Basics of Paediatric Care

Dr Joyce CHUNG

Email: okjoyce.chung@polyu.edu.hk

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 Learning Outcomes:
By the end of this session, students will be able to:
• Understand the importance of pain management in paediatrics.
• Describe the methods of assessing pain.
• Identify the nursing interventions needed when performing
some pediatric procedures and care.
• Describe the basic knowledge of resuscitation in children.

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 Outline of the topics
 Pain management
 Positioning of a child during procedures
 Administration of Medication: Parenteral/Oral/Optic/Otic
 Special procedures: Suctioning/Aerosol Nebulizer
Therapy/ Peak Flowmeter/ Naso/Orogastric tube
placement /Enteral feeding
 Specimen collection: Nasopharyngeal Aspiration/Throat
swab/Urine collection
 Cardiopulmonary Resuscitation (CPR)

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 Pain management
• Pain experience influences by:
developmental level, cause & nature, ability to express

• Associated with fear, anxiety & stress

• Family plays an important role: Family- centered care

• Should approach by recognizing, responding and

reassessing the pain

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 Pain management
Recognizing pain
Observation and parental impression are commonly used
and a number of self-assessment tools have been
designed for children over 3 years of age.
• Vital sign changes may be a general reaction to
physiologic stress
• Pain assessment tool
Consider the developmental age of the child

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 Pain assessment tools

FACES Pain Rating Scale

(Age of 3 can be used)
FLACC Scale (Behavioral Score)

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Assessing children’s emotional responses during stressful medical procedure:
Children’s Emotional Manifestation Scale

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Li, H.C.W. and Lopez, V. (2005)
 Pain management
Responding to pain
Age-appropriate explanation should be given with
reassuring
1. Non-pharmacological approach
• Non-nutritive sucking with oral sucrose/glucose
• Touching therapy
• Kangaroo Care
• Distraction
• Art, music or play therapy with the involvement of
trained play specialists

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 Pain management
2. Pharmacological approach
• Local: anaesthetic cream (e.g. EMLA cream), local
anaesthetic infiltration, nerve blocks
• Analgesics: Mild/moderate – Paracetamol, NSAIDs
: Strong – Opioids (e.g. Morphine)
• Sedatives and anesthetic agents:
Ketamine, midazolam, nitrous oxide
• Antiepileptic (e.g. carbamazepine, clonazepam) and
antidepressant drugs (e.g. amitriptyline) for neuropathic
pain
Route: Oral if possible/ IV/SC/PR. Intranasal administration
is becoming increasing popular.
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 Pain management
3. Reassessing pain
• Vital part of pain management
• Child’s pain scores should be regularly reviewed

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 Positioning of a child during procedures

Mummy restraint
Infant restraining board
• Procedures used: jugular venipuncture; femoral
venipuncture; blood taking; placement of a
nasogastric tube; specimen collection e.g. NPA
• Keep observation of the child’s condition, perform
assessment of peripheral circulation.

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 IV access
• The patient is positioned to prevent movement
during the IV insertion procedure.
• Local anesthetic medication - EMLA cream may be
used if prescribed (needs 30-60 mins. to be
effective), covers with transparent dressing.
• Wipe it off before performing the insertion.
• Secure IV site after insertion by using transparent
dressing.

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https://www.activeforever.com/pdf/brochure-tegaderm-dressings.pdf
Femoral venipuncture Jugular venipuncture

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 Administration of medications

• Children’s reactions to medication administration can

be affected by developmental characteristics

• Body surface area / Child’s body weight

are common method to determine amount of
medication administration
 Must obtain an accurate body weight

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 Oral medication
• Liquids, pills, tablets, and caplets
• Frequently in a liquid form
• Use syringe/calibrated small medicine cup or
dropper for administration

* 3 checks 5 rights + allergy history MUST be

checked
* Stop any procedure if any query arise esp.
from parents

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 Oral medication
• Elevate the child’s head or at upright position unless is
contraindicated.
• Place small amounts of liquid along the side of the
infant’s mouth by the oral syringe or let the baby suck.
• Administration of 0.2 to 0.5 mL at a time helps prevent
choking.
• Allow the child to swallow between amounts
• Empower parent to participate if necessary

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 Intramuscular medications

• Widely used (esp. vaccination except BCG)

• Most stressful and painful experiences for the child
• Get adequate assistance and well informed to the
parent and child
• 21-25 gauge needles (0.5 to 1 inch) are usually
recommended to use for infants & children
• Evaluate the child’s muscle mass & choose
appropriate site.
• Rotate injection sites for multiple injections.

