Pediatric Potpourri

Pediatric Potpourri Barb Bancroft RN, MSN, PNP BBancr9271@aol.com

The approach—newborn-- first 28-30 days of life • Newborn vision is the only special sense that is not mature at birth—visual acuity for a newborn is 20/100 to 20/200 • Bladder capacity is only 15 ml (1-2 ml per hour per kg of body weight)—lots of diaper changes –6 to 8 wet diapers per day (weigh their diapers for I & O)

The approach—infant-- 30 days to first birthday • Infant—consistency of care is essential for an infant to develop trust; attend to expressed needs immediately and consistently; observing your facial expressions and moods at one month • Causes of depression

Mirror neurons • Monkey see, monkey do

Learning, learning, learning…from their environment • Synapses are forming in the newborn and infant brain at the incredible rate of 3 billion/second • 28 week old fetus—124 million connections • Newborn—253 million • 8 months—572 million

The approach—toddler– One to 3 years old • Toddler—autonomy; 300 words; begin to tolerate some separation from primary caregiver; temper tantrums are normal; negativism is common; enjoy rituals, consistency, learning toileting skills and locomotion; egocentricity—don’t ever ASK if you can do something…can I look in your ears? NOOOOOOO

Which ear would you like me to look in first? • How do you look at the back of a toddler’s throat? • Open your mouth and pant like a doggie… • Turn them upside down if they won’t open their mouth…

Life revolves around their “head”… DON’T go to the head first

The approach—the preschooler– Three-years old to fifth birthday • Preschooler—may talk incessantly (900 words); evolving from “me, me, me” to seeing other’s viewpoints; use magical thinking to solve problems and make sense of their environment; may deny pain or other problems through magical thinking (KENDRA) May be dependent on security objects and items…HANDLE WITH CARE AND DO NOT LOSE!! “ my bankie, my teddie” • Preschoolers are also very aware of surroundings; always include the child in conversations • Don’t forget that hearing is the LAST special sense to go in patients in a coma (STACY) • CONCRETE thinking

The approach—school-age—Early: 6 to 10Late: 10 to 12 years • Acquisition of skills achieves a sense on competency; failure to do this may lead to a sense of inferiority • Conscience is forming and peer group interactions are highly influential • Concrete thinking (early) • Early—engage about schoolwork/sports/art projects; encourage, praise efforts • Late—computer games, sports

The approach—adolescence—13 to 18 years • Think beyond the present, are logical and use reasoning (HAHAHA…) • Abstract thinking • Group identity is paramount and risk-taking is common secondary to peer pressures • The teen-age brain

The prime real estate of the brain—the frontal lobe • The prefrontal cortex • The motor association area • The motor cortex • Broca’s area—voluntary speech and communication • (the last 2 areas are well-developed in early adolescence, however the prefrontal cortex and the association areas are immature in teenagers and continue to develop into the early 20s)

So, what is the prefrontal cortex? • It’s the center for judgment, insight, reasoning, organization, future planning and problem solving, and it has extensive connections with the emotional and instinctual centers in the limbic system, especially the amygdala. • These levels are critical for emotional learning and high-level self regulation. • This is the pathway that is immature in the adolescent brain

An easier way to put it—the prefrontal cortex is your MOTHER • And MOM is inhibitory---what’s the only word a MOM needs to know? NO.NO.NO.NO.NO. • Judgment and insight • Socialization • She puts the checks and balances on behavior—especially on the amygdala—the wild beast within (the instinctual nucleus of the brain) • Parents, who act like parents, do this for teenagers; parents who act like teenagers, do not

The anterior cingulate gyrus of the prefrontal cortex • Weighs options, makes decisions • Girls brains mature faster; pruning starts earlier than boys; girls move more quickly toward maturation of all brain circuits and mature 2-3 years earlier than boys

Neuronal dropout over the first 21 years—inverse relationship to brain development • PRUNING • # of neurons at birth ~ 4000 per mm³ • # at age 21 ~ 2100 per mm³ • #at age 75 ~ 1050 per mm³

