Pediatric Infusion Therapy

Wendi S. Redfern

Jeanne E. Braby

INFUSION THERAPY IN INFANTS AND CHILDREN

This chapter focuses on aspects of infusion therapy specific to neonatal and pediatric patients. It highlights developmental considerations, disorders, and disease processes unique to this population, intravenous (IV) therapies commonly used in children and adolescents, and necessary adaptations and adjustments to vascular access techniques and devices for the neonatal and pediatric population. Two ongoing considerations in the administration of pediatric infusion therapy are emotional preparation of the child and initiation of vascular access. This chapter examines these topics in detail, along with special nursing considerations and specific intravascular therapeutic modalities.

PSYCHOSOCIAL STAGES OF DEVELOPMENT

Children are not small adults. An area of concern is the child’s emotional needs, which require patience, education, and understanding from infusion nurses. Psychosocial age and ability, as well as each child’s particular developmental stage, exert major influences on emotional needs. When hospitalized, some children regress and exhibit behaviors more common in a younger age group (e.g., a child who is toilet trained may regress to
the diaper stage). These children resume developmental landmarks once treatment ends or the child’s condition stabilizes. Thus, even though children of varied ages and intellectual capacities receive similar infusion therapies, they require education before, during, and after infusion therapy that considers their particular emotional and developmental variables.

Developmental Stages

A full understanding of each developmental stage enables the health care team to provide individualized care that focuses on each child’s physical functioning and emotional coping skills. This level of care is appropriate and nonthreatening. It enhances the ability of staff to recognize that a child’s needs vary markedly, according to stress levels as well as by growth and developmental levels.

A significant difference between children and adults is in the preparation for the procedure. A developmentally tailored approach is essential when working with children. Table 21-1 reviews growth, development, and useful approaches when working with children of different developmental stages.

This chapter cannot cover all the principles and theories of growth and development. Instead, important principles are highlighted. Erikson is credited with the development of
the most widely accepted theory of personality development (Erikson, 1963). Each stage has two components, the desirable and undesirable aspect (Table 21-2). There are five stages that relate to childhood: trust versus mistrust, autonomy versus shame and doubt, initiative versus guilt, industry versus inferiority, and identity versus role confusion. Successful completion of each stage is ideal. Hospitalization can cause children to regress to an earlier stage. Parents need to know that this is a normal response.

TABLE 21-1 GROWTH AND DEVELOPMENT: INTRAVENOUS INSERTION STRATEGIES FOR PEDIATRIC PATIENTS

Age	Growth	Development	IV Tips
Infancy (birth to 12 mo) (includes neonatal period from birth to 28 d)	Rapid Maturation of body systems Birth weight doubles at 6 mo/triples by 1 y	Social affective play Attachment to caregivers Separation anxiety begins at approximately age 6 mo.	Do not feed the baby before IV placement or aspiration may occur. Provide comfort during and after the procedure, using a pacifier and distraction, such as a mobile.
Toddler (12-36 mo)	Weight gain slows Birth weight quadruples by 30 mo Height at 3 is half adult height Head circumference growth slows Chest circumference larger than the head/abdomen	Cause-and-effect thinking Exploratory phase Imaginative play	Require short, concrete explanations immediately before treatment Give simple choices Assistant required for positioning
Preschool/early childhood (36 mo to 6 y)	Growth stabilizes Annual weight gain is 2.2 kg (5 lb) Height increase ranges from 6.4-7.6 cm (2.5-3 inches) Most growth in legs	New gross motor skills Fantasy vs. reality Follows simple commands Fear blood loss/invasive procedures	Need preparation before procedure Distracted with age-appropriate toys Play therapy with medical toys May need help to hold the child still
School-age (6-12 y)	Growth/development gradual Annual weight gain is 2-3 kg (4.5-6.5 lb) Height increase is 5 cm annually (2 inch)	Solitary, interactive play Superhero fascination Fantasy about procedures based on the level of understanding	Can be told about IV a short time in advance Allow to assist with tasks like tearing tape and counting I/O Allow for privacy Allow the child to cry
Adolescence		Logic, reasoning, and concept of permanence Develop skills Dramatize Identify role models	Approach using adult terms Prepare teens in advance, allowing them to participate in care
Early (11-13)	Little size difference between sexes Growth spurt at the end of early stage	Seek independence Peers are important
Middle (13-15)	Girls surpass boys in height and weight; then boys surpass girls	Sexual identify and body image Mortality is a concern
Late (15+)	Body proportions similar to adult parameters	Career planning High idealism Favor close, intimate relationships Seek significant other

THE NEWBORN AND INFANT

The newborn stage is from birth to 28 days, while the infant stage is from 29 days to 12 months. For the purpose of this review, the neonate and premature infant will be included in the infant stage. Unique considerations will be delineated when necessary. Neonates, and in particular low birth weight and premature infants, have a low tolerance for physiologic stress, including changes in environmental temperature, bright lights, and loud noises. When performing a procedure, it is important to keep those factors in mind. Temperature regulation becomes more efficient as the infant matures.

TABLE 21-2 ERIKSON’S STAGES OF PSYCHOSOCIAL DEVELOPMENT: INFANCY TO 18 YEARS

Stage	Basic Conflict	Important Events	Outcome
Infancy (birth to 18 mo)	Trust vs. mistrust	Feeding	Reliable, affectionate care instills a sense of trust
Early Childhood (2-3 y)	Autonomy vs. shame/doubt	Toilet training	Control over physical skills and a sense of independence lead to feelings of autonomy
Preschool (3-5 y)	Initiative vs. guilt	Exploration	A sense of purpose is created when children assert control and power over their environments
School-Age (6-11 y)	Industry vs. inferiority	School	New social and academic demands require new coping skills; success ensures competence
Adolescence (12-18 y)	Identity vs. role confusion	Social relationships	Teens need to develop a sense of self and personal identity. Success leads to an ability to remain true to oneself

While a pacifier is useful to comfort an infant, it is essential to be mindful of the infant’s breathing and assure that the nares remain patent. In some cases, it may be necessary to stop a procedure to suction the infant and ensure that the infant is able to breathe comfortably and effectively. Lengthy procedures may also require that the procedure be halted; allowing the infant to recover from physiological stress.

