wk 2 Peds
Sensory Nervous System: Focus on Vision and Hearing in Pediatrics
Purpose of session: Understand sensory issues first (vision and hearing) to anticipate engagement and care for kids with impairments.
Assessment starting points:
Thorough head-to-toe assessment includes vision assessment.
Parents may notice/hear concerns; early screening is common in NICU for preemies due to prematurity risk factors.
Visual impairment concepts to know (not exhaustive memorization of all conditions):
Myopia = nearsightedness (can see near, struggle with distant objects).
Hyperopia = farsightedness.
Strabismus = deviation of eye alignment.
Screening in school/nursery settings:
All kids should be screened; screening is not diagnostic—it's to identify potential problems and trigger referrals.
Tools used vary by age and literacy:
Snellen chart uses letters; appropriate for kids who know letters (usually older preschool/early school-age).
For preverbal or non-letter readers: picture-based charts or the ‘E’ chart (orientation-based) to assess vision.
Modified Snellen or picture-based charts are used for children who don’t know their letters yet.
Practical screening workflow:
If a child fails screening, referral is made to an eye specialist: Optometrist or Ophthalmologist.
Guardian/legal guardian must provide the referral and follow through for evaluation and treatment.
School nurses and community resources can facilitate access to care for kids without private pediatricians.
Risk factors for visual impairments (key ones to star in notes):
Prematurity in utero/infection in utero.
General factors linked to risk for visual impairment in pediatrics.
Accessibility and support for visually impaired kids:
If a child reads Braille, use Braille-based methods and resources.
When a child uses glasses, ensure proper use and availability during tests, clinics, and procedures.
Communicate with the child by directing activities to the side of their good vision when possible.
Common questions and classroom implications:
A child sitting at the back with headaches may indicate vision problems affecting classroom performance.
Vision screening is relevant for school-aged kids and can be part of school nurse duties.
Corpus of ocular cancer basics (engage content):
Retinoblastoma is a life-threatening pediatric tumor of the retina/optic nerve, rare in adults.
Hereditary component exists; higher prevalence observed in certain populations (e.g., children of Asian heritage noted as higher risk in course material).
Red reflex testing during well checks: normal red reflex is expected; a white reflex indicates potential retinoblastoma and requires immediate referral.
Signs that may prompt urgent referral:
Asymmetry in red reflex (one eye red, the other white) or any abnormal reflex pattern.
If a child’s reflex cannot be reliably evaluated in primary care, refer to ophthalmology.
Hearing: newborn screening and early identification
Newborns are screened for hearing impairment shortly after delivery (auditory screening in NICU is common).
Prematurity is a risk factor for both vision and hearing impairment.
If a screening failure occurs, a formal evaluation is pursued (referral) to determine management and intervention.
Ear infections (otitis media) in pediatrics: overview
Common pediatric issue with distinct categories: Acute Otitis Media (AOM) vs chronic otitis media and otitis externa (ear infections in different regions).
Anatomy driver: Eustachian tube in children is more horizontal and shorter, which impedes drainage and promotes fluid buildup behind the tympanic membrane, increasing infection risk.
Conceptual aid: moving fluid drains better than stagnant fluid (like ponds with constant inflow and outflow).
Acute Otitis Media (AOM): key features
Abrupt onset of middle ear infection, potentially with fever and ear tugging.
Younger children may present with nonspecific symptoms like fussiness or lethargy; older kids may report ear pain.
Management approaches for AOM
Antibiotics are commonly used but there is a trend to avoid antibiotic overuse when possible.
Watchful waiting (three-day-rule) may be chosen for mild cases: provide a prescription but delay filling for up to ; if symptoms improve, the prescription may be discarded; if worse, fill it.
If symptoms are more severe or not improving, antibiotics are prescribed.
Antibiotic stewardship and risks:
Antibiotics carry risks (side effects, resistance, etc.); conservative use helps reduce overuse while managing symptoms.
