1. What is
Paediatric Nursing?

2. On children It takes special understanding to know children
They are complex, they are hard to understand
They are different
They are valuable
They are vulnerable
They have a need to be loved and to be valued

3. Paed-iatric, (Pais Iatros)
Pais = Latin = child
Iatros = Greek = physician, to treat or ‘hospital’ (‘iatrogenic’)
The Americans don’t know much Latin and consequently they have confused ‘Pais’ with the Latin ‘Ped’. Probably, after the French variant of ‘pais’ (‘ped’). Hence the US ‘pediatric’ (foot physician).

4. Just words Children’s Nurse Is modern usage
Grammatically incorrect (where do you put the apostrophe ?)
What is a nurse – therapist – physician’s attendant or carer?
The term ‘pediatric’ was first used in the USA, from about the middle of the nineteenth century.
The first time it was used in the UK was in 1928 when Sir Frederick Still gave birth to the British Paediatric Association. He put an ‘a’ in the word to be true to correct Latin usage.
Forfar, J. O., A. D. M. Jackson, et al. (1989). The British Paediatric Association London, The Royal College of Child Health and Paediatrics.

5. What IS a child? Children: Are louder than adults
Get into trouble faster
Fall off a theatre trolley faster than an adult
Will never take their medicine but …
Eat bleach
Swallow 50 Ferrous Sulphate tablets in one go

6. What IS a child? The child:
Is more intelligent than an adult (you try learning a new language in three years)
Is physically optimal
Loves, unconditionally
Forgives, unconditionally
Is more beautiful
Has a future, not a past
And he said: "I tell you the truth, unless you change and become like little children, you will never enter the kingdom of heaven. Matthew 18:3

7. On children Kahlil Gibran The Prophet 1926
And a women who held a babe against her bosom said, Speak to us of children.
And he said:
Your children are not your children.
They are the sons and daughters of life's longing for itself.
They come through you but not from you,
And though they are with you yet they belong not to you.
You may give them your love but not your thoughts.
For they have their own thoughts.
You may house their bodies but not their souls,
For their souls dwell in the house of tomorrow, which you cannot visit, not even in your dreams.
You may strive to be like them, but seek not to make them like you.
For life goes not backward nor tarries with yesterday.
You are the bows from which your children as living arrows are sent forth.
The Archer sees the mark upon the path of the infinite, and He bends you with His might
that His arrows may go swift and far.
Let your bending in the Archer's hand be for gladness;
For even as He loves the arrow that flies, so He loves also the bow that is stable.
On children
Kahlil Gibran
The Prophet 1926

8. Physiological differences
Children are faster
Respiratory rate adult 18 child 20-40
Oxygen consumption child ↑
Fluid intake adult 1500ml, Child ↑
adult 70ml / kg / day
newborn baby 150ml / kg / day
Fluid output adult 1500ml
child 1ml/kg/hr ↑ than adult
Cardiac rate Child ↑, adult 70, baby 120
The younger the child, the bigger the difference
Physiological differences not commensurate with size
Children are not small adults THEY ARE DIFFERENT

9. Healing Time taken for a femoral fracture to heal: Newborn One week
5-yr old Four weeks
10-yr old Eight weeks
Adolescent Three months
Adult Four months or longer

10. Drugs
Higher doses given to children (higher metabolic rate, larger extracellular space)
Smaller physical doses given
Some drugs not given
The younger the child (foetus) the more different re drugs (Thalidomide)
Need for greater accuracy
Different routes

11. Body proportion Relatively large head and brain
Head receives greater proportion of cardiac output
Head surface area greater
Greater heat loss from head

12. Small adults?
Surface area: body weight ratio is double (infants / adults) = greater heat loss
Oxygen consumption relative to body weight is double that of adults (6-7 ml/kg/min)
Higher metabolic rate

13. Not determinable from the adult value
Vital signs
Age
Pulse
Respiration
Weight
B.P.
Birth
30-50
3.4 Kg
80 / 45
6/12
120
25-35
7.5 Kg
90 / 60 1y
110
20-30
10 Kg
95 / 65
3-6y
90-100
14.5 Kg (3 yrs)
/ 60-70
7-10y
80-100
20-24
23Kg (7 yrs)
/ 60-80
11-14y
70-90 20
34Kg (11 yrs)
/ 70-80
Not determinable from the adult value

14. Cardiac output
Babies have limited ability to increase stroke volume hence higher heart rate
Cardiac output is higher per unit of body weight
Lower vascular resistance hence lower BP
Tachycardia most effective means of increasing cardiac output and the first sign of shock
Cardiac output decreases with HR less than 180bpm

15. Fixed stroke volume (infant)
Bradycardia = decreased cardiac output
Bradycardia caused by:
Hypoxia
Vagal stimulation (laryngoscopy)
Halothane
Etc.

