The sick kid Pearls & Pitfalls Dr. Fatoumah Alabdulrazzaq M The sick kid Pearls & Pitfalls Dr.Fatoumah Alabdulrazzaq M.D,FRCPC,FAAP,PEM(C)

Objectives To know the barriers and pitfalls in managing children while in ED To know the strartegies for managing those barriers and pitfalls to have a better outcome from the children’s visit to ED

Introduction 20-40% of patients presenting to the ED are children Children typically have a lower severity of illness than their adult counterparts during visits to ED They also present with some of the most serious illnesses with potentially devastating outcomes

The relative rarity of critically ill or injured children means that clinical experience potentially may be lacking or even atrophied over time Clinical inexperience coupled with the unique management issues of children has the potential to create some degree of uneasiness in even the most experienced emergency physicians

Difficulties Special Characteristics of Children Parent-Child Attachment Chronology of Developmental Periods

The clinician must interpret the symptoms of a sick child within the context of the child's unique personality and temperament Temperament is the personal style and way of interacting with, or responding to, the environment Flexible children have a generally positive mood and adapt quickly to their environment. Fearful or cautious children are slower to adapt to the environment and will be shy in new situations. They tend to seek out the caregiver and require the security of the parent's proximity and more time to adapt to new situations.

Barriers to Communication Data Collection Pitfalls in the History

Data Collection The history acquisition sometimes is difficult At times, it may be necessary to seek out the best historian (child, parent, caregiver, or baby sitter) to obtain a reliable and accurate history of present illness. Obtaining an accurate history from a child often is challenging and is inversely proportional to the child's age

Once children reach school age (5-10 years of age) they are better at communicating their symptoms. However, information distortions still may occur secondary to pain, fear, anxiety, and supplementary information from the parent still is needed

Pitfalls in the History Parents and other caregivers on occasion can provide the interviewing physician with unreliable historical accounts. An over-emphasis on specific information or innocent exaggeration may occur. A report of "vomiting all day," when clarified, in reality might be only four episodes throughout the entire day.

Inexperienced or medically naive parents may not know what symptoms to look for nor how to gauge behavioral changes indicative of a serious ailment or deterioration This may cause them to underestimate the symptoms or present a benign rendering of the sequence of events that led to the traumatic incident or clinical deterioration. Other parents simply may be poor historians or inattentive observers.

History taking The caretaker and the child's complaint may not reflect the organ system involved (i.e., crying) or may distract the physician from the actual area of concern. An accurate history should include the evolution of the present illness or, in the case of trauma, the circumstances that led up to the event.

Practical Clinical Strategies General Principles -The clinician's assessment should approach the child from an age and developmentally appropriate perspective The ED physician who understands the fears and anxieties particular to each stage of development will be able to adjust the approach accordingly

Evaluation of children with special needs Challenging. Differentiating what elements are new in their current clinical presentation from chronic disease features often is difficult to ascertain. Here again, the child's caregivers must be relied upon to help. Another source is the nursing staff or medical records, since these children tend to be frequent visitors to the ED.

Examination

Take Home messages The best practice for pediatrics require optimal conditions The examiner shall strive for the environmental , clinical and psychological conditions that allows the best and most appropriate assessment based on the child’s health status