tations can be frank breech (legs are at the fetal face with

the buttocks presenting), complete breech (the buttocks

are presenting, but the fetal hips and knees are flexed), or

incomplete or footling breech (one leg is the presenting

part). Breech presentation is dangerous because the buttocks and legs do not fully dilate the cervix. The fetal head

can become caught in the birth canal during delivery.

Likewise, the cervical opening is not completely occluded

by the buttocks, so cord prolapse can occur.

DISPOSITION

All mothers should be admitted to a postpartum unit, and

the infant should be admitted to a neonatal nursery.

SUGGESTED READING

Lazebnik N, Lazebnik RS. The role of ultrasound in pregnancyrelated emergencies. Radial Clin North Am. 2004;42:315-327.

Stallard TC, Burns B. Emergency delivery and perimortem

C-section. Emerg Med Clin North Am. 2003;2 1 :679-693.

VanRooyen MJ, Scott JA. Emergency delivery. In: Tintinalli JE,

Stapczynski JS, Ma OJ, Clince DM, Cydulka, RK, Meckler GD.

Tintinalli's Emergency Medicine: A Comprehensive Study Guide.

7th ed. New York, NY: McGraw-Hill, 20l l, pp. 703-71 1 .

The Pediatric Patient

joseph Walli ne, MD

Katrina R. Wade, MD

Key Points

• Inherent differences exist between pediatric and adult

patients.

• Physicians have to treat both the parent and the child.

INTRODUCTION

Infants, children, and adolescents constitute approximately

a third of all visits to emergency departments (EDs) in the

United States. Of these pediatric visits, more than half are

for urgent/nonemergent problems such as otitis media,

respiratory and gastrointestinal infections (often viral),

asthma, fractures, sprains, soft tissue trauma, and minor

head trauma. The challenge of pediatric emergency

medicine is to prevent mortality or increased morbidity by

catching the few cases that need hospital admission or

emergent intervention and ensuring proper discharge of

less ill patients.

Children are considered minors up to their 1 8th birthday. Although no consent is needed for life-saving interventions, minors require their parent's or guardian's

consent for routine medical care and discharge. An exception to this rule is the emancipated minor. "Emancipated

minor" status allows a person less than 18 years of age to

consent for medical care without parental knowledge, consent, or liability. The exact legal terms of what makes a

minor "emancipated" varies slightly from state to state, but

generally includes one or more of the following: marriage

(including becoming divorced, separated, or widowed),

membership in the armed forces, becoming pregnant or

having children, living separately from parent(s) or

guardian(s), or, finally, demonstrating the ability to manage one's own financial affairs. Of the preceding criteria,

discovering a patient is pregnant is the most common

• The older the chi ld, the more reliable the clinical

impression.

• Disposition can be affected by unique family situations.

situation the authors' have encountered that leads to

emancipated minor status.

Another important legal issue for clinicians working

with children is our role as mandated reporters. We have a

duty to protect vulnerable young patients. If there is

reasonable cause to suspect that a child has been abused,

neglected, or placed in imminent risk of serious harm, we

are obligated to involve government agents such as child

protective services, police, etc.

There are many aspects of clinical pediatric emergency

medicine that differ from adult emergency medicine

practice. Not only must you vary your approach to each

patient based on their anatomic, physiologic, and

developmental status, you also have to establish an effective relationship with the patient and his or her caregiver.

In other words, physicians have to treat both the parent

and the child. We review some of these differences later in

this chapter.

CLINICAL PRESENTATION

..... History

Obtain as much information as possible from the child.

Questions should be direct and stated in terms the child

can understand. Further details and clarifications should

be sought from the parents, guardians, or caregivers. The

younger the child, the greater reliance on history obtained

from the parents, and the more the history may be

1 96

THE PEDIATRIC PATIENT

Table 47-1. Average quantity of feedings based on age.

Age

1-2 weeks

3 weeks-2 months

2-3 months

3-4 months

5-12 months

Volume/Feeding (every 3-4 hrs)

2-3 oz

4-5 oz

5-6 oz

6-7 oz

7-8 oz

influenced by the parent(s)' perception of symptoms.

When taking the history, children can become anxious

when separated from parents. Separate children from

parents only when absolutely necessary ( eg, in the case of

an adolescent patient when a sexual and/or illicit drug

history needs to be obtained) or in a younger patient

when abuse or neglect is suspected. Unusual complaints

such as weight loss, night sweats, headaches, or back pain

in a small child should prompt concern for more indolent

or life-threatening underlying pathology, particularly

malignancy.

Important historical information needed in all

pediatric patients includes birth history, immunizations,

prior medical problems, medications, allergies, develop ­

mental milestones,