16. Heart Changes from foetal circulation may be incomplete (heart sounds)
The need to watch for signs of congenital HD, especially when the ductus arteriosus closes
Poor feeding (exhaustion)
Palour,
Cyanosis (right to left shunt)

17. Ventilation
Ribs in neonates are more horizontal (limits anterio-posterior chest expansion, limited ‘bucket handle’ effect)
 Infant much more dependent on diaphragm and susceptible splinting with
gas in the stomach (ventilation with bag and mask)
Position (lithotomy)

18. Respiratory rate Age RR Term 30-50 1 year 20-40 3 years 20-30 6 years
16-22
10 years
16-20
14 years
14-20
18 years
Estes, M.E. (2002). Health assessment and physical examination. Albany. Delmar.

19. Airway Airways have smaller diameter Cartilage of trachea is softer
Airway more easily obstructed (can be obstructed by mucus)
Airway can be compressed if the neck is flexed or hyperextended
Sternum, ribs (chest wall) is cartilaginous and soft
Intercostal muscles much less effective
Infants may be obligatory nose breathers for first 4 weeks
Recession, grunting, wheeze

20. Intubation -1
Shorter time before hypoxia develops because of higher oxygen consumption (6-7ml/kg/min compared to 3ml/kg/min in an adult)
Larynx is higher (infant C3, adult C6)
Larger tongue
Epiglottis is U shaped and longer
Angle of the mandible is greater (120 degrees)
Trachea has anterior inclination
Large head

21. Intubation before puberty
Cricoid cartilage narrowest point of the larynx before puberty and is circular
 an uncuffed tube can be used until years
Nose accommodates the same size of tube as does the larynx before puberty
Length of trachea varies  need to check that both lungs are being ventilated

22. Dental development

23. Dental development

24. Injection sites and need for greater accuracy

25. Small limbs and safety

26. Blood
Blood volume greater (80-85ml/kg) at term but absolute volume is small
Haemoglobin greater gm/l at term
Premature babies: Hb low because iron stores are laid down late in pregnancy
Hb predominantly foetal (takes up oxygen at low tension but releases it less well to tissues)

27. Fluid At birth, about 80% water (60-65% in adults)
Premature babies have more water  fluid loss more critical
Neonates and infants initially lose extracellular water
Extracellular space is larger at this age (50%) body weight
 fluid losses are greater
Smaller intracellular space has less fluid to shift when losses occur (babies become sicker quicker)
Minor blood loss may be important in a small child

28. Extracellular Space
Bigger extracellular space = higher dose of drugs which are distributed there
Extracellular electrolytes (chloride) lost in larger amounts in dehydration

29. Circulating blood volume
Neonates
90ml/kg
Infant
80ml/kg
Child
70ml/kg
Adult
65-70ml/kg

30. Dehydration Higher proportion of water
Children exchange 50% water daily (adults 17%)
Child metabolic rate higher (more water produced and excreted, greater risk of acidosis)
Immature renal apparatus (neonates)
Large surface area (skin)
Large surface area (gut)

31. Maintenance requirements
Body weight
Age
IV maintenance
< 10 kg
1-12 months
ml/kg/day
10-30kg
1-10 years
60-90ml/kg/day
>30kg
10 years +
40-90ml/kg/day

32. Small vessel large spout
Adult
Child

33. Kidneys Differences only an issue in the first few weeks
Glomerular filtration less
Reabsorption of water reduced (cortical tubules and  sodium excretion not fully developed
 Dehydration occurs faster

34. Liver Lack of some liver enzymes in neonates and premature babies
Poor metabolism of some drugs (chloramphenicol)
Idiosyncratic metabolism of some drugs (morphine)
High levels of bilirubin in the neonate

