Shapless, pliable ear

Edematous, thin skin 

Creases on anterior 3rd sole of foot 

Undescended testes

Gaping large majora

Hypotonic limbs

Weak gasp reflex

Complete but exhaustible Moro reflex 

Weak sucking reflex 

Present up to 4 to 5 of age 

spreading out the arms

unspreading the arms

crying 

birth weight doubles by 6 months

birth weight triples by 1 year

Length doubles by 4 years 

growth slows at 2 years 

Term infants lose 5-10% of their body weight during 1st 72 hours

Birth weight regained in 7-10 days 

Total body H20 decreases at the expense of ECF compartment 

Adult levels attained at 1 year of age

1 year= 10 kg 

3 years= 15 kg

5 years= 19

7 years= 23 

9 months head is 50% of adult size

2 years it 75%

2 years the upper jaw grows rapidly to accommodate teeth 

Failure of this forward growth= pierre robin, goldenhar treacher collins 

First tooth= 6 months

All baby teeth complete= 28 months

permanent teeth= 6 year---> grown by 12-14 

Perfuses low resistance placental circulation

40% of ventricular output goes to placenta 

5-10% goes to lungs 

Ductus contract first few days--> fibroses in 2-4 weeks 

foramen ovale closes in 1st few days--> may repoen in next 5 years

Avoid hypoxia and acidosis

First 24 hours= 120

1 month= 160 

Hyoxia, hypothermia, and laryngscopy cause bradycardia 

Limited blood volume 

80 ml/kg (full term)

Limited stroke volume 

Have high HR to maintain CO 

2-3X greater in neonates than in adults 

220-350 ml/kg 

reflects greater metabolic rate and O2 consumption 

PR & QRS intervals increase with age

At birth QRS right sided (RV intrauterine development)

1st month it moves leftward as LV muscle develops 

25% of adult levels at term

Adult levels by 2 years

impaired saline, H20 loads, and drug excretion 

Decreased tubular function: at risk for hyponatremia, osmotic polyuria, metabolic acidosis 

50-100% >/kg in children than adults

Live near limit of acid compensation.... prone to acidosis during acute illness 

Decreased GFR

Decreased concentrating capacity

Decreased Na Reabsorption

Decreased Bicarb

Decreased free H2O clearance 

Increased urinary loss of K and Cl

Albumin levels are adult values at birth but reduced in preterm infants

Drug metabolism less efficient (P450 50% adult values at birth)

Decreased serum proteins so decreased drug binding 

Prone to hypoglycemia 

inadequate glycogen stores

deficient gluconeogenesis 

Hypoglycemia

glucose < 45 mg/dl after 24 hours of birth 

Infants may not demonstrate symptoms of hypoglycemia could lead to irreversible CNS damage 

Jitteriness

Lethergy

Weak Suck

Temperature instability 

9-12 weeks

10-11 g/dl --> due to decrease in erythropoesis 

Stabalizes at 3rd month--> 11-12 g/dl

At birth 70-90% of Hgb is HgbF 

Within 3 months HgbF is 5% 

Hgb drops over 3 months as circulating volume increases more rapidly than bone marrow function

Despite reduced hemoglobin, 02 delivery not compromised as O2/ hemoglobin dissociation curve is shifted to the right--> more delivery 

Vitamin K, II, VII, IX, X (20-60% of adult values)

Prolonged PT

Immature liver

All neonates should recieve prophylactic Vitamin K to prevent hemorrhagic disease 

nervous system anatomy complete at birth

Functional myelination not complete until 7 years old 

Preterm infants should be assessed in terms on conceptual age 

cerebral autoregulation is present and functional from birth

perinatal ischemic stroke 

white matter disorder

intrauterine inflammation 

Cerebral vessels are thin walled and fragile

Prone to intraventricular hemorrhages

Risk increased with hypoxia, hypercarbia, hypermatremia, low Hct, awake airway manipulations, rapid bicarbonate administration and fluctations in BP and cerebral blood flow 

Birth extends to L3

1 year old, ends at L1, permanent position 

Tendency to ignore the need for analgesia in infants and small children

Neonates including those born prematurely, may have INCREASED sensitivity to pain

Infants who have inadequate analgesia may experience an increase sensitivity to pain as older children 

Caused by retinal vessel proliferation and retinal detachment

Leading cause of blindness 

Common among neonates weighing < 1500 g

Cause by increase O2 tension in retinal arteries

Safe PO2 level now considered 50-70 mmHg  

Hypoxia

Hyper/hypocarbia

Blood tranfusion

exposure to light

recurrent sepsis 

Large surface area to weight ratio with minimal subQ fat and less brown fat

Poorly developed shivering, sweating, and vasoconstrictive mechansims 

Cognitive Development

Attachment

Separation

Temperment 

Pre-logical explanation= magical thinking

to

Concrete Logical= contamination (eating bad food)

to

Formal- logical= physiologic causes of illness 

Most stressful for infants, toddlers, and pre-school children

< 10 months= tolerate short periods of separation

11 months- 6 years= cling to their parents

> 6 years= accept brief periods of separation (use to school) 