The psychosocial need of the infant is to begin to develop trust. The infant learns trust when his or her primary needs are met. Along with the basic need of nourishment, the infant needs to feel secure. Caregivers can help the infants feel secure by quickly responding to their cries, talking to them in a soft, soothing voice, keeping them warm and dry, and provide comfort during holding whenever possible.

Communication with the infant depends on his or her developmental age. Younger infants usually respond best to a soft soothing voice prior to and during procedures. As the infant grows, developing trust may mean playing a game of “peek-a-boo” to begin establishing rapport.

Crib side rails should always remain up unless a caregiver physically has a hand on the infant. By 4 to 5 months of age, infants begin to put things in their mouths; therefore, safe care dictates keeping all small objects out of reach.

In addition, all infants under 1 year of age should be in a safe sleep environment. The components of safe sleep are a firm mattress and no toys or loose blankets in the crib (Flook & Vincze, 2012). Band-aids or adhesive dressings that could be “chewed off” are considered a choking hazard and should be avoided. By 4 to 8 months, infants may begin to exhibit “stranger anxiety.” Postprocedure, infants should be cuddled and allowed to play.

THE TODDLER

The toddler stage is from 1 to 3 years of age. Toddlers are beginning to use and develop language. Although they have a short attention span, toddlers are able to understand simple directions. The toddler’s psychosocial developmental task is developing autonomy. They should be allowed choices when possible. Pain should be assessed and managed using toddler language (hurt, owie, boo-boo). Toddlers often have a favorite toy, blanket, or sleep friend. Parents should be encouraged to remain with their toddler.

The toddler should be given age-appropriate information just prior to any procedure. Communication should be done by speaking slowly and using short simple explanations. Directions should be given one at a time. It is important to use words the toddler understands to describe what the toddler will see, hear, and smell. Dolls and toys to demonstrate the medical equipment will aid in the toddler’s ability to understand. For example, the toddler can first be shown how the doll will get an IV. Similar to the infant, it is important to keep small objects out of reach and not leave the toddler unsupervised.

THE PRESCHOOLER

The preschool stage is from 3 to 6 years, and at this phase of psychosocial development, the child’s task is to develop initiative. The preschool child should be offered reasonable choices (e.g., site for injection) to help foster independence and a sense of control. They are starting to socialize with groups. They fear being left alone and bodily harm. Preschool-aged children need clear rules and boundaries to develop their sense of security. By this stage, the preschool child has physically improved coordination, balance, and muscular strength.

An infusion therapy-teaching tool with pictures and large-print words in simple language can help preschoolers understand the procedure. Distraction using age-appropriate toys is an effective intervention. These items can include a Slinky, a clear sealed acrylic “magic wand” with floating sparkles, a kaleidoscope, and a bottle of bubbles for blowing. Medical play therapy, consisting of practicing IV therapy on a doll, is an ideal teaching strategy that enhances emotional preparation through acting out.

Similar to the toddler, explanations should be honest using terms of sensation (i.e., feel, hear, see, or smell). Usually, it is best to tell the child that the venipuncture will hurt but only for a short time. Define the term “time” by comparison with other procedures. For example, say, “The actual IV start takes about the same time it takes you to say the alphabet or count to 50.” It is important to assure the child that any procedure is not a punishment. Rewards such as stickers, given for cooperation, are well received.

THE SCHOOL-AGE CHILD

The school-age child (6 to 12 years) is physically maturing at a fast rate, although, emotional and social maturity does not always occur at the same rate. This is the stage of competence; the psychosocial task of the school-age child is developing industry. They are able to take on responsibilities, including home chores and schoolwork. School-agers have
increased attention spans and are eager learners. The school-age child understands cause and effect and logical reasoning. They are able to describe pain and continue to fear bodily harm. The school-ager desires privacy and enjoys a sense of control. Allow children to participate by tearing tape, opening alcohol swabs, or holding tubing. Family is still very important, but they may begin to prefer friends.

Explanations about procedures should be in language the school-ager understands. Written instructions are also an option. The child should be encouraged to ask questions and talk about his or her feelings. School-agers can handle longer teaching sessions and respond well to praise. Rewards are useful in recognizing their achievements. They also need to be reassured that procedures are not punishments. Behavior limits may need reinforcement. Parents need to be included in decisions, but the school-age child should be given opportunities for decision making.

THE 12- TO 18-YEAR-OLDS

The psychosocial task for the 12- to 18-year-olds is the development of identity. The adolescent is struggling to obtain a sense of self. They are preoccupied with their body appearance and the need to fit in with their peers. Separation from their peers can be difficult. They may have wide mood swings, and risk-taking behavior is common. The adolescent may challenge authority but still need adult support. Their rapid growth spurts may cause them to be easily fatigued, and their sleep patterns may change.

The appropriate approach for the adolescent is similar to that of the adult. Procedures should be explained and instructions given in writing. They should be encouraged to ask questions and talk about their feelings. Keep privacy as a priority during procedures and recognize concerns about body image. Decision making and involvement in self-care are essential for the adolescent.

DEVELOPMENT APPROACH FOR ALL AGES

Always be honest with children. Specifically, do not promise a certain number of IV attempts or “only one stick” because a child will lose trust if several attempts turn out to be necessary. Language used is important. Nurses may be able to assuage a child’s fear of needles by telling the child that once the IV is in place, the needle is no longer there and only a small “straw” is in the vein.

