Chapter 34. Pediatrics and Neonatal

"Little Adults"

Clinicians who don't regularly care for children often are fearful of them, particularly because many are nonverbal and may not cooperate with an exam. While children are not just "little adults," they will be much more willing to cooperate with the exam, and even procedures, if you spend a few minutes interacting with them, rather than interacting only with the parent. As much as possible, talk with children directly, as if they were an adult patient. Also, tell children the truth. If a procedure is going to hurt, tell them. They may not like that it hurts, but they will trust that, when you do something else and you tell them it won't hurt, you are telling the truth.1

Pediatric Developmental Milestones

Failure to progress through normal developmental milestones may indicate underlying medical problems, including malnutrition, anemia, HIV, hearing loss, chronic infections, lung disorders, and chronic toxicity (e.g., lead poisoning).2 To determine how well children are progressing, remember the four important milestones listed below.

For more complex testing, use the developmental assessment provided in Table 34-1, which was initially created to assess children in rural India.

Parents Caring for Children in the Hospital

In many cultures, a parent, usually the mother, traditionally helps to care for her own child in the hospital. While this should be encouraged in nearly all instances, in situations of scarcity, it has several advantages. It provides (a) low-cost bedside care, (b) continued breastfeeding, (c) emotional support from a known caregiver, (d) warmth for babies if mother and child sleep together, and (e) an opportunity to teach the mother important health care practices.

When to Refer Patients

In remote areas or in situations with scarce resources, it is important to know which children must immediately be referred to a hospital for admission or to specialists (possibly in a less urgent manner). The following rules (Table 34-2) were developed for practitioners in Papua-New Guinea, which has a chronic scarcity of health resources.5 However, the rules can be applied to all scarce-resource circumstances.

Normal Vital Signs

Knowing the normal neonatal vital signs for preterm infants (Table 34-6 later in this chapter) helps to determine whether a neonate needs resuscitation (assuming that the resources to do this are available) and whether the infant has been successfully resuscitated.

Which Newborns Need Resuscitation?

As soon as an infant is delivered, evaluate his condition to determine if additional intervention is needed. To do this, I devised the simple mnemonic, "BoTToM," which stands for the status of the normal newborn: Breathing spontaneously (Bo), Term infant (T), normal muscle Tone (T), and no Meconium staining (oM). If the baby does not meet the BoTToM criteria, have other practitioners (preferably two) take the child to a heated area of the room for further evaluation and, if necessary, resuscitation. If the baby meets all these criteria, dry the child and put him on the mother's chest for "Kangaroo care." (Kangaroo care is explained in detail in the following text.)

Stimulation

In most cases, neonates begin breathing without any stimulation. If not, drying and suctioning them is sufficient stimulation.

Suction

For neonates, sucking the mucous and meconium may require mouth suction. The easiest way to make a mouth-operated suction device is to punch two holes in the top of a sealed container, insert two rubber tubes through these holes, and begin sucking on one of the tubes (Fig. 34-1). The suction pressure is easily controlled by how hard the clinician sucks. Once common, use of these devices has decreased due to the risk of infection posed to health care workers. Yet mouth-operated suction devices have many advantages: They are easy to make, inexpensive, disposable, and portable; can be operated using one hand; and do not require a power source other than the clinician. Some studies found that using these devices is a relatively safe procedure, although others have found that they occasionally can transmit pathogens.6,7

In some regions, mothers of older children, in what is a type of a reverse mouth-to-mouth procedure, suck the mucus out of their baby's noses with their mouths.8 The danger of passing pathogens from baby to mother is probably a moot point.

Neonatal Hypothermia

Hypothermia can be devastating to neonates, especially those who are premature or small-for-dates. In fact, all infants <12 months old are highly susceptible to hypothermia, as are any children with marasmus (previously termed "protein-energy malnutrition"), large areas of damaged skin, or serious infections. Hypothermia is defined as a rectal temperature <35.5°C (95.9°F) or an axillary temperature <35.0°C (95.0°F). All hypothermic children must also be treated for hypoglycemia and for serious systemic infection.