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Ventrogluteal
- Place your index finger on the anterior superior iliac spine, middle finger on
the superior iliac crest, and your palm on the greater trochanter.
- Inject into center of the ‘V’ formed by the index & middle fingers
* Use your Rt. Hand for the child’s left hip and vice versa

Vastus lateralis
- Identify the middle third of the femur.
- Identify the area between 2 imaginary lines drawn from the greater
trochanter to knee – midanteriorly & midlaterally
- Injection site is located between the lines in the middle third of the
midlateral anterior thigh

Deltoid
- Identify site about 2 fingerbreadths below acromial process & just above
axilla
- Inject into upper third of deltoid muscle

Dorsogluteal
- Not recommended in children < 5 years of age / insufficient muscle mass
- Place child on abdomen & have him/her point the toes inward
- Draw an imaginary line between the posterior superior iliac spine & the
greater trochanter.
- Inject in the upper outer region above this line into the gluteus medius
muscle
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 Intravenous medications
• Usually use a volumetric infusion pump /
syringe pump to avoid fluid overload
• Assess patency, insertion site & side effects;
• Flush the line with 2 - 5 mL NS ( in neonate)
• For intermittent infusion, use a proximal port /
a syringe pump / medication port on volume
control chamber
• Clean the port and surrounding tubing with
alcohol swab

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 Intravenous medications
• IV push: Inject the medication slowly over the time
specified
• At the end, flush tubing with normal saline
• Monitor effect & S/E of the medication
• Monitor the infusion/injection site regularly
Easily to cause extravasation
** Color, tension of skin,
skin temperature, pain sensation,
crying & excessive limb movement
of the infusion site etc.
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 Otic medications
• Warm to room temperature
• Lie the child in a supine position with his/her head
turned to the appropriate side. The child can also lie
across parent’s lap.
• To instill the solution in a child < 3 years of age, pull
the pinna of the ear back & down.
• If > 3 years of age, the pinna is pulled back & up

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 Otic medications

• Holding the dropper ½ inch above the ear canal and

being careful not to contaminate the ear dropper.
• Gently massage the tragus (area anterior to the ear
canal) unless contraindicated due to pain.
• Have the child remain in the supine position
with the head turned for 3-5 mins.
• Distract the child if necessary.

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 Ophthalmic Medications
• Cleanse the eye with cotton ball/gauze soaked with NS if
necessary.
• Swab from the inner canthus of the eyelid to the outer
canthus.
Maintain the principle of ‘once swab once only’.
• Position the child supine in bed, or other flat surface,
looking up.
• Ask for assistance if necessary.
• Rest your dominant hand against the child’s
forehead.
• With the other hand, pull down the lower eyelid
to expose the conjunctival sac.
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 Ophthalmic Medications
• Administer the medication (Eye ointment)
- Place a thin ribbon of ointment along the
entire conjunctival sac from the inner
canthus to the outer canthus or as
prescribed (e.g., ¼ -in ribbon).
• Apply gentle pressure to the nasolacrimal duct
(the inner canthus) with your index finger for
about 30 sec.
• Have the child keep his or her eyes closed for
up to 1 minute after administration.

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 Suctioning
• Oxygenate the child if necessary (Pre-oxygenation).
• Apply intermittent suction with rotation of the catheter
while withdrawing it.
• The appropriate subatmospheric pressures to use when
suctioning are:
60–80 mm Hg (Neonates),
80–100 mm Hg (Infants),
100–120 mm Hg (Children)
• Limit continuous suctioning within the airway
≤ 5 seconds (infants) / 15 seconds (children).
• Allow 20-30 sec. interval between each suction.
• Limit suctioning to a total of 5 minutes.
• Assessment and evaluation (? O2 afterwards). 27
 Tracheostomy tube (TT) suction
** Usually TT without cuff for children
- Easily dislodge without any notice
- Oxygenation prior suctioning if required.
- Turn on the wall suction & check suction force.
- Use glove hand to take out suction catheter without
touching the tip
- Connect catheter to suction tube
- Insert suction catheter into TT without applying
suction by using dominant hand.
- Gently rotate the catheter while withdrawing it.
https://www.youtube.com/watch?v=lUzCWZiQS4c
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 Aerosol Nebulizer Therapy