While they’re pruning neurons, the pathways are continuing to mature • In addition, the pathways continue to develop, gradually improving the precision and efficiency of normal communication—completed in the early 20s • Especially the large bundle connecting the two hemispheres with the limbic system—the corpus callosum • And the pathways connecting the prefrontal cortex with the limbic system

The teenage limbic system • The limbic areas mature earlier than those involved in judgment, organization, and reasoning • DISCONNECT BETWEEN THE TWO • This discrepancy between expressing feeling vs. thoughtful evaluation accounts for many of the teen behaviors that dismay parents and teachers… • “but he was such a sweet little boy…”

The Teenage Brain • “I just don’t understand what happened…”

The biggest MISCONCEPTION: Looking like an adult means they act like an adult… • Even though they may “look like adults” adolescents find it more difficult to:

Think before acting… • Difficult to interrupt an action under way—ramming the back of the car in front of you…for example • The teenager freezes and screams (the limbic system--emotions) • The adult brakes hard and steers out of the way (the prefrontal cortex) • Back to the prefontal lobe that underlies planning and voluntary behavior

Adolescents find it more difficult to: • Choose between safer and riskier alternatives • Difficulty resisting peer pressure • It’s that prefrontal cortex again—they’re using it somewhat, but it’s overtaxed…throw in peer pressure…”Aw c’mon, just once…” the stressful situation on an already taxed prefrontal lobe may give in to better judgment--

General Assessment--observation • The most useful information is often acquired by watching the child move and play. • Mood and behavior • Level of activity • Toddlers usually lie down when sick

School bullying • Schoolyard bullies are at increased risk to grow up as abusive adults • 4 x greater risk of striking or threatening an intimate partner • (Falb K, et al. Arch Pediatr Adoles 2011)

The order of the exam is not carved in stone… • Try to do everything you can with infants and toddlers sitting on their parent’s ankles or on their lap • Lying the child on the examination table increases vulnerability

The order of the exam is NOT carved in stone… • Take advantage of all opportunities • If the diaper needs changing, check the external genitalia • If they offer…GO for it…

If they are relaxed, check their belly… • “Ms. Bancroft, can I ask you a question? • Have you ever….?”

Facial expressions and the cranial nerve exam… • Frown, smile • Facial nerve (VII)

Cross your eyes… Make a face • Raspberry • CN III (oculomotor) – eyes • Facial expression (VII) • Stick your tongue out (XII)

Don’t go to the painful area first.. • Compare the good side with the bad side—looking at the good side first • Good ear, bad ear • Good ankle, bad ankle

State of hydration.. • Does this infant continue to feed? • Quality of cry—tears (+ or -) grunting • Drooling in kids can lead to dehydration quickly

DIGRESSION ON HYDRATION I KIDS:What 3 individual clinical features are the most accurate for predicting 5% dehydration? • Abnormal capillary refill • Abnormal skin turgor • Abnormal respiratory pattern • What conditions can lead to dehydration? Vomiting, diarrhea, diabetic ketoacidosis (DKA)

Clinical findings to estimate the degree of dehydration—mild dehydration • Body fluid lost (mL/kg) -- < 50 • Weight loss -- < 5% • State of shock--impending • General appearance—thirsty, alert, restless • Systolic blood pressure -- normal • HR -- normal • Respiration -- normal • Radial pulse – normal rate and strength

Clinical findings to estimate the degree of dehydration—mild dehydration • Capillary refill -- < 2 seconds • Skin elasticity – retracts immediately • Anterior fontanel -- flat • Mucous membranes – normal to dry • Tears – present • Skin color -- pale

Clinical findings —moderate dehydration • Body fluid lost (mL/kg) – 50-100 • Weight loss – 5-10% • State of shock -- compensated • General appearance – thirsty, restless or lethargic; irritable to touch • SBP – normal (orthostatic) • HR – slight elevation (orthostatic) • Respiration – deep, may be rapid • Radial pulse – rapid and weak