The "warm chain" for infants (as opposed to the "cold chain" for vaccine preservation) is a set of interlocked procedures designed to minimize the likelihood of hypothermia around the time of birth.9 These include ensuring that the place of delivery is draft-free and is stocked with the appropriate materials to immediately dry and wrap the infant (including a warm cap for the head). In addition, the mother and baby should be covered together, and start early breastfeeding. When keeping the mother and baby covered together is continued over the first days and weeks of life for small or premature infants, it is referred to as "Kangaroo Care."10

"Kangaroo Care" for Very-Low-Birth-Weight Infants

Developed for resource-poor areas, Kangaroo care provides an appropriate heat source (mother) that helps maintain neonates' temperatures, improves survival rates, and spurs weight gain.11

It allows low-birth-weight (<1500 g) babies, some as small as 700 g, to be safely fed, warmed, and bonded to their mothers. The technique is to breast-feed the infant with skin-to-skin contact. Place the child on the mother's bare chest or abdomen (skin-to-skin) and cover both of them. Alternatively, clothe the child well (including the head), cover with a warmed blanket, and place him in an incubator with an incandescent lamp over, but not touching, the child's body. Even in a public setting, mothers can continue such care under a loose dress. After the infant is discharged home, they should continue to use Kangaroo care.12,13

Kangaroo care reduces the risk of reflux and aspiration, reduces apnea and infection, and shortens the hospital stay. It also encourages bonding between mother and baby, improves lactation, decreases the amount of time health care workers must spend with the family, and apparently improves the infant's psychological adjustment.14,15

Baby Bags

A simple way to maintain the neonatal warm chain is to swathe the child in a plastic "baby bag" immediately upon birth.

"Baby bags" are made by loosely swaddling the infant in polyethylene doubled over on itself, with one thickness above and two below the infant. This retains the neonate's body temperature and moisture. Dry the head, but do not cover the baby's head with plastic wrap! This material, often used as household plastic wrap and industrial packing, is inexpensive (<5¢ US) and lightweight (<20 g for a piece to cover an infant). Optimally, it is used in conjunction with a radiant warmer. Similarly, a thermal blanket laid over an infant helps preserve heat and moisture. Covering the baby's large head with a hat might further maintain heat.16-18

Incubators

Commercial incubators often do not work in developing countries, usually because they are not maintained properly. The use of one working incubator for several infants only serves to facilitate cross-infections. Using electric heating pads to warm babies tends to overheat them, may produce burns, and has led to deaths.17 For ways to improvise incubators, see "Equipment" later in this chapter.

Airway/Ventilation

Oxygenated Mouth‐to-Mouth Resuscitation

Without equipment, neonates can be successfully resuscitated using mouth-to-mouth breathing. The best way is to run an oxygen tube into the corner of the child's mouth, with oxygen flowing at 3 to 4 L/min. The clinician uses her cheeks as bellows and "puffs" into the neonate's mouth. Observe chest rise to determine if the ventilation is adequate.19

Frog Breathing

This technique of ventilation, known as Frog breathing, is suitable only for temporary use in babies under about 5 kg.20 However, this is true ventilation, not apneic oxygenation.

1. Insert an 8- or 10-Fr nasogastric tube through one nostril into the stomach. Drain it to gravity to prevent the stomach from overinflating.

2. Give nasopharyngeal oxygen at 2 L/min. Insert the oxygen cannula to a depth equal to the distance between the side of the baby's nose and the tragus (front of the ear). Do not insert it farther than this, or it may go into the esophagus.

3. With one hand, slightly lift the baby's chin, extend the neck, and pinch the mouth shut. With the other hand, pinch the baby's nose for about 2 seconds so that oxygen fills the lungs. Then release the nose for about 2 seconds and allow the elastic recoil of the lungs to empty them; you must allow adequate time for the exhalation phase. Watch the chest expand and deflate.

4. Give 12 to 15 breaths per minute. Ensure that the stomach does not inflate. If ventilation is inadequate, intubate the infant. (See Chapter 8, Airway.)