• Route: Inhalation
• More effective than by using puff technique.
• Allow to use in pediatric specialty
(Proper PPE and special room arrangement)
• Fill the nebulizer chamber, using a syringe to
measure the precise amount of isotonic diluent
& medication ordered.
– Using sterile NS for injection in dilution (according to
description).
• If gas flow is used >> at least 6L/min.
• Hold the nebulizer during administration.
• Be aware of claustrophobia (mask)→ ↑ stress 29
 Peak Flowmeter

• Measure pulmonary function in children

with resp. conditions e.g. asthma
• After taking a deep breath, the child
should blow as hard and fast into the
meter as he/she can. Read the number
achieved.
• Repeat this procedure two more times
(Altogether three times).
• Average the numbers from all the
readings to derive the PFR.
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 Naso/Orogastric tube placement

• Select appropriate size of feeding tube

(generally 5-8 French).
• Position the child using a developmental
approach.
• Measure the length of tube to be
inserted:
From the tip of the nose to the earlobe and
from the earlobe to the point midway
between the xiphoid process and umbilicus

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https://mychart.geisinger.org/staywel/html/Inpatient/3,89295.html
 Naso/Orogastric tube placement
• Gently insert tube into nostril/mouth, aiming down
and back.
• While inserting the tube, position the child’s head to
optimize passage into the esophagus by gently flexing
the head forward.
• When the enteral tube reaches the pharynx &
the child gags, ask child to swallow.
• Allow to rest as needed. Observe the child during the
procedure.
• Secure the tube (+ skin protection) & perform tube
verification.
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 Enteral feeding

• Assess the feeding regimen, ? NPO

• Hand hygiene
• Prime the tubing to eliminate air.
• Positioning of the child: Sitting position
(Preferrable).
• Head of bed should be elevated 30-60
mins. after feeding.
• Check and test the feeding tube to
ensure the feeding tube is in-situ.

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 Enteral feeding
• Assess for residual fluid in GIT e.g. Q4H before
feeding
• If the gastric residual volume > one half of the
previous feeding volume, hold the present feeding,
note the color and consistency, and notify the
practitioner.
• If there is a small amount of residual, return the
aspirate and continue with the enteral feeding
procedure.

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 Nasopharyngeal Aspiration
• Apply PPE in an isolation room
• Position: supine (newborn, infant) or held on knee
(young child) with the head in an extended position
• Aim: To reach the nasopharynx
• Insertion length: corner of nose to front of ear →
• insert 2/3 of the measured length
• Procedure: same as suction procedure
* Maintain the container in an upright position
Monitor RR and any changes during the procedure
: Obtain the mucus from the nasopharynx →
use the same suction catheter to aspirate
the content in the culture medium bottle
: label the specimen, comfort the child & parents
: Usual aftercare
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 Throat swab
• Explain the procedure to the child & parent
• Use the light to overview of the throat
• Gently swab back of the throat along the
tonsil area

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 Urine collection (urine collection bag)
• Position the child on the back with the legs in a
frog-like position.
• Remove the diaper & clean the perineum/
prepuce of the child by soap & water.
• Remove the protective backing from the adhesive
• Make sure the bag does not cover the anus
• Boy: insert the penis & scrotum into the bag
opening, the adhesive adheres to the perineum
& the symphysis.

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 Urine collection (urine collection bag)

• Girl: Position the lower half of the adhesive on the

bag on the perineum first and then press the
adhesive up toward the symphysis.
• Replace the diaper & wait for the child to void.
• After the child has voided, transfer urine to specimen
container

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CPR for children

Cardio-
pulmonary
Resuscitation
(CPR)
Signs of poor perfusion may include cool
extremities, decrease in responsiveness,
weak pulses, paleness, mottling and
cyanosis

© 2020 American Heart Association, Inc.

