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The main ideas from this information are: - Children are not small adults and have specific issues and concerns that affect them. - It's important to approach children of different ages and developmental levels in a calm, efficient, professional, and sensitive manner. - Treating children can offer special rewards and it's important to care for parents and caregivers as well. - Different physical and emotional changes occur during childhood, and it's important to understand these changes and milestones. - Infants have specific reflexes and behaviors that can indicate their development and health. - Inconsolable infants or persistent crying can be signs of significant illness. - Infants are predisposed to hypothermia and become more active and mobile as they grow. We'll get as far as we can, but if we don't lecture, we'll get through all the pediatrics absolutely. But if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, but if we don't lecture, we'll get as far as we can, That used to be the old thinking in EMS and medicine is that children are little adults. They're really not. They have specific issues and concerns that affect them. Your assessment is the same. The way you process the scene is the same, but your findings will be different because they're anatomically different. Illnesses and injuries that children sustain and their responses to them vary based upon age and developmental level, which we talked about developmental levels and life span development in Chapter 7. It's important to remember that children are not small adults. Like I said, they're EMS providers and pain can make child assessment difficult. Children can have a tendency to not want to talk to EMS, to be afraid. They go to the doctor, they get shot. They go to the doctor, they get these painful procedures. You show up, you get a stethoscope right in the back of your uniform, and they think, oh my God, it's going to hurt. I find a lot of times I go to children and I say, look, you've been to the doctor, right? So I'm going to do the same assessment your doctor does, but I'm not going to poke you with anything. Or if I have to poke you, I will tell you first. So something to that effect. Once you learn how to approach children of different ages and what to expect while caring for them, you'll find that treating children offers some very special rewards. Nothing is better. I've never had as good of a day, obviously saving a life was a good day, but to take a child that's really scared, really hurt, and by the time you get them to the hospital they're laughing and joking with you. There's nothing better. That makes your day. When caring for EMS patients, you must care for paid parents and caregivers as well. You have multiple patients, right? It's not just, especially if you have new parents and they have a young child that's injured and they really don't know what to do, they can be as emotionally distraught. Sometimes I've seen parents, the kids just sit there like, the kid's fine, and the parents are running around the room all anxious and excited. Sometimes the parents are more upset than the child is. A calm parent usually results in a calm child. That is definitely true. And use your parents, use the parents to help you calm the child. Use them as your best resource. How is it best to talk to your child or approach your child? Remain calm, efficient, professional, and sensitive. This one right here, a calm parent usually results in a calm child. An upset, agitated, or anxious parent will definitely cause an upset, anxious, or agitated child in many instances. Many physical and emotional changes occur during childhood, from birth to age 18. When we know the first month of life, from birth through 30th day, we call that neonate, right? Newborn. Neonatology is the study of newborns. Infancy is one month to one year. Toddler is one to three years. Preschool is three to six. Then you hit your school age, and then you hit your adolescence. So infancy is defined as the first year of life, usually first month after birth is neonato, or the newborn period, right? Zero to two months, they spend most of their time eating, sleeping, and pooping. Right? That's what they do. They do it to make it easier to develop. I will tell you that a child will develop about 10 million neural connections within their first year of life. And then 90% of those will become dormant as the child develops that one million neural connections they'll use throughout their life. So they're using a massive amount of energy. They're growing. You're going to find that children have twice the oxygen demand, twice the metabolism, because they're growing. Infants can grow as much as 30 grams a day. That's like bamboo. You don't watch that, right? I can remember one time I went on active duty. I ended up going to, this was many years ago when I was first in. I went on active duty. I was gone for about five months. And I came back, and I looked in the, my son had been born, just been born, and I left. And I came back, and I looked in the crates just five months, and I'm like, that's not my child. It was huge. It was giant in just five months. The amount of change. You don't see it every day when you're with the child, but when you're not with the child, you definitely see the difference. They respond mainly to physical stimuli, right? People talking to them, touch, the holding, the caressing, that kind of thing. To not tell the difference between caregivers and parents, usually that starts about six to seven months. It's called that stranger anxiety, right? And that's one of the things we look for. If I have a