Clinical findings —moderate dehydration • Capillary refill –2-3 seconds • Skin elasticity – retracts slowly (> 3 seconds) • Anterior fontanel -- depressed • Mucous membranes – very dry • Tears – absent • Skin color -- gray

Clinical findings to estimate the degree of dehydration—severe dehydration • Body fluid lost (mL/kg) -- >100 • Weight loss -- >10% • State of shock -- uncompensated • General appearance –drowsy, limp, cold, sweaty, older may appear apprehensive, younger may be comatose • SBP – very low or absent • HR – very elevated • Respiration – deep and rapid (hyperpnea) • Radial pulse – feeble, rapid, may be impalpable

Clinical findings to estimate the degree of dehydration—severe dehydration • Capillary refill -- > 3 seconds • Skin elasticity – retracts very slowly • Anterior fontanel -- sunken • Mucous membranes—very dry to cracked • Tears -- absent • Skin color -- mottled

Dehydration and urine volume/osmolarity/specific gravity • Mild less than 2-3 mL/kg/h; 600 mOsm/L; 1.010 • Moderate (oliguric) less than 1 mL/kg/h; 800 mOsm/L; 1.25 • Severe=anuric; maximal osmolarity; maximal

Assessment of pain

Vital signs in kids • Weight (always!!! Basis for fluid replacement, doses of medication, fluid and electrolyte balance) • Temperature—rectal, oral, axillary, tympanic membrane • Pulse (apical heart rate is best for young kids) • Respirations—place your hand on the infant chest to determine RR • Blood Pressure—proper cuff size!! • Pulse oximetry

Weight … • Best index for a healthy child is appropriate weight gain • ALARM SIGN: Failure to gain weight is the first indication of a serious problem • Weights are essential for determining fluid requirements and medication dosages

Breast-fed babies gain weight more slowly • Benefits of breast feeding? • Teeth alignment • Immune system • Response to vaccines • IQ • Reduction in IgE-mediated allergies

Obesity in kids…33% • Complications of obesity—the first generation to NOT outlive their parents at the rate we’re going • Type 2 diabetes—50% of all kids with newly diagnosed diabetes have type 2 diabetes

Is it any wonder? • French fries are addicting (as are illicit drugs and nicotine) • The earlier you start… • Areas of the brain that have to do with addiction—the nucleus accumbens and the ventral tegmentum • Why isn’t anyone addicted to??

ALARM…rapid weight gain in girls • RAPID weight gain in young girls or teenage girls • Sexual abuse ? • PCOS (polycystic ovary syndrome)

Height/length • Growth occurs in a step-wise pattern • Spurts and lulls • Vertical growth occurs during sleep when GH is released during the late stages of SWS • Do kids have growing pains at night? • Adenoiditis, sleep apnea, and growth • How about tonsillectomies for hyperactive kids? ADHD?

Vertical growth and Iron • Iron is essential for growth • Iron deficiency anemia in kids usually due to dietary deficiency OR • Consider celiac disease • (may also have a bleed somewhere, but most iron deficiency in kids is due to a lack of adequate iron in their diet) • Ulcerative colitis causes bleeding in GI tract • Teenage girls? Menstrual blood loss…

Temperatures • Temperature-regulating mechanisms are not well developed in infants and young children, so temperature may fluctuate as much as 3° F in one day • Young infants do not shiver and lack adequate adipose tissue to insulate against heat loss • Exercise, stress, crying, ambient temperature, and diurnal variations all influence body temperature • Always document route (po, axilla, rectal, tympanic)

Temperature • The diagnosis of fever is a rectal temperature of at least 38.0º C (100.4º F). • For every one degree F increase in temp above normal, the basal metabolic rate increases by 10% • Increased BMR = increased insensible water loss • SKIN: proportionally larger body surface area in kids leads to greater amounts of body fluid loss and less temperature regulation • Dehydration occurs much sooner in kids with fever • Drooling kids

Pediatric Potpourri