Safety is always the primary concern for all hospitalized children. Their hospital bed should remain a safe place (Hockenberry et al., 2011). Invasive procedures should be performed in a treatment room whenever possible, and parents should be encouraged to stay with their child.

Parents are often permitted around-the-clock visiting hours to stay with their hospitalized children, even in neonatal and pediatric intensive care units. For ill children, this can be comforting and provides an emotional support system. Frey, Ersch, Bernet, and Baenziger (2009)
suggested that parents who stay with their hospitalized children are inevitably involved in safety issues and may help detect critical (harmful or potentially harmful) events precipitated by health care professionals.

During the procedure, parents/caregivers may provide emotional support and represent security during an actual procedure, but they should not be used to restrain a child unless no other assistance is available (i.e., in-home care). Parents/caregivers can be instructed to use positioning for comfort techniques to hold a child still for venipuncture while still helping a child feel secure (Sparks, Setlik, & Luhman, 2007; Figure 21-1).

If a parent chooses not to accompany a child into the treatment room for IV insertion, the infusion nurse should honor this decision and not make parents feel guilty. Providing comfort and praise after the IV insertion is an ideal means of parental involvement.

Knowledge of the expected developmental stage is important; however, the health care team must remember to assess each child individually, not just according to age or physiologic maturity. In some cases, children have disease processes, such as renal disease, that can result in growth delays, causing staff to mistake the child’s actual age. When teaching parents and children, it is best to ask, “What questions do you have?” as opposed to asking, “Do you have any questions?” This simple change in wording gives the learner permission to ask questions of the health care team without feeling intimidated. Child and family education is addressed in Box 21-1.

FIGURE 21-1 Positioning for comfort prior to venipuncture. (Courtesy of A. M. Frey.)

Pain Assessment and Reduction

Studies indicate that infants and children respond to noxious stimuli and experience pain (Leahy et al., 2008; Walco, 2008; Walden & Gibbins, 2008; Zempsky, 2008a, 2008b). In one study, pediatric inpatients reported IV line placement as the leading cause of procedure-related pain, on the same level of pain as postsurgical pain (Cummings, Reid, Finley, McGrath, & Ritchie, 1996). The memory of previous painful events, including venipuncture, can have both psychological and physiological impact on later painful episodes (Leahy et al., 2008). Evidence suggests that repeated painful procedures may have cumulative effects on the developing brain (Walden & Gibbins, 2008).

Assessment of pain in children requires the use of different pain scales (Jacob, 2009). Self-report is the most reliable indicator of pain; however, this is not possible in the preverbal child. Behavioral observations are used in some neonatal and pediatric pain scale tools. The FLACC Pain Assessment Tool is an example of a behavioral tool comprised of an interval scale that measures pain from 0 (no pain behaviors) to 10 (highest pain behaviors). The behaviors observed using the FLACC scale are: Facial expression, Leg movement, Activity, Cry, and Consolability (Table 21-3).

There are also pain scales that evaluate the neonate using physiologic indicators along with behaviors. The premature infant pain profile (PIPP) scale is used for infants 28 to 40 weeks of gestational age. The variables assessed are gestational age, eye squeeze, behavioral state, nasolabial furrow, heart rate, oxygen saturation, and brow bulge (Jacob, 2009) (Table 21-4).

Everyone who starts IVs in children should be knowledgeable in techniques to maximize comfort and minimize pain. An easy acronym to remember these techniques is BSPECLD (Table 21-5). Buffered lidocaine can be administered intradermally or with needleless injection. This can be very effective in reducing the pain from a needlestick.

Sucrose has been very effective in reducing pain response in infants during invasive procedures. The sucrose is administered orally or via a syringe at least 2 minutes prior to the procedure, preferably with a pacifier since nonnutritive sucking has been shown to be a nonpharmacological pain-relieving method (Cohen, 2008).

Pain Ease is a vapocoolant (topical skin refrigerant) with rapid onset (Farion, Splinter, Newhook, Gaboury, & Splinter, 2008). Spray continuously for 4 to 7 seconds from a distance of 3 to 7 inches, or a cotton ball can be saturated and held over the site for 4 to 7 seconds. Avoid using vapocoolant on patients with poor circulation, on children < 4 years old, or on broken skin.

Frequently, topical anesthetic creams are a choice in the pediatric population. EMLA is a topical anesthetic made of lidocaine 2.5% and prilocaine 2.5%. It requires a minimum of 60 minutes to provide effective pain relief. Liposomal lidocaine LMX4 is another topical anesthetic cream containing 4% lidocaine. The onset of action is quicker than that of EMLA
(30 minutes). Both creams may be associated with the development of methemoglobinemia in susceptible children, particularly in young infants (Zempsky, 2008a, 2008b). Table 21-6 provides a summary of some medications for pain reduction.

TABLE 21-3 FLACC PAIN SCALE

	Scoring
Category	0	1	2
Face	No particular expression or smile	Occasional frown, withdrawn	Frequent to constant quivering chin, clenched jaw
Legs	Normal or relaxes	Uneasy, restless, tense	Kicking, or legs drawn up on the abdomen
Activity	Lying quietly, normal position, moves easily	Squirming, shifting, tense	Arched, rigid, or jerking
Cry	No cry (awake or asleep)	Moans or whimpers	Crying steadily, screams, or sobs
Consolability	Content, relaxed	Reassured by occasional touching, hugging, or being talked to	Difficult to console or comfort

Distraction can be one of the greatest skills to develop for use in pediatric care for nonpharmacologic pain control (Cohen, 2008). Have the child blow bubbles or take a deep
breath when you puncture the vein to “blow the hurt away.” Counting and singing are other good distractors for a preschool or school-age child. Tell them to sing or count louder if they have any pain. For the older child, distraction may include asking about school, teachers, pets, and favorite places.