Other otitis forms: Otitis externa (otitis of the outer ear) also exists and requires separate management.
Myringotomy and tympanostomy tubes (ear tubes)
Myringotomy: surgical creation of a small hole in the tympanic membrane.
Tympanostomy tubes: small tubes inserted to vent the middle ear and facilitate drainage of fluids.
Typical duration of tympanostomy tubes is about ; tubes eventually extrude on their own.
If a parent reports a tube extrusion: do not attempt to reinsert the tube yourself; contact the practice to decide whether replacement surgery is needed or if observation is appropriate.
Practical scenarios and communication: handling family questions about ear infections and tubes
Explaining watchful waiting as a standard of care; reassuring families that not every mild ear infection requires immediate antibiotics.
If a tube falls out: inform the practice and follow the clinician’s guidance on next steps.
Ocular cancers and red reflex (additional emphasis)
Retinoblastoma presents as a white reflex in one eye on flash photography or light examination; red reflex in both eyes is a good sign.
Abnormal reflex requires urgent referral and testing; delayed treatment can be life-threatening.
Pain assessment in pediatric patients: why special tools are needed
Children may not be able to articulate pain well, especially infants and toddlers; pain assessment requires developmentally appropriate tools.
Two primary scales to learn and apply: FLAC and FACES.
FLAC pain scale (Face, Legs, Activity, Cry, Consolability)
Designed for children from who may not be able to verbalize pain.
Five categories: face, legs, activity, cry, consolability.
Scoring per category: 0 = normal/no pain; 1 = mild/moderate signs; 2 = clear pain indicators.
Total possible score: (5 categories × max 2 per category).
Interpretation examples:
Face: 0 = no expression; 1 = occasional frown; 2 = constant frown or clenched jaw.
Legs: 0 = relaxed; 1 = uneasy/restless; 2 = drawing up/kicking.
Activity: 0 = quiet/normal; 1 = squirming/tensing; 2 = arched/rigid/jerky.
Cry: 0 = none or quiet; 1 = moaning/whimpering; 2 = crying/screaming.
Consolability: 0 = can be soothed easily; 1 = needs comforting; 2 = not consolable.
Use even if the child is asleep; the tool can be applied without waking the child.
Faces pain scale
Aimed at ages roughly ; commonly used with children who can identify faces corresponding to pain intensity.
For young children, explain the scale clearly using age-appropriate language; children as young as can reliably use a faces scale when guidance is provided.
For older children/adolescents, the numeric Visual Analog Scale (0–10) can be used.
Pain assessment in practice: data interpretation
Pain scales are the primary tool for assessing pain; vital signs (heart rate, etc.) support but should not be sole indicators of pain.
Vital signs may be influenced by fever, anxiety, or other conditions; use clinical judgment and patient-reported scales.
Pain management: pharmacologic approaches by pain level
Mild pain: use non-opioid analgesics such as acetaminophen (paracetamol) and NSAIDs (e.g., ibuprofen, naproxen) with weight-based dosing and appropriate intervals (e.g., every for acetaminophen).
Important dosing note: acetaminophen has liver toxicity risk with improper dosing; use weight-based dosing and avoid excessive dosing.
Moderate pain: combine acetaminophen/NSAIDs with opioids as needed; consider using NSAIDs first and reassessing.
Severe pain: escalate analgesia; opioids (e.g., morphine) may be required; reassess frequently (e.g., after for oral meds; for IV meds).
Dosing strategy: follow weight-based dosing and adjust based on patient response; if initial dose does not relieve pain, do not hesitate to increase dose according to orders and safety guidelines.
Communication with families about pain medication: educate on dose amounts, frequency, and when to contact providers for adjustments.
Routes of analgesia and nonpharmacologic measures
Preferred routes: oral when possible; avoid intramuscular injections due to pain and distress.
IV analgesia for severe cases or when oral meds are not adequate, with careful administration to minimize distress.
