After participating in last Thursday’s webinar, I can categorically state that, until this point, I had never been given any really useful, practical advice on how to manage the paediatric patient. Vet school never really delivered any significant information on this topic although, to be fair, this was many years ago for me. Perhaps training in paediatric medicine has now improved and hopefully goes beyond a clinical examination which involves the checking of a neonate for a cleft palate and umbilical hernia. This webinar, delivered by European Specialist in Small Animal Medicine Alenka Hrovat Vernik, offers an excellent insight into how to practically handle these vulnerable patients and states how imperative it is to remember that these paediatric patients cannot be treated as small adults, they are very much, in Alenka’s words, unique.
Attempting to assess the hydration status of a paedatric patient is a prime example of why we should not be assessing these patients as we would adults. Using all the techniques we use in an adult to assess their hydration status does not cross over into the world of paediatrics. Firstly assessing skin turgor on the neck of a neonate is ineffective as they have too much fat in this area and secondly the mucous membranes of neonates often remain moist until they are suffering from severe dehydration. A neonate’s urine concentration is also unreliable as they cannot concentrate their urine until they are 8 weeks old, and finally their PCV does not match that of the adult as this does not stabilise until, once again, they are 8 weeks old. Alenka advised the best way to assess the hydration of the paediatric patient is to check their skin turgor on their ventral abdomen as this is where they harbour very little fat plus check the colour of their abdomen which will often change from pink in the hydrated patient to a slightly grey appearance in the dehydrated patient. Their mucous membranes also becomes pale with a slow capillary refill time.
Once the paediatric patient’s hydration status has been assessed it may be necessary to administer fluid therapy which is again another key area where neonates and adults differ. Firstly we have to be able to place an intravenous catheter into our patient, which, in Alenka’s opinion, we often spend too much time attempting to do. Time is crucial in a sick neonate and sometimes these patients will crash if we spend too much time trying to place a catheter. Alenka advises to attempt access to the cephalic vein only once and if placement is unsuccessful then you should immediately move on to try the jugular vein. If this attempt fails Alenka advises it is important for us all to get a bit braver and start placing intraosseus cannulas to immediately provide the necessary treatments such as glucose and essential fluid therapy. It is likely that this intraosseus access will only need to be used for a few hours until the patient has improved significantly enough to allow intravenous access. After either intravenous or intraosseus access has been achieved then it is vital to remember that paediatric patients need significantly more fluids than adults with, for example, the maintenance fluid rate for paediatrics being 6mls/kg/hr in contrast to 2 mls/kg/hr in adults. Alenka also advises that she would only use intraperitoneal fluids if the patient needs to be warmed up and only administers subcutaneous fluids in paediatric patients with mild to moderate dehydration.
Differences between adults and paediatrc patients also exists in any laboratory data obtained from these patients. Alenka advises we should tolerate a mild anaemia and reticulocytosis in paediatric patients until they are 5-6 months old but we should not be tolerating a neutropaenia or thrombocytopaenia, as the neutrophils and platelets of a paediatric patient should mirror that of the adult from birth. Blood glucose levels should also be the same as that of the adult with a significant hypoglycaemia being defined as glucose levels measuring less than or equal to 2.2 mmol/l. However Alenka explains in the paediatric patient which presents as an emergency we should assume every one of these patients is hypoglycaemic as they are much less able to cope with stress and disease leading to much higher glucose consumption. Differences in renal and liver parameters were also discussed within the webinar with Alenka presenting a reference range table which she advises using for assessing all lab values from paediatric patients presented to us in practice.
A participating member stated at the end of this webinar that they wished they had been given this information on managing paediatric patients 30 years earlier when they started out in practice and I couldn’t agree more. The advice delivered by Alenka was practical and will prove invaluable for any future paediatric patients I encounter in practice. I have only really offered a few snippets of advice from Alenka within this blog and there is so much more information to take on board, so, be you 30 years in practice or a new graduate fresh out of vet school, this is a webinar that must not be missed.