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June 30, 2015

Broadening the approach to pediatric assessment

EMT and paramedic curriculum covering pediatric assessment has historically focused on the pediatric assessment triangle (PAT), strategies for approaching different age groups, and pediatric airway management considerations. Although these foundational principles are still relevant in the primary assessment of pediatric patients, changes in the health and behavior of today’s children necessitate a broader approach to the overall pediatric patient assessment. Childhood obesity, lack of routine wellness checks or receiving vaccinations, pediatric mental health issues, and an increase in drug and alcohol abuse among pediatric patients all influence the field assessment of young patients.

Review of the pediatric assessment triangle

The pediatric assessment triangle refers to the triad of assessment categories used for the primary evaluation of a pediatric patient. Appearance, work of breathing, and an assessment of circulation via skin signs make up the points of the triangle. Any variance from normal is considered significant and indicative of some type of distress.

Rapid assessment of these three components allows the provider to quickly identify and treat life-threatening conditions in an infant or child. The assessment triangle is simple, easy to remember and a useful tool in the initial assessment of a sick or injured child.

After completing the primary assessment of a pediatric patient, providers modify their existing adult assessment to more appropriately meet the developmental stage of the child. Particular emphasis is placed on identifying common pediatric complaints such as respiratory infections and febrile seizures.

Although this approach is effective, it leaves the potential for discounting certain diseases or conditions as “adult” problems. Given the changes in health of today’s pediatric patient population, these “adult” conditions may be more prevalent in children than previously believed. Because of this, a broader approach is needed when performing a pediatric patient assessment.

A broader approach to the pediatric assessment

In the United States, 27 percent of children entering kindergarten are overweight or obese; by the 8th grade almost 39 percent are overweight or obese.[1] Assessment of an overweight or obese child requires the EMS provider to broaden their differential diagnosis list to include conditions previously reserved for the adult population.  

The prevalence of non-insulin dependent diabetes, a disease formerly considered rare in the pediatric population, has dramatically increased in children in recent years.[2] A study of diabetes in youth found that 22 percent of U.S. children with type 2 diabetes have early indications of kidney disease, and are at increased risk for hypertension, hyperglycemic emergencies and diabetic retinopathy.[3]

Pediatric type 2 diabetes is most common among minority groups, and generally presents with a slow and insidious onset. A thorough pediatric patient assessment should include blood glucose testing, and providers should have a high index of suspicion for diabetic emergencies in children who are overweight or obese.

Along with the increase in childhood obesity has come an increase in pediatric gallbladder disease,[4] non-alcoholic fatty liver disease,[5] and irritable bowel disease.[6] These diseases, like type 2 diabetes, are not traditionally thought of as childhood ailments, but must now be considered when assessing a pediatric patient with abdominal complaints. Careful questioning is important in order to obtain the specific details of the onset, duration and nature of the patient’s symptoms.

Providers may need to question both the child and the parent in order to gain a complete understanding of the presenting complaint, a process that can be challenging even for experienced providers.

Consequences of vaccine non-compliance

Many diseases previously controlled by vaccinating children have recently reappeared as serious public health concerns. Pertussis, measles, and influenza have infected individuals, particularly children, in steadily increasing numbers.

The anti-vaccine movement’s campaign falsely touting the dangers of the H1N1 influenza vaccine caused 70 million doses of the flu vaccine to be wasted in 2010[7], and 49 percent of influenza-associated pediatric deaths that year occurred in unvaccinated children[8].

In 2012, the United States experienced the largest outbreak of pertussis in 50 years, with the majority of cases occurring in unvaccinated children[9]. Between 2000 and 2011, two out of every three people infected with measles were unvaccinated. In 2013, most measles cases were in children whose parents had purposefully not immunized their children.[10]

These statistics clearly indicate the need for prehospital providers to consider vaccine preventable diseases when assessing pediatric patients. Providers need to re-familiarize themselves with the signs and symptoms of diseases previously considered “rare.” Parents should be questioned regarding the immunizations and boosters their children have received. Children presenting with potentially contagious infections, such as measles, should be managed accordingly with all appropriate precautions.

Pediatric mental health

Another change to the pediatric patient population is the increase in pediatric patients with mental health disorders. Although anxiety, bipolar disorder, and depression have traditionally been thought of as adult conditions, they can and do affect the pediatric patient population.