Using a Bird Ventilator for Children

In situations with limited resources, ventilators should be used only for those patients who have a good prospect of benefitting, generally quickly, from mechanical ventilation, such as patients with acute poisoning and for some neonates. The Bird "green box" pressure-cycled ventilator (Figs. 34-2 and 34-3), while relegated to museums in developed countries, is commonly used in remote areas. It is easy to disassemble and clean, requires relatively few parts, and has been a reliable piece of medical equipment for more than 50 years. It can also be used for intermittent positive-pressure ventilation (IPPV). To ventilate a child <12 months old, use an infant breathing circuit, which is usually supplied with the ventilator.21

Pressure-cycled means that the patient's inspiratory effort triggers the respirator, and gas flows at the rate determined by the gas flow-rate control. Gas continues to flow into the patient's lungs until the pressure in the system rises to the level set on the expiratory pressure control, then the flow stops until the patient triggers the respirator again. If the patient is too small or too weak to make even the minimal effort required to trigger the flow of gas, the gas flow can be started automatically by turning on the expiratory time control. The air-mix control adjusts the concentration of expired oxygen to 40% (knob out) or 100% (knob in).

Set the controls on the Bird ventilator as described in Table 34-3.

Fluids

Storing Breast Milk

Breastfeeding is the norm in resource-poor areas. Yet pumping the breast and storing breast milk introduce the problems of contamination and bacterial growth. Table 34-4 describes various storage methods and their potential safe periods.

Newborn Fluid Requirements

Fluid requirements relate to a neonate's weight. Table 34-5 gives the normal daily fluid requirement, in mL/kg/d, for each birth weight.

Nasogastric Tube

Neonatal-sized nasogastric (NG) or feeding tubes can be made from the insulation on an electrical cord (2- to 2.5-mm external diameter). To remove the insulation, make a cut in the insulation at the length needed and slip it off the wire core. Smooth out the patient's end by passing it over a flame. Clean it before use.25

Neonatal Incubator

A neonatal incubator is one of the easiest pieces of medical equipment to improvise. A number of methods are described below. Use your imagination to construct your own incubator from existing supplies.

One disaster team wrote, "The nurses made cribs out of cardboard boxes lined with cotton and covered with plastic-lined incontinent pads…. Each infant was placed in the makeshift bassinet with two warmed intravenous fluid bags placed on either side of the baby's body."26

A wash boiler, broiler, or large metal pan, such as a turkey roaster, can be used as an incubator. Place a layer of hot bricks in the bottom and cover them with wire mesh. Place a pillow and blanket over this, leaving about 4 inches on all sides for warm air to circulate. Make small ventilation holes by cutting openings in the cover and at each end. When moist air is needed, a vat of hot water may be used in place of the bricks. Be sure to keep the air holes open, or leave the top partially open.27

Line a clothes basket with flannel or soft padding that has sewn-in pockets to hold 10- or 12-oz bottles. Fill the bottles with hot water and put them in the pockets. Keep the temperature even by refilling every other bottle at regular intervals.27

Another method is to use a laundry basket and make a support for two or three electric lightbulbs to fit over the top (Fig. 34-4). Cover with a blanket or comforter. Shield the baby's eyes from the light.27

Crib/Playpen

Make a basic crib or playpen by inverting a table and draping mosquito netting over it (Fig. 34-5). Be sure that the table's underside is smooth; if not, cover it with a blanket or piece of canvas. Tack it down well. Note that this also protects the child from mosquitoes, which is highly desirable, and even lifesaving, in many regions.29

Phototherapy Box

Light therapy is often needed for neonatal jaundice, which arises due to a transient deficiency in bilirubin conjugation combined with an increased turnover of red cells, or in exclusively breast-fed infants when the breastfeeding results in poor caloric intake. The goal of light therapy is to lower the concentration of circulating bilirubin or to keep it from increasing by converting it to molecules that can be excreted even when normal conjugation is deficient.30

A simple phototherapy device for neonatal jaundice can be constructed from a wooden box and six 40-watt daylight fluorescent tubes (Fig. 34-6). Cut the box to a depth about double the diameter of the light tubes. Mount the tubes parallel to each other on the inside of the box lid, and line the inside lid with a white reflecting surface to direct the light downward. Then, mount the box on supports so that it sits about 18 inches above the baby. A box 140 cm × 75 cm × 20 cm (55 inches × 30 inches × 8 inches) can be used over three cots or two incubators; the size and materials can be varied to meet local needs. Be certain that the baby's eyes are covered during phototherapy.31

Infant Bathtub

A baby's bathtub can be made by attaching a piece of canvas, tarp material, or plastic sheeting to the outside edge of a wooden box about the baby's size (Fig. 34-7). Leave some slack in the center. Fill with water before placing the baby in the bathtub.32

Urine Collection

For an improvised infant urine collection bag, see Chapter 5, Basic Equipment.