TABLE 21-4 PIPP PAIN ASSESSMENT TOOL

Observe	Indicator	0	1	2	3	Score
Chart	Gestational	>36 wk	32-35 wk, 6 d	28-31 wk, 6 d	<28 wk
15 s	Behavior	Active, awake, eyes open, facial movement	Quiet, awake, eyes open, no facial movement	Active sleep, eyes closed, facial movement	Quiet sleep, eyes closed, no facial movement
Baseline heart rate and oxygen saturations for 30 s	Heart rate maximum Oxygen saturation minimum	0 beats/min increase 92%-100%	5-15 beats/min increase 89%-91%	15-24 beats/min increase 85%-88%	25 beats/min increase <85%
Facial actions for 30 s	Brow bulge Eye squeeze Nasolabial furrow	None None None	Minimum Minimum Minimum	Moderate Moderate Moderate	Maximum Maximum Maximum
Evaluation of pain
Score 0-6 No action
Score 7-12 Nonpharmacological intervention, for example, swaddling, sucking (reassess in 30 min)
Score > 12 Pharmacological intervention (reassess in 15-30 min)

TABLE 21-5 BSPECLD TECHNIQUES

B	Buffered lidocaine
S	Sucrose
P	Pain ease
E	EMLA
C	Child life
L	Liposomal lidocaine LMX
D	Distraction

Guided imagery can also be helpful to reduce the anxiety and pain associated with IV insertion. Guided imagery encourages children to employ pleasant imagery as a distraction to pain. The child is encouraged to describe the details of the pleasant experience using different senses (e.g., see, hear, and feel). Instruct the child to concentrate on the pleasurable event. Guided imagery when combined with other nonpharmacologic techniques such as relaxation and deep breathing can be an effective approach to pain reduction (Phipps et al., 2010). Other techniques include rocking/holding, reduced light, swaddling/nesting, touch/massage, and positioning for comfort.

Nurses can become proficient in the use of nonpharmacological pain techniques or they may seek assistance from a certified child life specialist, a professional who has studied child development and the reactions of children to health care settings (Leahy et al., 2008). The child life specialist is available to help the child’s fear and anxiety by helping them understand and cope with the hospital stay through preparation, support, and play.

A combination of age-appropriate pharmacological and nonpharmacological pain techniques used with children prior to IV insertion helps to maximize comfort and minimize pain. In some cases, IV conscious sedation may be necessary to provide a more generalized sedation for insertion of a peripherally inserted central catheter (PICC).

TABLE 21-6 NUMBING AGENTS

Product	Method
EMLA cream (topical)	Place on the potential insertion site and cover with transparent dressing >1 h before procedure.
LMS-4 cream (topical)	Place on the potential insertion site 30 min or more before procedure. May cover with transparent dressing to avoid disturbance or ingestion by a child
Lidocaine hydrochloride 0.5%, 1% without epinephrine (intradermal) or needless injection device	Create an intradermal wheal 0.05-0.1 mL near the insertion site with a 26- or 29-gauge insulin needle.

PHYSIOLOGIC STAGES OF DEVELOPMENT

Physiologic Considerations

Human beings change both physically and emotionally throughout childhood, whereas parameter characteristics remain relatively constant after adulthood. For example, body circumference increases more than threefold in length and approximately 20-fold in weight from birth through adolescence (Hesselgrave, 2009). The body circumference of the adult, however, changes relatively little throughout the remainder of life. Thus, the stress levels and basal metabolic rates of the child are much higher than in an adult patient.

In the premature baby and term infant, renal function is immature, with inability to concentrate and excrete effectively, acidify urine, or maintain fluid and sodium balance. In the term infant, renal immaturity results in excretion of larger volumes of solute-free water than is seen in older pediatric patients (Blayney, 2013) by the end of the 2nd year, renal function reaches full maturity.

The immature hepatic system in the neonate and infant can affect intravenous medication and/or solution administration. Throughout the first year of life, the liver function remains immature. Digestive and metabolic processes are usually complete by the beginning of toddlerhood (Wilson, 2009).

THE SKIN

Skin color, turgor, temperature, moisture, and texture all reflect the child’s state of hydration and nutrition. Knowledge of the condition of the integumentary system particularly that of premature infants, is of extreme importance to the infusion specialist. The skin of the premature infant requires special precautions due to underdevelopment of the stratum corneum, with resultant thin, fragile skin. This dermal fragility can lead to dermal stripping, loss of water, and increased absorption and possible toxicity of agents, such as solvents and bonding agents that are applied to the skin. Neonatal skin care is a special skill. Because there is less cohesion between the dermis and epidermis, tape removal can strip epidermis, so as little tape as possible and tape padded with gauze or cotton fibers is used.

For skin disinfection in premature neonates, the Association of Women’s Health, Obstetric and Neonatal Nurses (AWOHNN) (Beauman & Swanson, 2006) recommends using chlorhexidine or povidone iodine and allowing it to dry, removing these products with sterile water or saline after the procedure is complete to avoid the risk of chemical burns. Evidence is currently inconclusive for chlorhexidine use in low birth weight infants. The use of isopropyl alcohol and alcohol-based disinfectants should be avoided in preterm infants. Except for specific congenital or acquired skin conditions, such as dystrophic epidermolysis bullosa, eczema, and other disorders, the barrier function of the integumentary system of the full-term neonate and older child is intact.

FONTANELS

The infant’s anterior fontanel remains open until the child is nearly 2 years of age. This provides an additional tool by which to assess hydration. The anterior fontanel is either completely flat or slightly sunken in a normal state. It is depressed in fluid deficit and bulging with increased pressure indicative of cerebral edema, hemorrhage, or fluid volume excess.