nine-month-old child, and I'm holding it, and the kid's looking at me, the kid's kind of just lying there and not upset, I'm questioning that. Is there something wrong with this child? Crying is one of the main modes of expression. You'll find that, like I remember, and many parents are, they know a tired cry, a hungry cry, a sick cry, you know, a wet diaper cry. You can tell the difference. You can say, yeah, I know what that is. They will follow with their eyes. They'll look around, right? They'll kind of focus on things. So, that's an important milestone is children that focus on things and follow with their eyes. You'll find that there's a couple of different things that we look for in infants. Like, first of all, the moral reflex, right? If I go to a child and kind of clap my hands and do something really fast, the child will do this. They'll kind of move out. They'll kind of be shocked. That's a moral reflex. We look for that. The palmer grasp. You ever have those people that say, oh, look it, he grabs my hand when I put my finger in. He likes me. No, he does that to everybody. It's called a palmer grasp. They grasp things with their hands. Or suckling and rooting. If you have a child that you rub the cheek, you rub the cheek and the face turns toward that rubbing, which we call the rooting reflex. The child is looking for the breast. Or suckling. Suckling is something we should see right away, immediately, when a child is born. Remember, everything's about the pie hole. Everything goes in the mouth, right? One of the issues with infants and aspiration. An inconsolable infant could be the sign of a significant illness. Parents should be able to pick up a child and calm it. Now, again, inconsolability could be a wet diaper. It could be hungry. But parents are usually pretty good about changing a diaper and feeding it. If it's still inconsolable, then there's an issue with that. Yeah, predisposed to hypothermia. They have an immature thermoregulatory system. They can't heat themselves up well. They don't have a lot of adipose tissue, which is ethanol fat, where they can insulate themselves. And they don't shiver. They don't have the muscular definition and coordination to shiver. So, they are more prone to hypothermia. Two to six months, they're much more active at this stage. They follow object with their eyes. Persistence, cry, irritability, or lack of eye contact can be an indicator of serious illness, depressed mental status, or a delay in development. You'll find two to six months, they can coo and babble. They can kind of laugh and smile. Sometimes, by the time they get to six months, they begin to kind of pull themselves along on the ground. Six to 12 months, become more mobile, which predisposes them to physical danger. They can climb up on things. They can stand up. And that's what they do. Maybe 10 or 11 months, they get up to the couch. And then they lift themselves up. You see, they're standing on the edge of the couch. And then they'll do this. And they'll bounce on the edge of the couch. And then they do this. And then they fall. And then once they stop walking, that's it. There's no more naps for you. They're up and they're around. Now, if the baby's lying on the floor, you can take a nap. Because it ain't going anywhere. Now, maybe once they stop moving, that's it. They place things in their mouths, which can lead to choking and poisoning. Again, everything's about survival. May cry is separated from the parents. Right around six to seven months, they get foot separation and dieting. Where they won't cry if they're with a caregiver that they're familiar with. They can recognize faces and sounds. Persisting cry or irritability can be the symptom of a serious illness. When we say that, we say a cry that's unconsolable. Observing infant from a distance. We're going to talk about the PAT, the Pediatric Assessment Triangle. Worker breathing, circulation to skin, and activity. And you're going to look at it from a distance. It's an assessment tool we use, like a general assessment. As mom's holding the baby, or dad's holding the baby, you can approach and do this assessment. Caregivers should hold the baby during their physical assessment. You can do all your assessment while the parent holds the child. As long as you can expose the skin, listen to the lung sounds and everything. Let the parent hold the child. It keeps the child calm. Provides sensory comfort. Anybody ever go and get you, you know, somebody listens, uses a stethoscope, and it's cold? You go, cold? Jeez, warm that up, will ya? Warm up the stethoscope, right? Think about it. You're going to put a blood pressure cuff. You're going to put some kind of something on the baby. Make sure you warm it up first. Do painful procedures at the end of the assessment. For infants, where do we check blood sugar from? Check blood sugar from the heel of the foot. Infancy to three years, we call that. After infancy, one to three years, we call it a toddler. Because they're toddling around. Now remember, a child is born with a head 60% its adult size. So they've got this big melon on this small body. So they're going to be talk heavy, and they're going to look like they're drunk all the time. And they're going to walk, and they're going to fall. That's kind of common. So children do get injured. Luckily, when they were made, they were made pretty resilient. Twelve to eighteen months, explorers by nature and not afraid. This is where they make great leaps. I mean, they start walking, they start running, they start climbing on things. I mean, I was about eighteen months old. I would climb out of my crib. And I'd take the pillows over on the