Measuring Volume

In neonatal units with limited nursing staff, being able to provide constant urine output measurements for noncatheterized infants can be valuable. To do this, first make an acrylic (Perspex) V-shaped tray that fits into an incubator. The tray should have a downward slope, so that the point of the V is in the center. Cover this with a fine (100 threads/inch) mesh (georgette) that is stretched over the tray's frame and attached with Velcro strips—two 2-cm strips on either side and three strips at either end (Fig. 34-8).

The mesh covering should keep neonates who are placed on this tray suspended above the bottom. Only urine and the most-liquid stools will pass through the mesh into the tray, collect in the tray's most dependent area, and drain out of the incubator through one of the low hood ports into a collecting/measuring bag.33

Restraint Devices/Methods

Sedation is not always available, safe, or appropriate. Therefore, infants and children may need to be restrained. Figure 14-4 shows one method to restrain a child. Note that under light ether anesthesia or ketamine, children may need to be restrained simply for safety.

Proctoscopy

Complaints of fecal blood are relatively common in infants and are usually due to anal fissures. However, investigating them, and the less frequent complaint of frankly bloody stools, may be difficult due to a lack of adequate equipment. To get a better view of an infant's rectosigmoid than can be obtained with an ear speculum (the commonly used method), fashion an infant proctoscope.

To make an infant proctoscope, take an appropriate length of rubber or plastic tubing (1 to 2 inches, depending on the child's size) and slip it over the end of a nasal speculum attachment or directly onto the end of an otoscope (without an ear speculum attached). A large-size NG, rectal, or similar tubing can be used. Immerse the tubing's end in hot water and stretch it onto the speculum using a hemostat. Smooth the cut edge with an open flame. With the child in a knee-chest position, lubricate the tube and carefully insert it under visualization.34 As with sigmoidoscopy, always aim for the lumen when it is advanced. If you don't see a lumen, don't advance it further (Fig. 34-9).

Inguinal Hernias

Inguinal hernias are common in infants and children. Reducing them is generally the first maneuver; surgery may not even be an option in austere circumstances. While it helps to provide some type of mild analgesic, a warm bath may work as well. An old maneuver, similar to the acute Trendelenburg position, in which adults are often placed for reduction, is to "lift the patient straight up by the legs, letting the body hang down; then pull the scrotum up and shake the contents back into the abdominal cavity."35

Subdural Effusions

Subdural effusions are particularly likely in meningitis due to Haemophilus influenzae and in children <2 years old, occurring in up to 20% of children <1 year old. In neonates with meningitis, measure the head circumference twice a week. Suspect an effusion if most of the following symptoms are present36: (a) fever persists for >3 days, (b) vomiting persists or recurs, (c) difficulty with feeding occurs, (d) head circumference increases, (e) papilledema appears, (f) focal neurological signs appear, (g) cerebrospinal fluid (CSF) protein rises, and (h) there is persistent or increased bulging of the fontanel (Fig. 34-10). Also consider a subdural bleed in critical neonates doing poorly after neonatal trauma (or suspected trauma) with a bulging fontanelle.

In resource-poor situations, ultrasound or transillumination may be the only available confirmatory tests. Transillumination is best done in a dark room using a standard 2-cell flashlight held tightly to the anterior fontanelle or, even better, a powerful narrow-beam flashlight with a rubber adapter over the light end to form a tight seal over the skull. If it produces >2 cm transillumination around the edge of the beam or there is asymmetry of the transillumination, it suggests underlying pathology. With unilateral intracranial fluid or swelling, the two sides appear different. However, this may not be true with bilateral pathology. Since findings may vary with the child's prematurity and age, the light source used, and the operator's technique, perform the procedure on a normal infant if there is any question about the results.37

Subdural Tap

If imaging or transillumination suggest a subdural effusion or if the clinical situation is dire and there is no time or ability to do any testing, perform the remarkably simple subdural tap. This is one of those times when, to save a life, you may need to "suck it up" and proceed.

