pH of vaginal secretions acidic; slight mucous vaginal discharge present;

-Perspirations increases;

-dramatic growth spurt;

12-13

-Pubic hair grows darker, over entire pubis;

-breasts enlarge

-axillary hair present;

-Menarche occurs

Physical growth of school age middle childhood

Rates differ according to gender and ethnicity;

-Girls grow more rapidly

-Develop their secondary sexual characteristics from 9 to 13;

-Boys develop with a lag of 2 years;

Awareness of physical body changes

Cognitive, sensory, language growth of school age middle childhood

Find their place in world, explore future;

Engage in team play;

Seek acceptance;

Interested in collections:

-Awareness of physical and socioeconomic differences in peer group (non-adherence of medical plan/ victims of bullying)

Social growth of school age middle childhood

Desire success;

development of concrete thought processes (reasoning, fears, misconceptions);

longer separation form caregivers;

attentiveness;

understands morals and relationships

Sexual maturation in male adolescents

15: Growth spurt continues, axillary hair present; facial hair fine and downy; voice changes with annoying frequencies;

16: Adult genitalia: pubic hair abundant and curly; sperm production mature;

17: pubis hair may extend to medial aspect of thighs; some degree of facial acne, enlarged breast tissue fades;

18: end of skeletal growth

Sexual maturation in female adolescents

15: Pubis hair triangular in distribution; breast areola and papilla form secondary mound; menstruation is ovulatory (pregnancy possible);

16: Pubis hair may extend to medial aspect of thighs; may have some degree of acne;

17: end of skeletal growth

Physical growth of adolescents

Puberty begins (hormones influence growth);

-Increase in muscle mass;

-General body development (nutritional status);

-Reproductive system

Cognitive, social, and emotional growth of an adolescents

Establishment of sexual identity;

Development of romantic relationships;

Exploration with sexual activity;

Experimentation with recreational substances (tobacco, alcohol, weed)

Effect of hospitalization on growth and developmental needs

May experience lapses or regression of development:

-socialization may be limited (emotional);

Pain can impede childhood development

Supporting a the child and family's needs through family centered care

Address the child and family as a cohesive unit;

Communicate clearly and openly;

Engage the family in Childs medical care;

Incorporate family's beliefs and values into medical decision making;

Anatomic Differences of Airways

Natural and artificial airways are significantly smaller (more easily obstructed by secretions, blood, edema, and foreign bodies);

Increased resistance to flow (Poiseulle's Law)

"Resistance to flow varies inversely by the 4th power of the radius";

-Adult radius has a 2.4x resistance, Infant has a 16x resistance in airway

Difference of Lymphoid tissue and tongue

Lymph tissue and tongue proportionally large in infants and pediatrics

Difference of Larynx

Pediatric and infants larynx more anterior than adults;

Epiglottis is stiffer and "U" shaped

Level of Glottis at different ages

Adults C5-6;

Children C3-4;

Infants C1-2;

Difference in trachea

Infant trachea is funnel shaped (Narrowest at cricoid/below the vocal cords);

Adult is tubular shaped (narrowest at cords/glottis)

Indepth look of Infant/Toddler Trachea

Softer than adults;

Cartilage/rings not yet formed;

Succumbs to pressure;

Cricoid membrane small-to-nonexistent;

Collapses in response to negative pressure;

Shorter making accidental extubation or right main-stem intubation more likely

Level of Carina at different ages

Adults T-6;

Infants T-3

Implications for intubation

Infant occiput (back of skull) is proportionately larger than in adults;

May need "Sellick maneuver/cricoid pressure" and/or straight laryngoscope to improve visualization;

Right mainstem intubation more likely;

larger tongue and lymph tissue impinges on airway, trauma more likely;

Cuffed tubes and narrow airways increase resistance to flow, increase WOB, non-cuffed airways may be preferred;

More difficult to visualize epiglottis;

Shorter trachea makes tube misplacement more likely

Lung growth in peds

Continues postnatally until approximately 8-12 years of age;

Born with approx. 30-50 million alveoli;

Adults estimated 500 alveoli;

Number of alveoli increases 10-20 times between birth and adulthood;

Infant alveoli shallow, thicker membranes and no pores of khon

The physiologic differences of cartilage

Infant cartilage is very soft in comparison to adults;

Allows the thorax and trachea to collapse when negative intrathoracic pressure is present;

Causes retractions, stridor, "see-saw breathing"

Diaphragmatic breathing

Pediatric patients are dependent on diaphragmatic breathing;

Accessory muscles not efficient or strong;

Ribs more horizontal, don't increase thoracic size much;

large abdomen

Metabolic demand

Metabolic rate is higher in infants and children;

Metabolic rate peaks during growth spurts (0-18 months and puberty);

-Basal oxygen requirements for adults (3 ml oxygen/kg/min);

-Basal oxygen requirements for infants (6 ml oxygen/kg/min);

Pulmonary reserve in infants/peds

Infant and pediatric response to need for increased minute ventilation;

-Increase in respiratory rate (not as efficient as increase in Vt because deadspace has to be ventilated with each breath);

-Adults tend to increase Vt, which decreases the proportion of deadspace ventilation, and is more efficient;

-Adding mechanical deadspace has a much greater impact on breathing for infants and children;

Increase in negative inspiratory pressure during respiratory distress causes ribcage to collapse, further decreasing Vt in infants and small children

The addition of 10 mL of mechanical deadspace in both adults and infants

Adults: Adult weight 150 lbs x 1 ml/lbs = 150 ml anatomical Vd;

