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Pediatrics

Why children are complex patients

Kids are not just miniature adults. That’s a distinction that matters immensely in medicine.

Dawid Ryski for the Boston Globe

CHILDREN ARE NOT miniature adults — that’s an especially important distinction in medicine.

Their metabolic rates are higher, so if there’s an interruption in oxygen supply, they will turn blue, or get hypoxic, more quickly. With more skin surface in proportion to their weight, they lose body heat more quickly. Children require smaller equipment and more precise procedures, meaning the tiniest error can turn deadly.

Adding to all of that, children move through the medical system with an entourage of parents or guardians who also require education, support, and interaction from doctors, nurses, and other clinicians.

“Their physiology, their medical problems, their psychosocial development, is vastly different than we deal with [in] adults,” says Dr. Mark Waltzman, senior associate in medicine in the division of emergency medicine at Boston Children’s Hospital and chair of pediatrics at South Shore Hospital.

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The fact that kids are different than grownups hasn’t always been the prevailing view. Even after the founding of Boston Children’s and other hospitals specifically for children in the mid-19th century, it took generations to fully appreciate children’s distinct medical needs. Well into the late 20th century, for example, doctors believed newborns didn’t have the neurological networks to feel pain, when they actually have a long memory for it. A study of baby boys who had no local anesthetic during circumcision found they experienced more intense pain responses to later vaccinations.

Just this month, the federal Organ Procurement and Transplantation Network, which oversees transplants, launched new guidelines requiring pediatric training for doctors who perform transplants on children. “It’s a big deal,” says Laura O’Melia, director of transplant nursing at Boston Children’s, where transplants can include hearts, lungs, kidneys, intestines, and other organs.

Waltzman credits the change in thinking to groundbreakers like Dr. Helen Brooke Taussig, the former head of the pediatric cardiac clinic at Johns Hopkins, who developed treatments for infant congenital heart defects — “blue-baby” syndrome — in the 1940s and ’50s.

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“I like to romanticize that that’s how pediatrics really got its wings,” Waltzman says, “because there were a few really, really insightful people recognizing that children were not just little adults, and that . . . kids who were dying of some diseases didn’t have to die.”

The specifics of treating children begins with their physiology. How they react to medication is one example.

> Related: For more on Boston Children’s 150th anniversary, click here.

“In the adult world, when you go see your doctor, you’re going to get a standard dose of a medication,” Waltzman says. “We can’t do that in pediatrics because kids metabolize medications very, very differently.” A child’s smaller blood volume means that a specific dose of medication is going to have a much more profound effect on a young patient.

Children also store less glucose than adults, and their high metabolic rates burn through the glucose they do have more quickly. As a result, when children become dehydrated, they are quick to break down the fats and proteins in their bodies, causing their blood to become more acidic. Waltzman explains that this can lead to problems with their heart conduction — the system that causes the heart to contract and pump blood — and other organ systems.

Then there are the variables of age and development, says Dr. Christine Greco, associate chief of the hospital’s division of pain medicine. She treats children dealing with acute and chronic pain, resulting from something as common as a sports injury or as rare as a nerve condition. Her team’s research has found that chronic pain results in changes in children’s brain function.

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To treat chronic pain, Boston Children’s relies on what Greco calls a “bio-psycho-social” model that uses the plasticity of children’s developing brains to an advantage. It utilizes non-opioid analgesics at times and deploys the expertise of psychologists, physical therapists, occupational therapists, music therapists, and other experts. This rehabilitative approach has not only led to better pain control, Greco says, “but we have shown that some of these changes in brain function and brain circuitry can be improved.” To treat acute pain, the hospital uses regional nerve blocks and non-opioid medications. When opioids are needed, the hospital uses the least amount possible.

That brain plasticity may also be a factor in how children bounce back from anesthesia, says Dr. Mary Ellen McCann of the hospital’s department of anesthesiology, critical care, and pain medicine. She and her team study the effects of anesthesia on the developing brain.

After scientists found general anesthesia could create issues in the developing brains of infant lab animals, the US Food and Drug Administration issued a warning in 2016 that “repeated or lengthy use of general anesthetic and sedation drugs” in children younger than 3 could affect development. But McCann has found different evidence. She was one of the lead investigators in a multinational study that compared infants undergoing inguinal hernia surgery under general anesthetics to those who had regional blocks. They found no developmental differences by age 5 between the two groups. More research is needed, but the study showed that children exposed to general anesthesia of just under one hour in early infancy start school with no detectable disadvantages to children who did not have anesthesia in infancy.

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Dawid Ryski for the Boston Globe

TREATING CHILDREN GOES beyond the purely physical, however, to dealing with social, developmental, and psychological issues, and, of course, anxiety.

Patients are allowed to request music in the operating room, for example, which is why McCann might have heard the theme song from Frozen more than anyone on the planet. Children also can choose a scent for the anesthesia mask. A parent often can accompany a child into the operating room. In addition, clinicians have tools like the J-Tip, a needle-free device with a trigger lever that uses compressed air to deliver a small blast of local anesthetic under the skin before an IV line is inserted or blood is drawn.

Boston Children’s has also created a child life services department to help kids and families deal with undergoing medical procedures and recovering from them. That could include supporting families in the intensive care unit, calming a child through stitches, or arranging a birthday celebration for a long-term patient, says Brianna O’Connell, one of the department’s 62 certified child life specialists. She adds that specialists, who are also clinicians, have their own academic degree focused on child development, and in the United States must be certified by the Association of Child Life Professionals.

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O’Connell works with the other clinicians to eliminate as much trauma as possible from hospital experiences.

“We use behavioral distraction to get them through painful and scary procedures with the idea that, hopefully, they’ll need less sedation, less medication, and that afterward, they won’t be so traumatized by it,” she says.

O’Connell explains that they take an “ABCD” approach. It starts with “assorted visuals” such as flashing lights to distract infants, I Spy books for older children, and iPads or virtual reality for teens. The next step, “breathing techniques,” includes guided breathing or, for very young children, singing, which helps regulate breath. Then there are “comfort measures” such as warmed blankets, stuffed animals, and cradling a child rather than restraining them on an exam table. Finally, “diversionary talk” uses guided imagery or conversation, such as asking a teenager to describe his latest trip to the mall.

In some cases, children can visit the hospital in advance and walk through stations explaining what will happen both before and after surgery.

“A lot of what we do in child life is preparation, in terms of letting kids feel ready, and a lot of that is exposure to the actual materials,” O’Connell says. “Then, step by step, the rehearsal of that experience.”

Parents and guardians also get support. O’Connell is in charge of developing simulations to train parents, guardians, and other caretakers in the home to handle medical tools such as feeding tubes — training that has become more important as children are discharged from hospitals earlier. A theater set-design company created a way to turn an exam room into a homey bedroom where parents and caretakers can use a lifelike mannequin to practice changing dressings or hooking up a nutrition line — tasks they will need to do at home without supervision. “Over the cabinets and the sink goes what looks like a bookcase and an armoire,” O’Connell says. Staff can also roll out a carpet or bring in a crib or a twin-size bed.

“Ideally, if we’re doing our jobs well,” O’Connell says, “their muscle memory is going to kick in and their experience is going to kick in. It won’t feel so scary and stressful in that moment.”

It all seems to beg the question: Why don’t adults get more of these pain and anxiety-relieving measures? “We need adult life specialists,” O’Connell says. “Adults hate needles, too.”