URINARY OUTPUT

Accurate measurements allow the practitioner to manage fluid balance. Fluid restriction or deficit is reflected by a high specific gravity; a low measurement reflects fluid retention or overload. If the child is in diapers, the weight of the dry diaper is subtracted from that of the wet diaper; the weight in grams equals the volume voided in milliliters.

HYPOGLYCEMIA

There are multiple etiologies of hypoglycemia in infants; however, hyperinsulinemia is often the cause of persistent hypoglycemia in the neonate (Fraser Askin, 2009). Other causes include abrupt discontinuation of IV dextrose solutions and high glucose demand that is not met, such as in a septic infant. Infants and children who are hypoglycemic display blood glucose levels of <45 mg/dL, have poor oral intake, and exhibit neurologic symptoms, such as lethargy, hypotonia, tremors or twitching, irritability, and eye rolling (Fraser Askin, 2009). An older child may complain of headache or display hallucinations or mental confusion. The mechanisms of hypoglycemia remain incompletely understood. Treatment involves oral or IV glucose, depending on the severity of the hypoglycemia.

THERMOREGULATION

Thermoregulation, the maintenance of normal body temperature, is a challenge to the premature neonate owing to large surface area, dermal immaturity, and thin layer of subcutaneous fat. Physiologic stress and increased metabolism, in response to hypothermia, will result in higher oxygen and caloric requirements. This process of thermoregulation continues throughout the infant’s first several months of life. Neonates do not shiver to maintain heat as adults do, and during infancy, the child’s ability to shiver increases. The older infant usually has acquired the benefit of insulation by the gradual growth of adipose tissue. By early childhood, the skin is thicker and the body has a higher percentage of fat and a decreased surface area-to-volume ratio; these factors enable children to cope with environmental cold stresses much better than the young infant.

When performing procedures such as IV insertion and dressing changes, the nurse must maintain a neutral thermal environment for the infant to prevent the possibility of cold stress, thus permitting the infant to maintain a normal core temperature with minimum oxygen consumption and calorie expenditure. Maintain temperature control by carefully exposing only the necessary extremity during a procedure and bundling the infant in a blanket. It is especially important to keep the infant’s head covered to minimize heat loss. If the room is cold, warming lights can be used to help keep the baby warm. Low birth weight and premature infants should remain in an incubator whenever possible since incubators are designed to maintain both temperature and humidity. A warm environment can be maintained using a variety of tools, including the following: warmer beds, incubators, cotton blankets, head coverings, heat lamps kept a safe distance from the skin, and hot packs for infant use; thereby ensuring that only the extremity of the IV insertion site is exposed.

VESSEL SIZE

Venous and arterial vessels in the infant and child are smaller than those in the adult. Anatomically positioned in the same locations throughout one’s life, the small size
and presence of subcutaneous fat may contribute to difficulty in locating those vessels. Vasodilation prior to venipuncture is helpful, along with other location measures including transillumination and infrared or near-infrared technologies (Frey & Pettit, 2010).

BLOOD VOLUME

The major differences from neonate to adult include a gradual decrease in blood volume, maturation of the immune system with regard to blood typing, changes in blood counts, and changes in requirements. Circulating blood volume changes throughout development with neonates ranging from 80 to 85 mL/kg versus the adolescent and adult at 60 to 65 mL/kg (Table 21-1) (Hazinski, 2013). The higher proportion of blood volume to lower body weight of the neonate and infant means that blood loss percentage is much higher in this group, even with small losses. The following is an example comparing blood volume loss between a 5-kg infant and a 75-kg adult.

25 mL blood loss from 75 – kg adult = <0.4% of total circulating blood volume (5,250 mL)

25 mL blood loss from 5 – kg infant = 6% of total circulating blood volume (400 mL)

Owing to smaller body surface area (BSA) and large circulating blood volume, the same amount of blood loss could be devastating to an infant, whereas it would not harm an adult.

Specific physical assessment areas indicative of hematologic function in children include color changes in the skin, lips, conjunctivae, mucous membranes, and nails, such as blue for cyanosis, pale for anemia, or yellow for jaundice. Examination of the fingernails and toenails for clubbing, the skin for petechiae, and the mucous membranes for bleeding are key assessment findings for the practitioner. Blood oozing from old venipuncture sites is often an indicator of a bleeding disorder or disseminated intravascular coagulation. When the application of a tourniquet on an extremity promotes evidence of petechiae distal to the tourniquet site, idiopathic thrombocytopenic purpura (ITP) or other platelet disorders may be of concern. Evidence of a bleeding disorder warrants analysis of specific clotting studies. Laboratory values as simple as the complete blood count, which includes hemoglobin, hematocrit, white cell count, platelet levels, and cell differential, can provide a very good picture of the child’s hematologic status. These values vary among age groups. In the newborn, neutropenia rather than neutrophilia is a more common indicator of sepsis (Burke & Salani, 2013).

FLUID BALANCE

Physiologic differences in children make them more vulnerable to changes in their fluid status. Water and electrolyte distribution varies drastically from infancy to adulthood. In general, the amount of water content decreases with age and changes in areas of distribution. The BSA is proportionately much greater in infants and children than in adults. This leads to increased loss of insensible fluid through perspiration through the skin. The preterm neonate is estimated to have a BSA that is five times greater than that of an older child or adult (Ellett, 2009).

The newborn has the largest proportion of free water in the extracellular spaces. At a rate of exchange seven times greater than that of the adult, the infant exchanges approximately half of its total extracellular fluid daily. The basal metabolism rate is also twice as great in relation to body weight in the infant as it is in the adult.

