Pediatrics Flashcards
1
Q
Children’s concepts of death table
A
-
Infancy 0-2 years
- sensory information
- estsablishing attachment
- aware of tension, unfamiliar, separation
- distressed by disruptions in routine
- comforted by sensory input (rocking, sucking, transitional object) and routines
-
Early childhood (2-6 years)
- death is reversible, not personalized, magical thinking, associative logic
- may not believe death can happen to them, believe can cause death by wishing someone would go away
- provide concrete info about being dead
- address guilt and feeling repsonsible because of thoughts
-
Middle childhood (6-12 years)
- mastering skills, fairness, cause and effect
- aware death is final, personalized
- understanding causality by external and internal causes
- aware that death can be caused by accident, illness
- may have difficulty with spiritual/abstract
- Child may request graphic details about death and illness
-
Adolescence (> 12 years)
- working on separation, individuation, identity formation
- universality of death, but distanced from it
- risky behaviour (everyone dies anyways, it can’t happen to me)
- access to supportive peers
- may need to talk about plans that will not be realized (school, marriage, kids, career, etc)
2
Q
List elements of sharing information about serious illness and death with children
A
- Explore how family communicates
- Find out HOW the family wishes information would be shared
- Do not talk to the children for the family. Assist.
- Use honest, gentle, simple language
- Let the child guide you
- Explore beliefs of child and family
- Be aware of your own beliefs (and differences)
- Reflect on emotions of child
- Work to support child and family in what is important to them
- Clarify child’s understanding in a non-testing way
3
Q
How can a family member speak to a child without crying?
A
- expression of emotion and grief normalizes feelings
- should not be so intense that child needs to comfort adult
- provide developmentally appropriate toys and play activities
- talk about favourite toys, shows, etc as introduction
- children may draw picture or used stuffed toys to express emotions
4
Q
Supportive measures for helping child through serious illness/ death
A
- Help families find language to use, developmentally appropriate concepts
- Misinformation leads to confusion and fear. Be honest
- Use videos, books, websites
- Support children in their play as it is often combined with grief.
- Share information paced according to needs
- Arrange environment to be welcoming and accessible to child
- support person for child
- Allow child to ask for what they need, listen to them and follow their lead
5
Q
Language tips for talking with children about death
A
- “He may look like he is sleeping, but being dead is very different than sleeping”
- “Dead means that a person’s heart isnt beating any more, they don’t need to eat anymore, they aren’t hungry or thirsty anymore, they don’t breathe anymore…”
- Use the words dead and death (unless sig cultural exceptions)
- Why? “Your sister died because she was born with something very wrong with her lungs that could not be fixed”
6
Q
Involving children at the time of death
A
- Children do better if involved in care of dying family member
- Support person (child life, volunteer. etc)
- Prepare them for what room and person will look like
- Let them know they can talk to their family member
- Ideas for ways child can say I love you.
7
Q
Children’s guilt
A
- Be aware of magical thinking
- Children can think they are responsible for death of family member because they wished they would go away
- Particular problem if child was bone marrow or organ donor
8
Q
Should children attend a funeral?
A
- do better if included in family rituals
- sadness is permissable, alright to cry, feel safe with own feelings
- Prepare child
- Give them details
- explain whether there will be a coffin
- simple language
- answer questions
- ask someone child trusts to accompany them
- allow child to choose whether to attend funeral or not
9
Q
Pain and Symptom Assessment in Children : principles similar to adults and unique to children
A
- 0-10 scale understood by 7-8year olds
- Faces Pain Scale - revised
- Behavioral observations of child by parents, health professionals
Principles similar to adults
- anticipate and prevent pain
- provide ATC meds
- oral route first
- IR for breakthrough
- titrate to pain relief
- anticipate and prevent adverse effects
- use adjuvants
- never limit opioids out of fear of constipation
Principles different to adults
- do not ignore or under treat pain in children
- non specific symptoms for pain (irritable, withdrawn etc)
- use pain scales for patient’s developmental stage
- Medical condition may affect pain assessment (cerebral palsy and facial grimacing)
- less likely to express specifics about pain
- IV > sc route as many kids already have access
- child may lack understanding of cause-effect relationship
- opioid rotations more common (instead of adding meds to manage Se of opioid)
10
Q
Pharmacokinetics and pharmacodynamics:
differences in children
A
- mg/kg
- non ventilated infants, dose is 1/3 usual dose and titrated.