35. Brain and NS
Brain is immature (different) in ways that are not understood (febrile convulsion)
Centrally acting drugs (morphine, barbiturates) have a greater depressant effect
Not all myelinated fibres are myelinated

36. Temperature regulation
Temperature regulation less efficient
High surface area
Premature babes have thin skin and less subcutaneous fat (body stores less heat)
Neonates do not shiver
Brown fat
Seriously prone to hypothermia

37. Assessment of shock
depression of the nail bed / forehead should result in return to normal in 0.5 secs
tachycardia is a sign of shock
bradycardia is a very late sign and may indicate imminent death
Hypotension late sign

38. Skin More liable to thermal injury
Saturation monitoring not reliable in the first 24h after birth and in premature babies (transcutaneous monitoring may be used instead)
Skin is thinner and can leak fluid in the very premature baby

39. Immune system babies more vulnerable to gram –ve bacteria
University students more vulnerable to bacterial meningitis

40. Safety

41. What is paediatric nursing?
Paediatric nursing is an ancient craft, the exercise of which has sought to ameliorate suffering throughout the ages; Paediatric nursing exists as a therapeutic intervention and is not merely ‘supportive’; Medicine’s primary goal is to cure the patient of disease and to remedy the effects of trauma. In contrast, paediatric nursing’s primary goal is to reduce discomfort and ameliorate the effects of disease, trauma and of treatment itself; Paediatric nursing uses science, including social, psychological and medical science to achieve its goal; however, paediatric nursing is not driven by science. Rather, paediatric nursing is driven by the therapeutic influence which one caring person can have on a suffering human being. It follows that, it is the relationship between the nurse and the child patient and family that is at the heart of the therapeutic activity called nursing. Paediatric nurses achieve much by simply being there with the suffering person, by demonstrating empathy and an unconditional regard for the child patient and his or her family and in relation to which, the words ‘affection’ and ‘love’ are fully appropriate.

42. NAWCH Charter NAWCH is now called Action for Sick Children Look it up!
Children shall be admitted to hospital only if the care they require cannot be equally well provided at home or on a day basis.
Children in hospital shall have the right to have their parents with them at all times provided this is in the best interest of the child. Accommodation shall therefore be offered to all parents, and they should be helped and encouraged to stay. In order to share in the care of their child, parents should be fully informed about ward routine and their active participation encouraged.
Children and/or their parents shall have the right to information appropriate to age and understanding.
Children and / or their parents shall have the right to informed participation in all decisions involving their health care. Every child shall be protected from unnecessary medical treatment and steps taken to mitigate physical and emotional distress.
Children shall be treated with tact and understanding and at all times their privacy shall be respected.
Children shall enjoy the care of appropriately trained staff, fully aware of the physical and emotional needs of each age group.
Children shall be able to wear their own clothes and have their own personal possessions.
Children shall be cared for with other children of the same age group.
Children shall be in an environment furnished and equipped to meet their requirements, and which conforms to recognised standards of safety and supervision.
Children shall have full opportunity for play, recreation and education suited to their age and condition.
NAWCH is now called Action for Sick Children
Look it up!

43. Professional organisations
ABPN Association of British Paediatric Nurses
NMC Nursing and Midwifery Council
Is not a professional body (often thought to be)
Is a government agency associated with the Department of Health
Is largely inactive in relation to paediatric nursing
ABPN – check it out!

44. Anne Casey’s model of paediatric nursing
Date published 1988
Senior Nurse. 8(4): 8-9
Based on Roper / Clarke
Type - Concept isolating
Key concepts:
child
family
nurse
partnership
ability of child / family to participate in care
health
environment
conception - maturity continuum
dependent - independent continuum
functioning, growing and developing
physically
emotionally
intellectually
socially
spiritually

45. The perfect model We don’t have the perfect model
Can you invent the perfect model
You could be famous
You could make some money
Try it now, invent your own model

46. Family Centred Care
‘a way of caring for children and their families within health services which ensures that care is planned around the whole family, not just the individual child/person and in which all the family members are recognised as care recipients'.
Shields, L. (2010). "Questioning family-centred care." Journal of Clinical Nursing 19(17/18):

47. What is
Paediatric Nursing?