As the child matures, there is a fluid shift from the extracellular fluid compartment. After the first year, total body water content decreases and distribution gradually changes to less fluid in the extracellular fluid compartments and more fluid in the intracellular fluid compartments. By the age of 2, 24% of body water is in the extracellular fluid, approximately equal to that of an adult.

ELECTROLYTES

Infants and children are especially prone to fluid and electrolyte imbalances because their bodies consist of more water in proportion to surface area than those of adults. Moreover, their immature body organs compromise their ability to handle imbalances.

Laboratory values to monitor in children include sodium, potassium, chloride, calcium, and glucose. In particular, plasma sodium concentration does not vary greatly from infancy to adulthood. In the premature neonate and full-term neonate, potassium and chloride concentrations are higher than any other time, whereas magnesium and calcium levels in the infant are lower than in older children and adults. Phosphate levels remain slightly higher than adult levels until about 5 years of age, at which time electrolyte parameters are within normal adult ranges.

Gastrointestinal disturbances, such as diarrhea, most often alter potassium levels. Children usually do not experience cardiac symptoms until the serum potassium falls below 3 mEq/L. Hyperkalemia is more common, especially in premature infants. The hallmarks of hyperkalemia in children are similar to those in adults—peaked T waves and widening of the QRS complex and ST segment depression on the electrocardiogram (Blayney, 2013).

Other common electrolyte imbalances in children include hypocalcemia, hyponatremia or hypernatremia (as seen with dehydration), and chloride disturbances. Infants are especially prone to hypocalcemia due to the increase of calcium deposition in the bones during times of stress and growth hormone secretion. Hypocalcemia is also attributed to blood transfusion with citrate preservative, pancreatitis, newborn intake of cow’s milk, vitamin D deficiency, and malabsorption. Conversely, lower calcium can result from excessive use of diuretics, tumor lysis syndrome during the initiation of chemotherapy, and immobilization (Roberts, 2013; Secola & Reid, 2008).

ASSESSING FLUID NEEDS

The amount of fluid required for maintenance levels depends on insensible water losses from the lungs, skin, urine, and stool output. Metabolic expenditures are an additional consideration when computing fluid requirements. Younger children have a higher fluid requirement due to a higher percentage of total body water. Requirements vary among term, low birth weight, and premature, high-risk infants. Adolescent fluid requirements are similar to those for adults.

A precise record of intake and output is the most valuable assessment tool for determining fluid requirements. To ensure accuracy in judging fluid needs, strict monitoring of intake and output, including diaper weights, for children receiving infusion therapy is essential. Infants have a greater urine volume per kilogram of body weight and a smaller bladder volume capacity than older children. Expected urine output with adequate intake should be 2 to 3 mL/kg/h for infants, 2 mL/kg/h for toddlers, 1 to 2 mL/kg/h for school-age children, and 0.5 to 1 mL/kg/h for adolescents (Hazinski, 2013).

MAINTENANCE REQUIREMENTS

Maintenance fluid requirements for neonates and children differ in terms of the volume allowed over 24 hours, but all fluid need calculations are in milliliters per kilogram of weight (Hazinski, 2013). There are multiple methods of assessing 24-hour maintenance fluids based on weight or meters squared (Ellett, 2009; Hazinski, 2013). These methods address only maintenance requirements for normal metabolism; they do not address insensible losses or additional metabolic expenditures that require further replacement therapy.

In the weight method, the most commonly used fluid estimates are based on the child’s weight in kilograms. The advantage of this method is its simplicity (Table 21-7).

In the meters-squared method, the child’s height and weight are plotted on a nomogram to obtain a surface area in meters squared (m²). This method uses an arbitrary estimated requirement of 1,500 to 1,800 mL of fluid per square meter.

Alterations in Fluid Needs

The most common cause of altered fluid and caloric needs is changes in temperature. In the neonate, the use of radiant warmers and single-walled incubators may effectively maintain the newborn’s temperature, but this temperature elevation in turn increases the infant’s insensible fluid losses. Phototherapy, although effectively used to treat newborn hyperbilirubinemia, increases insensible fluid losses and water requirements. These various losses must be included when determining fluid replacement needs. Other conditions that affect fluid requirements include diarrhea and nasogastric tube output.

TABLE 21-7 CALCULATING MAINTENANCE FLUID REQUIREMENTS

Newborn	60-100 mL/kg/24 h (up to 72 h of age)
0-10 kg	100 mL/kg/24 h for the first 10 kg
11-20 kg	100 mL/kg/24 h for the first 10 kg, plus 50 mL/kg/24 h for each kg >10 kg
21-30 kg	100 mL/kg/24 h for the second 10 kg, plus 50 mL/kg/24 h for each kg >10 kg, plus 20 mL/kg/24 h for each kg >20 kg

TABLE 21-8 ASSESSMENT: PARAMETERS FOR DETERMINING THE LEVEL OF DEHYDRATION

	Level of Dehydration
Parameter	Mild	Moderate	Severe
Alertness	Normal	Normal to listless	Normal to lethargic or comatose
Blood pressure	Normal	Normal	Normal to reduced
Eyes	Normal	Sunken orbits	Deeply sunken orbits
Extremities	Warm, normal capillary refill	Delayed capillary refill	Cook and mottled
Fontanel	n/a	Sunken	Sunken
Heart rate	Normal	Increased	Increased; bradycardia may be present
Mucous membranes	Slightly dry	Dry	Dry
Pulse	Normal	Normal or slightly decreased	Moderately decreased
Skin turgor	Normal	Decreased	Decreased
Urine output	Slightly decreased	<1 mL/kg/h	<0.5-1 mL/kg/h
Weight loss	3%-5%	6%-9%	≥10%

DEHYDRATION

Dehydration can occur rapidly in children who lose more water than they receive. Being alert for signs of dehydration is an important aspect of caring for pediatric patients. Physical assessment parameters for dehydration are outlined in Table 21-8.