-10ml/150ml = 6-7% increase;

Infants: Infant weight 10 lbs x 1 ml/lbs = 10 ml anatomical Vd;

-10 ml/10 ml = 100% increase

RTs working in pediatrics

Pediatric patients have less cardiopulmonary reserve, they progress from slight distress to full blown code very quickly (need to respond quickly);

RTs should be able to assess the need for the patient to be transported to specialty pediatric hospitals;

Assumptions in Family-Centered care

Family is a constant in a child's life;

Illness can affect the entire family;

Respectful, trusting partnership between the child's family and healthcare professionals is important;

Decisions of plan of care is collaborative with child, family, and healthcare team

The Hospitalized Infant

Effect of hospitalization:

Disrupts normal routine:

-Fussiness;

-Feeding difficulties;

-Disrupted sleep;

Separation from familiar caregivers:

-Compromises trusting relationship building

Needs during hospitalization:

-Continuity of direct caregivers (RNs/RTs);

-Maintain similar schedule to home;

-Use of developmentally appropriate toys and comfort items;

-Family/caregiver participation in care;

-Safe Sleep practices

The Hospitalized Toddler

Effect of Hospitalization:

Frustration:

-Temper tantrums;

-Regression in skills that they have recently mastered, such as potty training;

Stranger Danger

Needs during hospitalization:

-Use of simple language when explaining care/procedures;

-Providing choices;

-Safe place to play;

-Use of simple language when explaining aspects of care or procedures

Phases of Separation between child and caregivers

Protests (clings to caregiver/ pulls away from stranger);

Despair (sad, lonely, doesnt engage in play);

Depression and Greif;

Detatchment

The Hospitalized School Age child

Effect of Hospitalization: Better able to adapt if family is not present;

-Fear (fitting in with peers);

Needs during hospitalization:

-Provide time to play/socialize

-Offer choices;

-Explain care

The hospitalized adolescent

Effect of hospitalization:

-Frustration (dependence on family/Separation);

-Fear (Illness/Hospitalization affecting identity);

Needs during hospitalization;

-Respect of privacy;

-Provide opportunities to ask questions;

-Enable patient to actively participate in care-based decisions;

-Visitation time with friends and family

Reaction to Hospitalization

-Loss of control/autonomy;

-disruption of routine;

-Physical stressors (pain, immobility, changes in diets, sleep deprivation);

-Environmental Stressors (unfamiliar surroundings, people, constant lights, other patients);

-Psychological Stressors (lack of privacy, inability to communicate/knowledge, severity of illness, Parental behavior);

-Social Stressors (disruption of family/school routines, friend/family relationships, financial impact)

Needs of the Family

Information (Diagnosis, Plan of Care, Discharge Goals);

Accommodations (Meals, showers, laundry facilities)'

Reassurance and support (caregivers that listen, resources for stress, anxiety);

Communication (speak at family's level of understanding/honesty (preserving hope)

Supporting Siblings

Factors influencing a siblings response to hospitalization:

-Age;

-Developmental level;

-Nature of Hospitalization;

Common Responses:

-Anger;

-Jealously;

-Sadness;

How to help:

-Staying in family home;

-Maintaining school schedules;

-Engage with child life assistance (have sibling ask questions/talk about feelings);

-Provide opportunities for sibling to assist with tasks

Child Life Specialists

Help families cope with medical experiences (hospitalizations, diagnoses, devices);

Activities used to help coping (preparation, education, animal-assisted therapy, memory-making);

Animal-Assisted therapy (reduces fear, facilitates recovery, improved mood and engagement with medical plan)

Safety First in Care

Do least painful and invasive procedures first;

Standard Precautions;

Prevent falls (lock wheels, bed rails up);

Prevent choking, strangulations of cords);

Always keep one hand in contact with infant when reaching behind;

Remove all wrappers, bags, vials and careful placement of oxygen tubing;

Restriants

Papoose (wraps);

Limb;

Jacket (wheelchair);

Elbow (infants/toddlers);

Mummy restraint (swaddling);

Manual restraints (giving oral/aerosol meds, MDI with mask, CPT);

Three variables that will affect FiO2 available in an oxygen enclosure

flowrate of oxygen;

volume of enclosure;

Seal (how well tucked/sealed up/often opened for care);

What FiO2 would you recommend an infant in an isolette also use a hood to prevent fluctuation in the amount of oxygen available to the infant

40% or greater

Documentation of Hypoxemia

Infant (>28 days old) and child:

-PaO2

Complications of excessive oxygen use

Retinopathy of Prematurity;

Hypoventilation (chronic lung disease involvement like CF and BPD);

Atelectasis;

Pulmonary Vasodilation

Nasal Oxygen

Nasal Catheter:

Suggested flow 0.2-1 LPM;

Approx. FiO2 .24-.35

Nasal Cannula:

Suggested Flow:

-Infant 0.2-2 LPM;

-Pediatric 0.5-4 LPM;

Approx. FiO2 0.21-0.5

Oxygen Masks

Simple Mask:

-Infant 5-8 LPM

-Pediatric 5-10 LPM

Approx. Flow: 0.35-0.5;

Partial Rebreather:

10-12 LPM;

Approx. Flow 0.6 and up;

Non-rebreather;

10-15 LPM;

Approx. 0.8 and up;

Air entrainment;

Total flow to exceed patient insp. flowrate;

0.24-0.5

LVN with mask or trach collar:

Total flow to exceed pt. insp flowrate;

0.21-1.0