 Airway
• Check if there is any airway blockages of the child’s
mouth.
• Recovery position. Clear blockages with your fingers, then
check for breathing.
Airway opening
• Head tilt-chin lift maneuver (if stable cervical spine)
• Jaw thrust (unstable cervical spine)
• Prevent overextension of the head

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 Breath delivery
• Start if no breathing/ only grasping
• Bag-Valve Mask (BVM)/operator’s mouth:
Tightly seal up the mouth & nostrils
• BVM: using E-C technique
• Avoid excessive ventilation
• Avoid over-inflation of lung:
Small puffs of air & assess chest rise
• Give breath over 1 sec.
• If chest does not rise → Reposition the head/jaw
• Palpable pulse ≥60bpm but there is inadequate breathing
 rescue breathing breath ~ 20 to 30 breaths/min. (1 breath every
2 -3 sec.) until spontaneous breathing resumes.
• Reassess every 2 mins
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 Pulse assessment

• Infant: Palpate a brachial pulse

• Child: Palpate a carotid or femoral pulse
• If no definite pulse can be felt within 10 seconds, start
CPR, beginning with chest compressions.

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 Chest compression

- Spine is well support on a firm surface

- Rate: 100-120/min
- Location (Do not compress: Xiphoid process & ribs):
Infant ( 1 year old) : At a point of lower sternum just
below the intersection of the sternum (between
the nipples)
Child (1-8 yrs old): Lower half of the sternum
- Push hard, push fast, allow full chest recoil, minimize
interruptions in chest compression

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- Method:
Infant: 2 fingers, firm downward thrust
: 2-thumb -encircling hands technique
(2 rescuers)

Child: 2 hands / 1 hand (optimal for very small

child) on the lower half of the breastbone
(sternum)
- Depth:
Infant: At least 1/3 AP diameter, 1.5 inches (4 cm)
Child: At least 1/3 AP diameter, 2 inches (5 cm)

- Rate of Compression: Breath

30:2 (1 rescuer) vs 15:2 (2 rescuers) 44
 • C-A-B sequence as the
preferred sequence for
Pediatric CPR
• Treat reversible causes
Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hypoglycemia
Hypo- / hyperkalemia
Hypothermia
Tension pneumothorax
Tamponade, cardiac
Toxins
Thrombosis, pulmonary
Thrombosis, coronary
• Return of spontaneous
circulation
Pulse & BP
Spontaneous arterial pressure
waves with intra-arterial
monitoring

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https://www.ahajournals.org/doi/10.1161/CIR.0000000000000901
Cardiopulmonary Resuscitation (CPR)

https://www.billingsclinic.com/app/files/public/1fa175ae-97b9-46ba-97b3-
536551954915/bls-summary-of-steps.pdf https://cpr.heart.org/-/media/cpr-files/cpr-guidelines-
files/highlights/hghlghts_2020_ecc_guidelines_english.pdf
References:
Alexis A. Topjian. Circulation. Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart
Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care,
Volume: 142, Issue: 16_suppl_2, Pages: S469-S523, DOI: (10.1161/CIR.0000000000000901)
Highlights of the 2020 AHA Guidelines Update for CPR and ECC. Accessed Jan 26, 2021
https://cpr.heart.org/-/media/cpr-files/cpr-guidelines-
files/highlights/hghlghts_2020_ecc_guidelines_english.pdf
Hockenberry, Wilson, Rodgers, Hockenberry, Marilyn J., Wilson, David, and Rodgers, Cheryl C. Wong's
Essentials of Pediatric Nursing. Tenth ed. St. Louis, Missouri: Elsevier, 2017

Li, H.C.W. and Lopez, V. (2005), Children's Emotional Manifestation Scale: development and testing.
Journal of Clinical Nursing, 14: 223-229. https://doi.org/10.1111/j.1365-2702.2004.01031.x

Wong, C. L., Ip, W. Y., Kwok, B. M. C., Choi, K. C., Ng, B. K. W., & Chan, C. W. H. (2018). Effects of
therapeutic play on children undergoing cast-removal procedures: A randomised controlled trial. BMJ
Open, 8(7) doi:10.1136/bmjopen-2017-021071

Acknowledgement: Ms Jacqueline Ho

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 Q&A?

Please feel free to contact me at 2766 6322 or email to:

okjoyce.chung@polyu.edu.hk.

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