In recent years, pediatric depression has become a common reason for emergency department visits.[11] Of children diagnosed with depression, 2.4 percent will attempt suicide.[12] The assessment of pediatric patients must include consideration of any pertinent mental health signs or symptoms. Insomnia, irritability, isolation, and aggression may all be indications of early mental illness. Providers must maintain an index of suspicion of the potential for self-harm when caring for pediatric patients, particularly in those children with a previous diagnosis of a mental health condition.  

Education as an assessment component

Patient and family education can be added as an integrated component of the pediatric patient assessment. Many of the illnesses affecting children today are preventable. Educating children and their families in a professional and compassionate manner could provide the knowledge needed to prevent future emergencies. Discussing the importance of proper nutrition, physical activity, immunization and mental health care can be done throughout the assessment, treatment, and transport process.

Becoming familiar with local resources for free and low cost physical activities for children, preventative health services, and mental health providers will allow the EMS provider to refer patients and families to programs that may be of help to them. Identifying families that may benefit from such education and resources allows prehospital providers to alert hospital staff, so that the education may continue throughout the care of the patient.

The assessment of a pediatric patient must include not only the traditional pediatric assessment triangle, but also take into account the many differing aspects of the pediatric population. Obesity-related diseases, vaccine preventable disease, mental illness and the need for education can all be considered when assessing a child in the prehospital setting. By considering these additional factors, EMTs and paramedics are able to deliver high quality, compassionate care to this very important patient population.

References

1. Cunningham, Solveig A., Michael R. Kramer, and KM Venkat Narayan. "Incidence of childhood obesity in the United States." New England Journal of Medicine 370.5 (2014): 403-411.

2. Dabelea D, Mayer-Davis EJ, Saydah S, Imperatore G, Linder B, Divers J, et al. Prevalence of type 1 and type 2 diabetes among children and adolescents from 2001 to 2009. JAMA. May 7 2014;311(17):1778-86.

3. Maahs DM, Snively BM, Bell RA, Dolan L, Hirsch I, Imperatore G. Higher prevalence of elevated albumin excretion in youth with type 2 than type 1 diabetes: the SEARCH for Diabetes in Youth study. Diabetes Care. Oct 2007;30(10):2593-8.

4. Mehta S, Lopez ME, Chumpitazi BP, Mazziotti MV, Brandt ML, Fishman DS. Clinical characteristics and risk factors for symptomatic pediatric gallbladder disease. Pediatrics. Jan 2012;129(1):e82-8.

5. Gökçe, Selim, et al. "The relationship between pediatric nonalcoholic fatty liver disease and cardiovascular risk factors and increased risk of atherosclerosis in obese children." Pediatric cardiology 34.2 (2013): 308-315.

6. Long, Millie D., et al. "Prevalence and epidemiology of overweight and obesity in children with inflammatory bowel disease." Inflammatory bowel diseases 17.10 (2011): 2162-2168.

7. Poland, Gregory A., and Robert M. Jacobson. "The age-old struggle against the antivaccinationists." New England Journal of Medicine 364.2 (2011): 97-99.

8. Centers for Disease Control and Prevention (CDC. "Influenza-associated pediatric deaths--United States, September 2010-August 2011." MMWR. Morbidity and mortality weekly report 60.36 (2011): 1233.

9. Cherry, James D. "Epidemic pertussis in 2012—the resurgence of a vaccine-preventable disease." New England Journal of Medicine 367.9 (2012): 785-787.

10.  Gastanaduy PA, Redd SB, Fiebelkorn AP, Rota JS, Rota PA, Bellini WJ, et al. Measles - United States, January 1-May 23, 2014. MMWR Morb Mortal Wkly Rep. Jun 6 2014;63(22):496-499.

11.  Sun, Diana, et al. "Emergency department visits in the United States for pediatric depression: estimates of charges and hospitalization." Academic emergency medicine 21.9 (2014): 1003-1014.

12. Cooper, William O., et al. "Antidepressants and suicide attempts in children." Pediatrics 133.2 (2014): 204-210.

About the Author

Shawna Renga, AS, NREMT-P, currently works as an instructor for the United States Coast Guard Medical Support Services School in Petaluma, Calif., providing EMT training for helicopter rescue swimmers and Coast Guard corpsmen. She also works part-time for a private ambulance company, and lives with her husband and two sons in Sausalito.
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