The classifications of dehydration are type, depending on the level of serum sodium, and by degree, depending on the weight loss, patient history, and physical assessment. The three types of dehydration are as follows:

Isotonic—sodium is within normal limits and electrolyte and water deficits are equal (e.g., mild vomiting and diarrhea).
Hypertonic—sodium is elevated and water losses are greater than electrolyte losses (e.g., too concentrated formula intake).
Hypotonic—sodium is low and electrolyte losses are greater than water losses or water intake is large (e.g., diabetes insipidus, drowning in fresh water) (Ellett, 2009).

To determine the degree of dehydration, nurses must calculate the percentage of weight lost. For each 1% of weight loss, the patient has a loss of 10 mL/kg of fluid, requiring replacement in addition to maintenance and ongoing losses. If a child presents with severe dehydration, administration of a fluid bolus of normal saline or lactated Ringer’s at a dosage of 20 to 40 mL/kg is necessary. Oral rehydration is initiated at a rate of 50 to 100 mL/kg if the child is mildly to moderately dehydrated. Infusion therapy continues if the child does not tolerate oral rehydration therapy or the child’s condition warrants IV correction.

FLUID OVERLOAD

Fluid overload and intoxication are less common than dehydration but can occur more readily in infants, whose immature kidneys are unable to excrete excess fluid. A serum sodium <130 mEq/L in an infant that is not associated with dehydration is a sign of water intoxication (Perkin, deCaen, Berg, Schexnayder, & Hazinski, 2013). Treatment includes reducing fluid delivery and administering IV furosemide.

ACID-BASE BALANCE

Acid-base balance is part of the overall picture of fluid balance. In the neonate and infant, higher BSA equals increased metabolism and more production of waste products requiring excretion. Buffering mechanisms are less mature, resulting in a deficit of bicarbonate. Combined with increased production of waste and an immature renal system, metabolic acidosis is more common in this age group (Hazinski, 2013). As the infant matures, pH ranges approach normal parameters of 7.35 to 7.45.

When a child has diarrhea, he or she loses bicarbonate in the stool resulting in a metabolic acidosis. Conversely, when a child is vomiting or has a nasogastric tube, metabolic alkalosis can result from the large amount of acid lost in gastric secretions. When replacing electrolytes, frequent monitoring of laboratory values and fluid balance is necessary to prevent acid-base imbalances.

Parenteral Nutrition

Parenteral nutrition (PN) is the intravenous administration of nutrients, including sterile water, carbohydrate in the form of dextrose, fat, protein in the form of amino acids, electrolytes, vitamins, minerals, trace elements, and medications. PN support should only be used when feeding into the gastrointestinal tract is contraindicated or inadequate. PN has become one of the most important therapeutic parameters in the successful management of certain pediatric diseases, but it does not come without its risks, and close monitoring is necessary. Specific guidelines have not been determined, but in general, PN is started if it is anticipated that an undernourished infant will not be able to receive enteral feeds for 1 to 2 days, if a well-nourished infant will not be able to receive enteral feeds for 3 to 5 days, and if a well-nourished child will not be able to receive enteral feeds for 5 to 7 days. Infants born prematurely typically start on PN support within 24 hours of birth due to low nutrient stores (Davis, 1998; Koletzko, Goulet, Hunt, Krohn, & Shamir, 2005).

PN can be supplied via a peripheral access or central access depending on the strength of the solution. Peripheral access limits the amount of calories that can be provided because the osmolarity maximum for a peripheral line is 900 mOsm/L. Given the density of certain PN additives, this means a very large volume would have to be supplied to meet the patient’s calorie needs, which are usually not possible due to fluid restrictions. Therefore, peripheral PN is used for short-term benefit; usually <2 weeks. If full nutrition support is needed, PN needs to be administered through a form of central access. Some examples of conditions that may need full PN support are prematurity, diaphragmatic hernia, gastroschisis, malrotation/volvulus, necrotizing enterocolitis, abdominal trauma, and chylothorax (Samour & King, 2012).

With the addition of PN to their therapy, affected children can be expected to gain weight normally with only parenteral nutrients. In addition, PN supplies enough calories to
maintain the positive nitrogen balance required for normal growth and development. The parameters used to determine caloric needs are age, resting energy requirements, level of physical activity, and severity of illness.

CONSTITUENTS OF PARENTAL NUTRITION

Usually, hospital or home IV agency pharmacy staff formulate PN solutions and perform admixture of solutions under a laminar-airflow hood. As stated previously, the general constituents for PN are protein, carbohydrates, fat, electrolytes, minerals, trace elements, vitamins, and medications. Pediatric requirements for IV nutrition follow general guidelines and are based on protein, calorie, and fluid needs per kilogram of body weight.

Protein for PN solutions is provided in the form of crystalline amino acids, which deliver 4 cal/g. Amino acid solutions for infants contain similar amino acids that are found in the plasma of breast-fed infants. The type of amino acids used to make the solution cause the pH to be lower, which is excellent for the neonate because this allows more calcium and phosphate to be added without precipitating, which is imperative for bone development. Protein may be limited in patients with cirrhosis with encephalopathy, in patients with chronic kidney disease who are not on dialysis, and in patients who have protein metabolism or urea cycle disorders. Conversely, examples of instances when protein needs may be increased are in patients with burns, sepsis, large wounds, and after trauma (Corkins et al., 2010).