Deal better with stress of brief separation

Use caregivers as a secure, stable base 

Distressed by unfamiliar situations (pre-op area) even in the prescence of their caregivers 

After brief separation exhibit anger, distress, and avoid physical contact

Emotionality, activity, reactivity, and sociability

Ease at which infant becomes aroused or anxious

energy or intensity of behavior

tendency to avoid or approach strangers 

Ages 1-5 at greatest risk of extreme anxiety (Peaks at 1 year*)

Previous procedures

Trait Anxiety- shy, inhibited, lack social adapative abilities 

Parental Behaviors- anxious parents increase anxiety risk of chid 

Facilitate coping skills and adjustments of children and parents

Reduce anxiety during the pre-op period only 

Use play experiences, puppet shows, role rehersal using dolls, DVDs

Negative effect on < 3 y.o

6 y.o benefit program 5 days before surgery- need time to process (more anxiety if just 1 day before surgery)

3-6 y.o increased ability to distinguish fantasy from reality 

Evidence does not support routine use of PPIA 

May disrupt OR routine, sterility, or refuse to leave child

Parents become anxious seeing child flaccid or going thru stage 2

Parents may cause excessive reassurance, commands, criticism--> need adequate prepartion (Must be informed) 

Privilege not a Right!

Pre-med + PPIA= less anxiety for the parent

Pre-med + PPIA= no further reduction in anxiety for the child 

Children recieving pre-med are less anxious and more compliant than those who are accompanied to the OR by the parent 

Nonpurposeful restlessness, agitation, thrashing, crying, moaning and disorientation.

Up to 18% of children develop this

Age (2-5)

Previous Surgery

Type of Procedure (eyes, BMT, tonils & adenoids)

Type of Anesthesia (less with propofol) 

Children < 3 years are greater risk of aspiration

 majority occurs during induction of children***

13% on emergence vs 30% in adults 

2 hrs= clears

4 hrs= breast milk

6 hrs= formula

8 hrs= extremely large meal or high fat intake 

1/2 life empty clears from stomach is 15 mins

98% will be empty in 1 hr

water, fruit juice NO PULP, carbonated beverages, clear tea, black coffee 

Do no encourage

risk of hypoglycemia, poor child cooperation, hypotension on induction 

Have child spit gum out

Continue with elective surgery--> no clear evidence that this increases aspiration risk

Decreased competence of LES

Air swallowng during crying

Diaphragmatic breathing

Shorter esophagus 

Children are more likely to have asthma, otitis media, hav fever, dental caries

Strong association between airway complications on induction and emergence 

Inadequate preparation of child and family may lead to traumatic indunction and post-op pyschological disturbances

Need to tell about BP cuff, EKG leads, Precordial stethoscope, pulse ox, CO2 monitor, IV post induction 

Give parents and child ample time for questions 

Married

in the military

economically independent

** deserve complete confidentiality**

max stress for parents

not old enough to be frightened by strangers

Maximum fear of separtion ***

Significant post-op emotional upset and behavioral regression

Begins magical thinking 

Concerned about body integrity***

Begins to understand explanations

Fear of separations remains 

May interpret everything literally ***

Tolerates seperation well

Understand explanations

Fear of not waking up at all 

Issues reguarding self-esteem and body image**

Developing sexuality so fear loss of dignity**

Fear of unknown 

Independent 

Delay in developmental socialization and communication skills

onset before 3 years

Doesnt respond well to changes in routine

Sensitive to light, sound, touch, and pain

Decision to pre-med (ketamine vs versed) made on individual basis 

Highly benefit from PPIA 

Purulent URI with fever, wheezing, rales--> postpone elective surgery for 4 weeks***

Most kids have a runny nose all year long so use good judgement

Tailor anesthetic to decrease risk--> LMA/Mask, Propofol

Bronchospasm risk increase 10 fold in children with URI***

Formerly premature infants must remain overnight if their post-op conceptual age (gestational age + chronological age) is < 50 weeks 

Risk of post op apnea and bradycarida is high! 

Anticonvulsants should NOT be withheld the day of surgery

Children receiving Depakote (valporic acid) should have documented LFTs in the past 6 months 

Macroglossia, Narrowed Cricoid Cartilage, and greater frequency of airway obstruction

Often resistant to sedative premedication

Risk of suluxation of atlanto- occipital joint and

subsequent spinal cord injury with neck flexion 

Weakness and parathesias of upper extremities should be sought, routine C-spine NOT necessary 

Resistance to pre-med

Cardiovascular instability

Lower seizure threshold

Increased PONV 

Most increase catecholamines

Methylphenidate (Ritalin)

Dexamphetamine (Dexedrin)

Bupropion (Wellbutrin)

Atomoxetine (Strattera) 

Child should always be 1st case in morning

1/2 total morning dose of insulin for out-patient surgery

IV- D5LR, monitor hourly glucose

Major surgery admited the night before- insulin and glucose drips 

Appropraite to inform ONLY adolescent

Careful not to disclose pregnancy while explaining postponement of surgery

parents have NO legal right to information 

Address acceptable tranfusion therapy with family/parents/patient

In emergencies the child should be protected by transfusing blood without a court ***