Pediatrics for the Anesthesiologist

Pediatrics for the Anesthesiologist

The Psychosocial Development of Infants and Children

Anesthesia care providers are keen to understand the pharmacology and physiology attendant to the care of their patients, but often miss the very important and often critical role that the psychosocial development of a child plays during the perioperative period. In fact, the normal development of a child is very much affected by acute and chronic illness as well as painful and frightening procedures. The consequences of maladaptive behaviors within the family of a child that is chronically ill are seen frequently by physicians and nurses. These patterns of behavior in stressful circumstances vary with the age, the culture in which the child is raised, and the developmental level of the child. For the anesthesia care provider, an understanding of normal development and of the relationship between parents and children at various stages is important. Likewise, an understanding of the changes in behavior and cognition with growth is necessary to provide the best perioperative care.

Term Infants to Age Six Months

Healthy term infants are recognizable by muscle tone that allows them to bring their arms to the midline and raise the proximal portions of their lower extremities off a flat surface. If the infant is healthy, they will begin to gaze in the direction of a voice soon after birth. An infant without tone is either “sick” or more premature than the gestational age suggests. Infants will establish head control by four months and should be tri- podding (three point stance) by six to seven months.Infants are self-aware soon after birth but are usually only specifically responsive to leaving their parents at nine months of age or later. This is in part due to the inability of younger infants to recognize the differences between the faces of individuals. In these circumstances, wrapping an infant in a blanket and taking them to the operating room will usually suffice to calm the infant; premedication for anxiolysis is not required and may complicate management – vomiting versed on induction and/or prolonged wake up.

One of the reasons that mothers and nurses have learned to swaddle newborns is to reduce the strong startle reflex that may be present up to three months of age. Loud noises, cold hands, bright lights or virtually any other acute stimulus will cause the infant to startle; that is, to become very awake, very hypertonic, and very upset. Babies that are swaddled can’t complete this reflex and are much less likely to fuss.

Toddlers – Ages Six Months to Two Years

Infants will usually be pulling up to a standing position at a year of age or a little later. Toddlers that are not pulling up and taking steps by eighteen months of age are delayed and should be evaluated. Concurrent with this motor development, children will begin to mouth words and copy the words that they hear from mama and daddy.

From the age of 18 months until age 4 – 5, separation is characteristically difficult in the unpremedicated child with age two representing a peak time for some children to be maximally stressed when they leave their parents. Some two year olds that are particularly terrorized will have frank

tantrums and may hurt themselves. Experienced clinicians don’t try to take these children to the operating room until they are well medicated. Contemporary research on this separation process suggests that there are very real and negative behaviors that children may develop after a particularly stressful separation and/or induction including bed-wetting, night terrors, or inability to sleep. Some of these new behaviors continue for months after the surgical procedure and emulate the posttraumatic stress syndrome sometimes encountered in adults after particularly stressful events. Children that have multiple operative procedures should be expected to have an increased incidence and severity of these behaviors. Children are terrorized at age two, in part because their ability to verbalize their fears is not well developed. Fear of the unknown is at its maximum and by age two kids can usually understand that it is mom and dad that protect them. Anesthesiologists must understand from the perspective of the child they are taking them away from their safe place. As children grow and they can express their fears, clinicians have a better chance to address these fears directly; explaining the steps in the process and, perhaps, allaying anxiety. After age five and until adolescence children may respond well to going with a clinician to the operating room, especially if this activity represents a novel experience.

At any age, the astute clinician will pay attention to the hyper anxious parent. These may be the parents that know too much and are frightened about the possibility that they will lose their child. Often, these parents have followed the infant through a long and only partially successful stay in the neonatal intensive care unit; experiencing the daily ups and downs attendant to prematurity. They may question everything that is being done and, occasionally, may be quite angry about real or

perceived slights, inefficiencies, or frank failures of the healthcare system. Parents with many anxieties can and will transmit those anxieties to the child, genetically and behaviorally. These parents take a lot of time and it is reasonable to pull up a chair, answer their questions, and forget about turnover time. If the parents are capable of calming themselves, there is an increased likelihood that the child will be calm. Word to the wise: Give them as much information as is required for assurance. The outward display represents an inner fear of the unknown, and a loss of control.

Beware of the silent child. Children that are older than two and will not talk to a friendly clinician are very frightened. The approach that I have developed is to assume that a silent child is a very worried child, talk to the parents about your observations, and premedicate heavily. Sometimes it helps to assure the child that there will not be any sticks or hurts; for kids over the age of about three, that is a first order worry. Please note also that children that are maximally stressed will have a profoundly increased sympathetic tone; normally this translates to a requirement for doses of drugs that are at the higher end of normal – especially anxiolytics.