floor, and I'd climb up and climb out of the crib. My mother would find me all over the house through the night. They're like molars. They may not be able to chew food, increasing the risk of choking. Some European countries, they don't offer baby food like we do. They just take adult food, they cut it up small, and you either choke or you eat it. That's the way they do it. You know, if you think about it, the fastest growing animal is the blue whale. And it can go from one cell organism to about, you know, twenty tons in, you know, three years. The human being does not grow quite that fast. But we neurologically are the fastest developing of any animal. Because we go from one cell organism to basically a walking, talking little adult in about thirty months. Think about it. In about thirty months. So, by the time you get to about two years, you can actually hold a short conversation with a kid. They can draw, they can color, they can walk. They understand about 250 to 300 words. They feed themselves. So, assessment may have stranger anxiety. Again, the toddler's will, they carry that right up into early childhood. They resist separation from the caregiver. They have a hard time describing pain. They understand the difference between emotional and physical pain. I take your cookie away, you're going to cry. You fall down, you cry. It's got to be the same thing to them. Pain is pain. They can be distracted. Talk about things. You know, play games with them. Talk about their favorite cartoons. One of the best things you do, you take an extra large glove and you blow it up. And it looks like a chicken head. You draw two faces on it. You draw two eyes and a mouth on it. They love playing with those, right? Let them play with the stethoscope. Let them listen to your lung sound. Put the blood pressure on yourself. Show them how it works. Show them the equipment. Persistent cry can be the system of a serious illness. Again, crying. This is their main mode of anxiety expression, right? They're not going to yell and throw things. They're going to cry. Previous medical experiences may lead to hesitation toward you. Again, they've gone to the doctor. They get poked. They get prodded. They get poked. They get stuck with a needle. I'm not going to do that. I'm here to assess you. I'm not going to poke you with a needle. Three to six years have a rich imagination and can be fearful about pain. This is when they begin to develop and they understand now the difference between physical and emotional pain. They believe injury is the result of being bad, right? So, you have to talk to them. Look, you're not in trouble. We just want to make sure that you're okay. Foreign body aspiration, airway obstruction continues to be a high risk. Anybody know what the number one aspirating item is? What's that? A little toy. Well, I mean, a non-unconscious patient. Balloon. Not poof. What do you mean? What kind of toy? Balloons. Balloons are bad. I hate balloons. I know they're at every party. I can't stand balloons. I don't like balloons. The problem with a balloon is when kids inhale it, it gets down to the mucosal membrane of the airway. It sticks to the airway because it's rubber. It's difficult to get out. I hate balloons. Can't understand direction and be specific in describing pain at this point. This is preschool age. History must still be obtained from the caregivers. But even a two-year-old. Look to your two-year-old and talk to the two-year-old. You look to the parents to confirm and to get information, but talk to your patient. The worst thing you can do is ignore it. Even a two-year-old. They recognize that, right? Communicate simply and directly. And appeal to the child's imagination. Play games with them. Like I said, sometimes I've been known patients are really upset. Let them play with my phone. What do you like to watch? What cartoon do you like to watch? Pull it up on YouTube. Let them watch YouTube. Never lie to a patient, especially your child. You lie to them once, and they're going to remember it. And you're going to lose them. Be honest with them. If something's going to hurt, tell them it's going to hurt. And none of this, you're going to feel a little pressure. I remember going to the doctors, and the doctor said, you're going to feel a little pressure. Bullshit. Pain. Just say pain. It's going to hurt, but it's only going to hurt for a moment. You have to do this. They can be distracted. Again, at the feet and moving to the head. We always do foot-to-head assessment up until about the age of four or five. By the time they get to four or five years old, kids have been to the doctor multiple times, and they understand what the assessment process is. Always have the parent with you. The only time I don't want a parent or caregiver with me is if I suspect child abuse. Then I probably want the parent or caregiver away if I can get them away. Use adhesive bandages, band-aids, to cover sites of injection on the small wounds. You know, and they talk about modesty. You know, some kids, you go into somebody's house, and it's like a four- or five-year-old. It's naked time. Clothes come off, and the company comes over, and they run through the house. My son, at five years old, would go take a shower. He'd come out of the shower, wrap him in a towel, run to his room, and lock the door. And I knock on the door. I'm like, hey, what's going on? Don't come in. I'm changing. I'm like, you're five. I need you. So, respect the modesty of the child, even at the young age. Six to 12, beginning to act more like adults. They can think in concrete terms, and they can respond sensibly. You can actually, especially when you talk about