Paediatrics Flashcards
In England, at what age my a child give consent?
If under 18 they are considered a child. 16 and 17 year olds may make decisions of legal standing, but parents can also give consent for them. Courts may also overrule competent 16 and 17 year olds.
Under 16, a Gillick-competent child may give or withhold consent but again this may be overruled but a parent, guardian or court if in their ‘best interests’
Who can consent on behalf of a child?
Mother
Natural father if married, or divorced, from mother
Unmarried father if on birth certificate or in Parental Rights and Responsibilities agreement with mother
Legal guardia
Anyone with court order with right to consent
Person over 16 with care and control of child (limited rights, and not if they are aware that parents would disagree)
Court of Law
The child if appropriate, in extenuating circumstances
Can a child be given a life-saving blood transfusion if the parents are Jehovah’s witnesses and refuse?
In an emergency, yes to save or preserve life. Electively the child must be made a ‘ward of court’ with two consultants declaring blood necessary to save life or prevent serious harm.
What are the normal RR, HR and SPB in a child <1?
RR 30-40
HR 110-160
SBP 70-90
What are the normal RR, HR and SPB in a child aged 1-2?
RR 25-35
HR 100-150
SBP 80-95
What are the normal RR, HR and SPB in a child aged 2-5?
RR 25-30
HR 95-140
SBP 80-100
What are the normal RR, HR and SPB in a child aged 5-12?
RR 20-25
HR 80-120
SBP 90-110
What are the normal RR, HR and SPB in a child aged >12
RR 15-20
HR 60-100
SBP 100-120
What is meant by ‘premature’?
Birth before 37 weeks gestation
What is a neonate?
a baby up to 28 days old or 44 weeks post conceptional age
What is an infant?
A baby up to 1 year
What is a toddler?
A child around the early stages of walking 1-3 years
What is a child?
Legally, anyone who is not yet 18 years old. Practically, 3 years to puberty
What is an adolescent?
Broadly puberty-18
What is normal childhood dentition?
First teeth around 6 months, with 20 primary teeth complete by 3 years.
Permanent dentition begins around age 6 and the last primary teeth are usually lost by 14.
In what ways is the respiratory system of child different to that of an adult? Why is this relevant?
- Higher airway resistance (narrower airways) therefore partial airway occlusion leads to more dramatic airflow obstruction e.g. secretions, tubes
- Funnel shaped larynx therefore more likely to get subglottic oedema post-extubation
- Neonates have far fewer alveoli and surfactant only begins at 24-26 weeks. Therefore premature infants develop respiratory distress and may require exogenous surfactant
- Ribs are more horizontal, compliant and have no ‘bucket handle’ movement therefore breathing is essentially diaphragmatic. Therefore gastric distension quickly impairs ventilation.
- Higher resting O2 consumption and RR. Minute volume is rate rather than volume controlled. Small FRC and closing volume in a neonate occurs within tidal ventilation. Therefore any small reduction in FRC may lead to lung collapse and they desaturate more quickly than an adult. CPAP may be effective.
- Increased vagal response to upper airway stimulation, more likely to get laryngospasm. Both vagal stimulation and hypoxia may lead to bradycardia.
- High minute volume and metabolic rate mean more rapid onset/offset of volatile anaesthesia.
What circulatory changes occur at birth?
With the first breath, pulmonary vascular resistance decreases and as the umbilical cord is clamped and the placenta is taken out of circulation, the systemic vascular resistance increases. These events change the pressure gradient between the right and left atria causing the foramen ovale to close. This happens as the septum primum is pressed against the septum secundum.
The aortic PaO2 then rises, causing the closure of the ductus arteriosus over the next 10h. This is due to local smooth muscle contraction but over the next 3 weeks it fibroses and becomes the ligament arteriosum. The muscle contraction can be reversed initially by hyperaemia or acidosis.
In what ways is the cardiovascular system of child different to that of an adult? Why is this relevant?
- Low SVR, high PVR caused by acidosis or hyperaemia can lead to a right-to-left shunt in neonates.
- Cardiac output is increased by increasing HR not SV as the ventricles are small and less compliant than in an adult.
- Bradycardia is a result of hypoxia, Cardiac output is lost below HR of 60.
How is the paediatric ECG different to that of an adult?
Right axis deviation
What is the circulating volume of a neonate/infant/child?
Neonate 90ml/kg
Infant 80ml/kg
Child 70ml/kg
Describe some relevant differences between the neonatal/infant nervous system and adults?
Myelination incomplete in neonates
Parasympathetic system predominates- susceptible
to bradycardia with vagal stimulation
Reduced cerebral auto regulation in the neonate- hypotension may lead to significant brain injury. Sudden increases in pressure may cause intraventricular haemorrhage.
Spinal differences- dural sac ends at S3/4 in neonate (S1-2 in adult), spinal cord ends at L3-4, at 1 year this has moved to L1-2.
Sacral vertebrae are incomplete allowing caudal anaesthesia.
Describe some differences of the neonatal GI system compared to adults
Reduces lower oesophageal sphincter tone- may have reflux
Low carbohydrate reserves- prone to hypoglycaemia
Jaundice common in neonates due to immature liver function, higher haematocrit and shorter red cell life. Usually benign but pathological causes must be excluded if prolonged.
Why is vitamin K given to newborns?
Neonatal vitamin K stores are low which in turn means vitamin K dependent clotting factors are low. (2, 7 , 9 and 10)
Vitamin K is given to newborns to prevent haemorrhage disease of the newborn.
What is a normal neonatal Hb concentration?
18-20g/dL falling to about 10g/dL at 3 months