Age Five to Adolescence

From age five until adolescence, healthy children are usually resilient, if not sassy and most are self-assured. For these children, the key to a smooth induction is time and reassurance – for the child and the parent. Both must be allowed the opportunity to ask any question; it makes sense to sit down and get as much information out in the open as possible. For the child in this age group that has suffered through multiple trips to the

operating room, I ask the child directly what their concerns are, and try to provide direct reassurance; especially about topics that may have been managed poorly in the past. Postoperative pain control is at the top of this list.

Please note that a child with a substantial developmental delay will often have social and interactive skills that are not consistent with their chronologic age. This often becomes apparent when one attempts to take a child with autism to the operating room. Ask the parents what they think will be the best approach; most have been through this many times. Some children will be perceived as having developmental delays, when, in reality, they have normal intelligence and a sophisticated, “adult-like” demeanor. Some of these children will do fine when separating from their parents. Many will not. It is common, for example, for kids with myelomeningocele to be able to keep it all together while you are talking to them, only to have them “go to pieces” when you get ready to take them back to the operating room. This is one of those behaviors that is so common that it should probably be expected. Remember that they are scared and that they have likely had fifteen operative procedures; some not very much fun.

Adolescence

What can we say about adolescents? Behind a dour demeanor, they are

frightened children. They have concerns about privacy and they are not aware yet that most health care providers don’t want to see them without clothes any more than they want to be seen. Privacy is extremely important, especially for girls and young women. As a practitioner, you will never do harm by being hypersensitive to these needs.

Teenagers fear having their bodies mutilated; having surgery identifies them as being different from others in their peer group. This need to conform cannot be overstated; it is the driving force for many of the behaviors that are manifested in adolescents. Reassurance that the surgical scars will be very small can allay some of their anxieties. When I am having preoperative discussions with an adolescent, to the best of my ability, I try to address myself directly to the patient in the company of the parent. This accomplishes two things. First, your patient feels respected and can interact directly if they want to, asking questions or making comments, and, second the parent is hearing the same thing that the child is so that they can often corroborate accurate information or refute inaccuracies. In the stress of the moment, everyone forgets information that may be critical but forgotten. It has been my experience that parents appreciate clinicians that appropriately treat their children with respect.

Adolescents with profound developmental delay present a significant clinical dénouement. Many are large and strong; some are very aggressive. The goal for these patients is to get them into the operating room without harm to themselves or anyone around them. Talk to the parents about past behaviors in similar circumstances. Ask questions about what has worked well? Formulate a plan in consultation with the parents. Give them assurance that you will protect their child. Do your best to give them a picture of a clinician that is knowledgeable and experienced. If the situation requires intramuscular ketamine, explain why this is the best approach. Again, everyone is important to his or her parents on most days.

Other Important Issues Relating to the Management of Children and Their Parents

1. Parents have a picture of their baby before it is even conceived. This vision of what their child will look like rarely includes imperfections and for many families that pediatric anesthesiologists take care of, the differences between reality and expectations are stark. Consider, if you will, a mom and dad that, perhaps, had trouble conceiving and now are faced with a child with a meningocele, a cleft lip, or heart disease. The reality of what this family faces is in contradistinction to the vision the parents had for months or perhaps for years.

This is important because parents go through a grieving process – denial, anger, bargaining, depression, and acceptance. They grieve for the child that they did not have. Occasionally, a physician is inserted into the family dynamic when parents are in denial or are angry. The negative aspects of the normal grieving process may shock the clinician that is trying to care for a sick newborn. Keep in mind the stress that the family feels and, despite the natural impulse to meet fire with fire, consider how you would feel in a similar circumstance. Forgiveness is grace. All healthcare providers must keep that in mind.

2. A child is a parent’s most prized possession. One should never take this for granted. No matter what they look like; no matter what the defect is more than 99% of parents are putting the most important thing in their lives in your care. Parents want to know that the person that they are giving

their child to is competent, careful, and experienced. Talk to parents about what will be done and what they should expect. Take time to play with their infant. Display your humanity. Answer all of their questions. It is much easier for parents to let go if they have a positive attitude about a negative situation.

3. Children that have had surgical procedures before are wary of you. The impact of chronic illness on a child transcends the physical. After a year of age, children begin to recognize the setting and remember what happened the last nine times. Be sensitive to the child’s medical and social history and with the parents. Premedication with an anxiolytic that potentiates amnesia for the event is likely the best management that can be provided. The corollary to this is that individual consideration should be given to every child and their circumstances. A single recipe for all children is a bad method for management.