- infants higher risk of opioid toxicity because of higher surface area, incr fat-muscle ratio, decreased glycoproteins, decreased renal and hepatic clearance
- many medications not studied in children
11
Q
Fears and facts about pain medications in children
A
- address msiconceptions and fears with caregivers
- medications won’t impair ability to interact and play
- uncontrolled pain will impair ability to interact and play
- children not at increased risk of adverse effects
- not at increased risk for addiction
12
Q
What is the most common cause of pain in children with cancer, compared to adults
A
- procedures and treatment related interventions
- vs adults : disease related pain
13
Q
Checklist for analgesic therapy in children
A
- pain relief at lowest effective dose
- anticipate, prevent and treat side effects
- use ATC dosing
- Dosing:
- oral preferred or use port
- equianalgesic dose (oral: iv)
- ensure preparation is suitable to child (taste, frequency, etc)
- avoid IM, rectal
- no transdermal fentanyl if opioid naive
- no demerol, no mixed agonist-antagonists meds
- no codeine (metabolism)
- use topical anesthetics before needles
- Use analgesic to match pain
- acetaminophen mild
- Codeine - controversial for mild-moderate
- hydromorphone, morphine. diamorphone for moderate-severe pain
- Review pharmacokinetics
- < 50kg - mg/kg
- > 50 kg - usual adult dose
- non ventilated infants < 6 months, use 1/3 - 1/4 usual starting dose
- Start with IR dose
- Change to SR formulation once requirements are known
- Breakthrough analgesia q1h (10% MEDD). If> 4 BTD used in 24 h, increase ATC dose
- Bowel routine
- Adjuvant analgesics (gabapentin, steroids, TCA, ketamine)
- Use non pharm things (massage, tens, distraction, hynotherapy)
- Reassure family more options available
- Proactively address misperceptions, concerns
- Child is reliant on another for analgesia
14
Q
Pediatric Opioid dosing
A
- Morphine ORAL (3:1)
- < 50 kg : 0.15-0.3 mg/kg q4h
- > 50 kg : 5-10 mg q4h
- Morphine IV/SC
- < 50 kg : 0.05-0.1 mg/kg q4h
- > 50 kg 2.5-5 mg q4h
- Hydromorphone ORAL (1:3- 1:5)
- < 50 kg 0.06 mg/kg q4h
- > 50kg 1-2mg po q4h
- Hydromorphone IV/SC
- < 50 kg 0.015 mg/kg q4h
- > 50 kg 1 mg q4h
- Codeine ORAL (1:1.5)
- < 50 kg 0.5-1mg/kg
- > 50 kg 30-60 mg q4h
- Codeine IV/SC
- < 50 kg: 0.5 mg / kg q4h
- > 50 kg: 15-60 mg q4h
- Oxycodone ORAL
- < 50 kg : 0.2 mg/kg q4h
- > 50 kg : 5-10 mg q4h
15
Q
Dyspnea in pediatrics
A
- cancer
- cystic fibrosis
- muscular dystrophy
- spinal muscular atrophy
- cerebral palsy with infections
- congenital heart disease
- metabolic storage disease
- neurodegenerative disease
16
Q
Measurement / Assessment of dyspnea
A
- Are you a little or a lot breathless?
- Can you show my how breathless you feel? (VAS)
- What can you do / not do because your breathlessness is bothering you?
- Dalhousie Dyspnea Scale (effort, constriction, throat tightness) > 8 years
17
Q
Non Pharmcological Treatment of Dyspnea
A
- cold facecloth
- fan
- scent
- positioning
- child may not be able to position themselves (infant, CP, SMA)
- bad side down for effusion
18
Q
Pharmacological treatment of dyspnea
A
- Opioids
- Benzodiazepine
- sedation
- advise family that medications won’t change appearance or pattern of breathing
- secretions treat for family
19
Q
How are children different than adults wrt palliative care?
A
-
Different disease type and longer trajectory (60% non malignant)
- congenital, genetic, neuromuscular, respiratory, cancer, GI
- high prev cognitive impairment
- HIV AIDS
-
Communciation
- verbal, non verbal and cognitive impairment
-
Complexity of ethical dilemmas
- cannot consent, but can assent
-
Drug dosing
- not tested or approved for kids
- mg/kg dosing
- drug clearance
- surface area of child
- delivery mode
-
Children depend on proxy for medications and assessment
- situational, cultural and family role impact this.
-
Role of family in peds is different
- long term nature of illness, heavy burden
- ++ support needed for families
20
Q
List factors that impact pain in peds
A
-
Cognitive:
- understanding
- control
- expectations
-
Behavioural
- overt actions
- parent/staff response
- physical restraint
- physical activities
- social activities
-
Emotional
- anxiety
- fear
- frustration
- anger
- depression
All influenced by :
- age
- developmental level
- previous pain experience
- culture
- family learning
- gender
21
Q
Myths in pain in children :
Newborns do not experience pain, do not have mature nervous system
A
- 26 weeks in utero fetus can feel pain
- newborn is highly sensitive to pain
22
Q
Myths in pain in children:
Children do not feel as much pain as adults
A
- as much or more than adults
23
Q
Myths in pain in children: Children will get used to pain. They will have no memory of it, or lasting effect
A
- Continuing pain has long lasting effects on CNS
- permanent reorganization of neural pathways
- negative impact on future pain experiences
24
Q
Myths in pain in children: Children cannot explain pain reliably
A
- 20 months can say where it hurts, how much, and what makes it better
- Pain intensity at 3 years
- 4 years can indicate on body chart
25
Q
Myths in pain : If a child is distracted, they are not in pain
A
- Distraction and play is a coping mechanism for pain
26
Q
Myths in pain : If a child says he is in pain, but does not appear in pain, they do not need medications
A
- The child is the authority on whether they are in pain
- adults under-rate pain
- adults often have concerns that children exaggerate pain
- Adults diminish importance of pain in kids
27
Q
Myths in pain : A sleeping child is a comfortable child
A
- Sleep may be from exhaustion from pain
28
Q
Myths in pain : Opioids are dangerous for children and may result in addiction
A
- Invaluable for pain relief in kids
- children no more at risk for addiction than adults
- addictions not experienced in patients with true pai on therapeutic doses