eight, nine, ten, eleven, twelve, you can talk to them, include them in the assessment, ask them questions. Many times, they're going to look to parents, and you're going to look to parents to confirm information. They help take care of themselves. School is important. Children begin to understand that. By the time a child gets ten, eleven, twelve years old, they've experienced that. Grandparent, God forbid, a family member, like a child, a mother, sister, parent, you know, a pet. Usually, they've experienced it. Some more than others. Assessment begins to be more like the adult. When we talk about the school-age kids, again, you can go head to foot. Begin to gain their trust. Talk to the child, not just to the caregiver, right? Always include the child in this. Start with head, move to feet. If it's possible, give the child choices. I'm not going to say, can I take your blood pressure, because they could say no. Now, I have to go against their wishes. You want to give the child some autonomy. Which arm can I take your blood pressure? Which finger do you want me to do a blood sugar on? No. No. They still may say, you can't either. Okay, then I have to go against you, but at least you can give them some autonomy. Ask only the type of questions that let you control the answer. That's the biggest thing about being an attorney. In court, an attorney will never ask a question they don't know the answer to. And they won't ask a question that they won't lead them to another question that they want to ask. You have to control the conversation. Do not bargain or debate with the child. They're still pediatrics. You still tell them what they have to do. We want to give them some autonomy, but in the end, we have to do what we need to do. Allow the child to listen to you. Is there a heartbeat stethoscope? Put the blood pressure cuff on them. Let them listen to your heartbeat. Let them do your blood pressure. Can I understand the difference between physical and emotional pain? I learned this quite a bit earlier. Provide simple explanations of what's causing the pain and what can be done. Explain it. I mean, don't use big medical terminology. Use basic English, but explain what's going on. Include that. When you talk to the parents, talk to the child. Ask the parent a caregiver advice about the best way to distract the child. This is especially important to children with special needs, right? These are parents or caregivers. Thirteen to eighteen, they're physically similar like two adults. They think they're adults, but they're not. They're emotionally not like adults, but physically, most of the time, they're pretty much like adults. Puberty begins. Concern about body image and appearance and strong feelings about privacy. So this is one of those things where if I have a female teenager, I will try and get a female EMT to do the assessment. Doesn't always work. I've had to do it. Uncomfortable for the patient. So just keep that in mind. And that goes, ladies, for you and boys, too. I mean, it goes both ways. Time of experimentation and risk taking often feel indestructible. Things like, I should be dead many times over for the things that I did as a kid. Struggles with independence, loss of control, body image, sexuality, and peer pressure, which can lead to a lot of bad choices. Bad choices, unfortunately, keep us in business. Assessment can often understand complex concepts and treatment options. You can include them. And remember, even a child that's 12 years old who may be sexually active and talks to you about birth control or something like that, or things that might be pregnant or something like that, you can't include the parents if they don't want it. Remember, that's reproductive rights. They're their personal rights. Allow them to be involved in their own care. Provide choices while lending guidance. EMTs of the same gender should do the physical exam if it's possible. If it's not, it's not. Allow them to speak openly and ask questions. They may be inquisitive as to what's happening. Risk taking behavior is common. It can ultimately facilitate developmental enjoyment and shape identity. That risk taking behavior allows them to mature independently. But it can also lead to trauma, danger, sexual practices. Female patients can be pregnant. Again, they have an autonomous right to their privacy when it comes to that. So it says try to interview without the caregivers present. No, opposite of that. Always try to interview with the caregivers in the room. And then if you find that the patient's not giving you the information you need or the child is stating that they don't want the caregivers or parents there, then that's a different story. Because I just want to make sure the parents are involved because I don't want the parents coming up to me afterwards and saying, what did my child say? Because I don't want to tell them, well, I can't tell you. You have to talk to them. It's easy just to have them there. But you don't want to make your patient feel uncomfortable. If your patient seems to have discomfort, if they're not giving you, if they're not being forthright with the answers, if you can tell that they're keeping things from you, then maybe you have to take them privately into the ambulance or give them some private time. They have a clear understanding of pain and get them talking to distract them. Body is growing and changing very rapidly during childhood. We talked about that. You must understand the physical differences between adults and children because it will alter your care. So first of all, differences between the adult and child, when we talk about anatomy, pediatric airway is smaller in