Nonpharmacological strategies: distraction, teddy bear, freezy spray, numbing cream, guided imagery, distractions tailored to age and development.
Child Life Specialist role: helps reduce hospitalization trauma, supports development, and designs child-friendly experiences around procedures.
For infants: swaddling, non-nutritive sucking (pacifier), and kangaroo care when appropriate.
The balance between efficiency and reducing trauma: investing a bit more time to use child-life interventions often reduces overall distress and improves cooperation.
Practical tips for pain management in clinical practice
Be proactive: do not tolerate unnecessary pain; use objectives pain scales and data to guide dosing.
Provide a plan before procedures (e.g., numb cream, distraction, clear explanations) to reduce distress and improve cooperation.
Communicate with the patient and family honestly; maintain safety and comfort as a priority during painful procedures.
Safety and ethical responsibilities in pediatrics
Non-accusatory, supportive approach to pain and procedures helps maintain trust and reduces trauma.
If a child expresses concerns or if a family reports concerning behavior, involve the supervising clinician (preceptor) and escalate appropriately.
Mandatory reporting in New Jersey (and generally in many places): any adult with credible suspicion of child abuse must report; failure to report can be a crime.
The caregiver-child dynamic in screening: ask targeted questions to uncover potential maltreatment (e.g., inconsistencies between caregiver reports and injuries).
Examples of screening questions:
Are you afraid of anyone at home?
Have you or your child experienced injuries inconsistent with explanations provided by the caregiver?
If maltreatment is suspected or disclosed, inform the appropriate authorities and hospital staff (preceptor, attending, security, etc.) and document findings.
Red flags and clinical reminders for maltreatment
Inconsistencies between caregiver’s report and the child’s injuries or history.
Unexplained injuries, multiple fractures in various healing stages, or stories that don’t match the physical findings.
Always prioritize child safety and seek guidance from supervising clinicians and authorities when abuse is suspected.
Connections to broader clinical practice
Vision/hearing screening is foundational to child development and school performance; early identification influences interventions and supports.
Eustachian tube anatomy and fluid management are central to understanding pediatric ear infections and their potential impact on hearing and speech development.
Pain management in pediatrics blends pharmacologic and nonpharmacologic strategies; parental involvement and child life support improve outcomes and reduce trauma.
Ethical and legal responsibilities protect vulnerable children and require clinicians to act on credible concerns, with teamwork and proper reporting channels.
Quick reference: key concepts and terms to remember
Visual terms: myopia (nearsighted), hyperopia (farsighted), strabismus (eye alignment deviation).
Screening tools: Snellen chart; picture/modified charts for young children; E-chart for non-readers.
Referrals: optometrist, ophthalmologist; community resources for uninsured/underinsured.
Ear infections: AOM (acute otitis media), chronic otitis media, otitis externa; Eustachian tube orientation and drainage dynamics in children.
Treatments: watchful waiting vs antibiotics; myringotomy; tympanostomy tubes; tube extrusion timelines; do not reinsert tubes yourself if they come out—contact the practice.
Pain scales: FLAC (Face, Legs, Activity, Cry, Consolability) scale; FACES scale; preferred age ranges: FLAC for ; FACES usable from about and up.
Pain management: weight-based dosing; avoid excessive acetaminophen; routes of administration; reassessment timelines: ; ; escalate as needed.
Nonpharmacologic strategies: distraction, guided imagery, numbing cream, freezy spray, child life specialists; infant comfort measures: swaddling, pacifier, kangaroo care.
Safety: mandatory reporting laws; screening for maltreatment; escalation pathways (preceptor, attending, security, law enforcement as needed).
The overarching message
Pediatric care requires systematic screening for vision and hearing problems, careful management of ear infections to prevent long-term consequences, thoughtful, developmentally appropriate pain assessment and management, and vigilant safeguarding of children through ethical practice and mandatory reporting when necessary.