Introduction – Children’s Health Pre-placement – MED 35

In case Children’s Health – Pre-placement

Children make up 50-60% of the Saudi Arabia population. Studies have shown that although not all Medical Graduates will become Pediatricians approximately 70% of graduates will be assessing and caring for children in their daily clinical practice (with almost 100% of graduates regularly looking after vulnerable young adults). It is therefore essential that all students receive robust training in the clinical assessment of infants and children.

One of the challenges in children is that they come in all different sizes from your premature baby, no bigger than your hand, to an adult size teenager. They also have different diseases and disorders, symptoms, signs and skills required in different age-groups.

To be able to help with this, paediatric patients are divided into five groups

Neonate – birth to 1 month

· Infant – 1 month to 2 years

· Young Child – 2 -6 years

· Child – 6-12 years

· Adolescent – 12-18 years

By now you will be familiar with the structured approach in taking a history and examination in an adult

The assessment and treatment of children has important differences to that in adult practice. A great deal of information from the history may be gained from a child even as young as 2-3 years with the support of their parent or carer, examination skills and clinical signs may be different and special consideration is required regarding drug and fluid treatment, and the ethical and legal responsibilities of parents, carers and medical professionals.

Why is the use of closed questions problematic in childhood?

Why is taking a history only from a parent/carer problematic?

Immunisation

One of the areas this block will touch on is immunisation.

The schedule will be covered in your GP placement but it is really important you are aware of it in the context of disease and this will be discussed throughout the cases in the next four weeks.

· The Saudi routine immunization schedule

A fully immunised baby presents at 5 months with a diahorreal illness. Which of the following is NOT likely to be a cause?

·          Adenovirus

·          Norovirus

·          Rotavirus

·          Salmonella

·          Shigella

Examination

Children will often initially be unwilling to cooperate with examination. Communication with the child during history taking and a flexible approach can assist this. Although similarities exist there are important differences in the way in which we approach the examination in a child. The following video clip will help demonstrate some of these:

Paediatric Early Warning Score (PEWS)

To be able to examine a paediatric patient and interpret the findings it is essential to know what is normal. Unlike in adults, even a simple value such as a Heart Rate changes throughout the different age groups.

Normal ranges and values at which there would be concern regarding the child’s wellbeing are expressed in a Paediatric Early Warning Score (PEWS).

Below is the Chart used in Children’s Hospitals. The normal values found for each observation are recorded in column 0 under the appropriate age of the child:

Paediatric Early Warning Score (PEWS) Chart

Using the PEWS chart, which of the following sets of observations is normal for a 6 month old baby?

·          Systolic BP 60, HR 148, RR 30

·          RR 26, HR 102, Systolic BP 68

·          O2 requirement 95% in air, HR 110, Cap refill 3 seconds

·         Cap refill 2 seconds, BP 70, O2 requirement 95% and over in air

·          Conscious level - alert, HR 98, RR 29

Growth Charts

Growth charts are a very important way of assessing a child’s growth and therefore wellbeing. In the cases following over the next few weeks you will be asked to plot the child’s measurements on an appropriate growth chart and comment on your findings

Please see the video below regarding how to plot the results correctly:

Plot the following results for an 8 month old baby boy born at 36 weeks gestation.

Weight – 8.6kg

height – 69cm

Head circumference – 44 cm

Plot an 8 month old baby boy's weight of 8.6kg on the growth chart below by clicking on the relevant area

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Plot an 8 month old baby boy's height of 69cm on the growth chart below by clicking on the relevant area

Plot an 8 month old baby boy's head circumference of 44cm on the growth chart below by clicking on the relevant area.

If you found this difficult please re-watch the video and reattempt as it is a very important skill.

During your clinical placement, plot the growth of the children you see and practice interpretation and explanation of these findings.

CASE COMPONENT

Further Material – Children’s Health Pre-placement – MED 35

In case Children’s Health – Pre-placement

Special issues in Pediatrics

Neonatal Examination

One special areas in pediatrics in neonatology (defined as the subspecialty of pediatrics that consists of the medical care of newborn infants, especially the ill or premature newborn. It is mostly a hospital-based specialty, and is usually practiced in neonatal intensive care units (NICUs)).

Examining newborns is an essential skill that you are requested to train for during the pediatrics rotation. Below is a starter video that describe some aspects of neonatal examination.

https://youtu.be/_w5NMP5CMKM

An essential part of neonatal examination is eliciting and judging Primitive (neonatal) reflexes. The following videos explains the idea of neonatal reflexes as well as the some of them.

https://youtu.be/vdiCep6OStA

Some of the most important reflexes are:

1. Grasp

2. Suck and Rooting

3. Moro

Basic Life Support in Children

It is vital that you know how to perform basic life support. This is a skill that everyone should have to saves lives both in hospital and at home. In children it has been shown that early and effective CPR really does save lives!

Please take a look at this learning package created by the Central Manchester Foundation Trust’s Education Department:

· Paediatric CPR – CMFT

What is the ratio of heart compressions to breaths?

·          15 breaths to 2 compressions

·          30 compressions to 2 breaths

·          30 compressions to no breaths

·          15 compressions to 5 breaths

·          15 compressions to 2 breaths

Why is the resuscitation schedule in children different to that in adults?

Background Science – Children’s Health Pre-placement – MED 35

In case Children’s Health – Pre-placement

Pediatrics ER (How to spot a sick child)

Recognition of an unwell child is often challenging as the initial presentation can be subtle and symptoms vague. In addition, children in general have intact physiological compensatory mechanisms making changes in observations and physical signs occur later. Tools are available however to identify children with early signs of serious illness.

Below is a short video to help you recognise the seriously unwell infant:

https://youtu.be/N35J3NLJW_s

The paediatric early warning score (PEWS) can be very useful in picking up the subtle signs, for example a degree of increase in respiratory rate.

Within the online cases for this block you will be asked to plot examination results on a PEWS chart, score and interpret the findings.

Why is it important to identify signs of illness in a child early?