diameter and shorter in length. All the organs are kind of higher up because there's less space in there. They have more external surface to internal volume, especially infants. So you'll find that in an infant, the airway may be as narrow as a drinking straw in an infant. That's a pretty small airway, right? Lungs are smaller and are also higher up. And the heart is higher in the child's chest. As you can see here, because of the child, remember that the occiput, the very back of the head, right? In a child, because the head is so large in comparison to the body, that could produce the very pronounced lying down on the bed or on a flat surface and their head does this because the occiput is so big. And it can include the airway and unresponsive patient. So what we do is put sheets or blankets under the child's shoulders and it raises up the chest and it brings the head lower. Number one airway obstruction on a conscious patient is the tongue. And remember, infant children have a larger tongue proportionally than adults. They don't have a bigger tongue than adults. It's just proportionally. It's bigger. It's one of the reasons why when we put an OPA in a child, we insert it directly in. We don't put it upside down and rotate it because we can push the tongue back in the airway. Glottic opening is higher and positioned more anteriorly and the neck is almost non-existent. Remember, we do brachial pulses on infants because they ain't got no necks. As the child develops, the neck becomes proportionally longer. As the vocal cords, epiglottis and everything take their correct adult position. They kind of grow a neck, so to speak. The neck kind of stretches out and everything puts itself into a normal position. They have the larger rounded occiput. Tongue is proportionally larger. They have a long, floppy, U-shaped epiglottis. This is one of the reasons why epiglottitis is very severe in children and not so much in adults. Because they have that large, floppy, U-shaped epiglottis. Omega-shaped, as it were. Less developed rings of cartilage in the trachea, which means they're more likely to occlude in the airway if their head gets in a bad position. And a narrow, funnel-shaped upper airway that allows all aspirants to go right into the airway. It's almost like a funnel and it goes right in. Anything that goes in the mouth goes right in. Children and an adult, the narrowest part of the airway is at the vocal cords, at the arytenoid cartilage, which would be right here. In infants and small children, it's lower. It's in the cricoid cartilage, the ring of the cricoid cartilage. So you can actually aspirate something and push it down beyond the vocal cords, which means I can no longer pull it out. We use what we call the gill forceps, the kind of curved forceps. You can go in and pull things out. But that's one of the reasons we don't do blind finger sweeps or airway obstructions, because you can push something down further into the airway, beyond the vocal cords, and I can't get them. And then they have to be taken out with a bronchoscopy, bronchoscope. Airway, again, the trachea of the infant is smaller than a drinking straw. Airway is usually obstructed by secretions, blood, or swelling. Infants are nose breathers. They're obligate nose and belly breathers. Right up until about 12 months, they breathe more. It's not that they'll breathe through their mouth. It's that they breathe more through their nose. It's their main form of breathing. So, therefore, if they get congestion, they could actually inhibit breathing. They're also belly breathers. They don't have developed intercostal muscles. That doesn't come until about 12 months, or 12 months and beyond. So, therefore, they're more diaphragmatic breathers. We call them belly breathers. So, they're obligate nose and belly breathers, which means you have a child that's sick with a lot of mucus in the nose, and they have a tight diaper or gas, and the diaphragm can't contract well, they can have respiratory distress just from gas and a crusty nose. Respiratory rates of 20 to 60 is normal for a newborn. Normal respiratory rates for an adult are 12 to 20. A child, 15 to 30. An infant, 25 to 50. As much as 60 or more for a newborn. So, 20 to 30, I'd expect that for a newborn beyond one month. In that first month of life, 20 to 30 is not unreasonable. Children have an oxygen demand twice that of adults. They have twice the oxygen demand because they have twice the metabolic rate. Because they're growing. You guys aren't growing, you're just maintaining yourself. They're growing as much as 30 grams per day, which means that hypoxia is very severe in children. It comes on more quickly because they need more oxygen proportionally than usual. Muscles of the diaphragm dictate the amount of air that the child inspires because they're diaphragmatic or belly breathers. Pressure on the abdomen, a tight diaper, gas, something sitting on the belly can actually produce respiratory compromise. Use caution when putting straps if you're immobilizing a child. Luckily, children don't generally have spinal cord injuries because they ain't got no necks and the spinal cord is very pliable, very flexible. So, they generally don't have spinal cord injuries. So, your chances of back-porting a child are very low. As a matter of fact, many times when a vehicle crashes where a child is in a car seat, what I'll do is I'll strap the child, I'll tape the child into the car seat. I'll assess the child. If I don't need to remove the child, I'll put tape around the head and put towel holes between the head and the car seat and tie the tape into place. The kid's immobilized. Can't move. Perfect.