Subdural Puncture Technique36

1. Shave the anterior half of the scalp and swab it with iodine.

2. Scrub as for surgery and put on sterile gloves, cap, and mask.

3. Drape the child's head but allow adequate space for breathing.

4. Have someone else hold the child's head firmly.

5. With a 19-gauge or 20-gauge short-bevel needle, puncture the scalp obliquely at the extreme lateral corner of the anterior fontanel, at least 3 cm from the midline. Advance the needle until the resistance gives at a depth of 0.5 to 1 cm. DO NOT GO DEEPER THAN THIS. Allow up to 15 mL of fluid to drain. DO NOT ASPIRATE FLUID. If necessary, rotate the needle, but do not move it from side to side (Fig. 34-11).

6. Unless there is definite proof (CT scan or an excellent ultrasound interpretation) that there is no fluid collection on the other side, repeat the puncture there.

7. Until there is no further drainage, repeat the procedure over the next several different days. Up to 15 mL per side may safely be removed each day.

Pediatric Vital Signs

You must know the normal vital signs for a child's age to appreciate and to treat deviations. Table 34-6 has the normal vital signs (and the amount of initial fluid bolus) for children from preterm (3 kg) to 14 years old.

Pneumonia

You do not need a radiograph to tell that a child does not have pneumonia. Large studies have shown that a diagnosis of pneumonia can reliably be ruled out if the child has no tachypnea, no increased work of breathing, and clear lungs on auscultation. This avoids doing a chest radiograph and using antibiotics.39

For clarity, an increased work of breathing is the presence of flaring at the nostrils, retraction, or grunting.

Tachypnea (with the respiratory rate counted for 60 seconds) is:

• 0 to 2 months old: >60 breaths/min
• 2 to 12 months old: >50 breaths/min
• >12 months old: >40 breaths/min

Interpret abnormal auscultation with caution, since it has only fair inter-rater reliability, except for patients with wheezing.

Diagnosis of Urinary Tract Infection Without Lab

In verbal children >24 months old, use a simple algorithm and basic urine dipsticks to make a presumptive diagnosis of urinary tract infection (UTI) (Table 34-7). While a urinalysis and culture are optimal, treatment can begin before these laboratory tests are performed (or without them, if they are unavailable).

Hypoglycemia with Decreased Level of Consciousness

Hypoglycemia is common in critically ill children. Treat it by wetting your finger, dipping it into granulated sugar (so that sugar sticks on the finger), and rubbing the sugar-coated finger on the inside (buccal portion) of the child's cheek or inside the lip. Repeat as often as necessary. Do not put your fingers between the teeth, since the patient may bite down as they awaken.

Oral rehydration solution (ORS) or sugar water can be given, generally with an NG tube, to provide sugar. See Chapter 11, Dehydration/Rehydration, for more information about these solutions.

Disabilities

Childhood disabilities present in situations of scarce resources as frequently as in other circumstances. All children, however, cannot be sent to specialists for evaluation. The following questions form a simple screening method to determine whether a child has developmental disabilities. A positive answer to any one question suggests the need for further screening by specialists.

General Questions for All Children41

1. Compared with other children, was there a major delay in your child's sitting, standing, or walking?

2. Compared with other children, does your child have difficulty seeing at any time—day or night?

3. Does your child have problems hearing?

4. Does your child understand you when you tell him/her to do something?

5. Does your child have any stiffness or weakness in his/her arms or legs or difficulty walking?

6. Does your child ever have fits, become rigid, or lose consciousness?

7. Can your child learn to do things as well as other children his/her age?

8. Does your child speak any recognizable words and is he/she understood?

9. Does your child appear dull or slow compared with children of his/her age?

10. For 3- to 9-year-olds, also ask: Is your child's speech clear enough to be understood by people outside your immediate family?

    Or

    For 2-year-olds, also ask: Can your child name at least one object (such as an animal, a toy, a cup, a spoon)?