Carbohydrates are provided as dextrose, which provides energy for body tissue function. If carbohydrate supply is inadequate, the body breaks down protein or fat to provide metabolic needs. Dextrose, administered in milligram per kilogram per minute increments, provides the main calorie source and typically provides 40% to 60% of the total calorie goal (6 to 14 mg/kg/min infusion rates). Dextrose in PN is in monohydrate form, so it provides not 4 kcal/g but 3.4 kcal/g. For example, 100 mL of 5% dextrose in water solution contains 5 g dextrose, or 17 kcal, and 100 mL of 10% dextrose in water solution contains 10 g dextrose, or 34 kcal. The strength of dextrose that can be administered peripherally in a child is 12.5%. Greater concentrations given through a peripheral IV can cause sclerosis, phlebitis, and extravasation injury if infiltration occurs. Although concentrated dextrose is needed to provide calories, the volume of fluid needed to dilute very concentrated dextrose is often deleterious to fluid balance in children, especially neonates. Higher concentrations of dextrose (up to 25%) in less volume of fluid may be delivered by a central catheter (Corkins et al., 2010).

The other source of nonprotein calories is lipids, delivered as a fat emulsion used to supply essential fatty acids that are needed for brain and somatic growth, immune system function, skin integrity, and wound healing. IV fat emulsions in the United States contain egg phospholipids as an emulsifier, water, and soybean or safflower oil as a source of polyunsaturated fats. Originally, fat infusion was kept to a minimum (only 2% to 10% of daily calorie intake) because it was thought that a higher fat intake resulted in pulmonary changes. This hyperlipidemia is now thought to have been brought on by rapid infusion rates, so a slower infusion rate over longer period is now the rule. Fat emulsions come in strengths of 10%, with 1.1 kcal/mL, and 20%, with 2 kcal/mL. Both may be infused peripherally or centrally, but the 20% solution is used most often. The typical lipid dosage for infants is between 2.5 and 3 g/kg/d, which equals 25% to 30% of total energy needs. Children over 2 years of age should also receive approximately 30% of their total calorie goal from lipids (Finberg et al., 1986). Fat should not provide more than 60% of total calories in any patient because ketotic acidosis may occur (Sapsford, 1994).

Micronutrients, minerals, vitamins, and trace elements are added to the PN solution in amounts established for IV maintenance requirements, based on recommended dietary allowances. Because calcium, phosphorus, and magnesium are incompletely absorbed from the gastrointestinal tract, IV dosages are much lower than the recommendations for oral intake. Calcium and phosphorous may precipitate in the PN solution when higher levels are prescribed; adjustment of the protein and pH level of the solution may assist in solubility. The yellow color of the total peripheral nutrition (TPN) solution results from the addition of multivitamins. Because multivitamins limit the shelf life of TPN, patients on home TPN are taught to add vitamins and other medication additives such as heparin immediately prior to infusion.

In some cases, total nutrient admixtures (TNA), in which all the nutrients are added to one bag, have been used in children. One major disadvantage of these three-in-one solutions is that the opacity of the lipids prevents the patient or caregiver from visually examining the bag for calcium-phosphate precipitates. The more common practice is to infuse the dextrose/amino acid solution separately in one bag, using a 0.22-µm filter into one arm of a Y set, and to infuse the fat, unfiltered, into the other arm of the Y. These smaller positively charged filters are able to remove microorganisms, gram-negative endotoxins, and reduce the risk of air embolism. If a TNA solution is used, a larger 1.2-µm filter must be used to allow for the lipid droplet to pass through. These filters can prevent particulate matter and larger organisms from passing through but are not able to filter out the smaller bacterial contaminants. Two-in-one infusion sets should be changed out at a minimum of every 72 hours and three-in-one (TNA) and lipid infusion sets should be changed out as soon as the infusion is done, or if the patient needs additional infusions, at least every 24 hours (Koletzko et al., 2005; Mirtallo, Canada, & Johnson, 2004).

NURSING ASSESSMENT AND MANAGEMENT

Once the child has been deemed a candidate for PN, a complete physical assessment including height, weight, head circumference, and nutrition and laboratory evaluations is completed by the physician/licensed independent practitioner (LIP), dietitian, and other members of the nutrition support team. Duration and route of PN are determined, and the appropriate catheter is placed. Initiation, advancement, and goals vary depending on age groups.

Infusions may run over 24 hours for the very sick hospitalized child or may be cycled down gradually by 4-hour increments daily, maintaining the same volume of infusion over less time. Cycling down to between 12 and 16 hours of daily infusion allows the child far more freedom. This is particularly true for children on home PN, who may infuse at night while asleep and still follow a fairly normal lifestyle of school and activities. Cycling the PN also may prevent or delay the onset of liver dysfunction (Btaiche & Khalidi, 2002). To prevent wide variations in serum glucose, the PN rate can be run at half the rate for the first and last hours of the cycle to lessen the likelihood of hypo-/hyperglycemia. Most infusion pumps can be programmed to taper up and down at the start and end of PN infusion for ease of delivery (Kirby, Corrigan, & Emery, 2012).

TABLE 21-9 SIGNIFICANT LABORATORY VALUES FOR THE PATIENT RECEIVING PARENTERAL NUTRITION

Parameter	Interpretation	High Value	Low Value
Prealbumin	Preterm: 9-33 mg/dL Term: 11-34 mg/dL Older children: 20-50 mg/dL	Dehydration	Acute protein malnutrition Infection Aggressive hydration
Transferrin	Preterm: 140-370 mg/dL Term: 200-370 mg/dL Older children: 180-260 mg/dL	Iron deficiency Hypoxia Chronic blood loss Stress	Impaired synthesis Protein malnutrition Chronic infection Chronic liver disease
Albumin	Preterm: 2.5-4.5 g/dL Term: 2.5-5.0 g/dL 1-3 mo: 3.0-4.2 g/dL 3-12 mo: 2.7-5.0 g/dL >1 y: 3.2-5.0 g/dL	Dehydration	Protein malnutrition Impaired digestion Excessive protein loss Chronic liver disease Advanced malignancy Hypervolumic dilution Chronic infection Nephrotic syndrome