Paediatric Assessment, Hospitalization & Pain - Cheat Sheet
Your 30-minute exam companion covering developmental assessment, vital signs by age, communication strategies, hospitalization responses, pain tools, and atraumatic care. Master the rules, remember the ranges, and ace the questions.
Principles of Paediatric Physical Assessment
Important facts
- Examine infants and toddlers ON THE PARENT'S LAP whenever possible; keep parent in view.
- Do observation and auscultation (heart, lungs, abdomen) BEFORE palpation/percussion — crying distorts sounds.
- Perform ears, mouth, and throat examination LAST in young children — these are the most upsetting.
- Allow toddlers and preschoolers to handle equipment (stethoscope, penlight) FIRST to reduce fear.
- Keep the child clothed until needed; expose only the area being examined.
- Count the APICAL pulse for a FULL MINUTE in infants and children under ~2 years; radial pulse is unreliable.
- Count respirations by watching ABDOMINAL MOVEMENT in infants (they are abdominal/diaphragmatic breathers); count for a FULL MINUTE.
- In infants, the apical impulse is located at the 4th intercostal space; it moves down and medially with age.
Key definitions
Atraumatic Care
Example
Performing an IV insertion in a treatment room rather than the child's bed keeps the bed a 'safe' space.
Minimizing physical and psychological distress during procedures by preventing separation, promoting control, and reducing pain.
Least-to-Most Invasive Sequencing
Example
Listen to heart and lungs before looking in the throat, because crying changes lung sounds.
Performing non-invasive/less distressing parts of the exam first (observation, auscultation) before the most distressing parts (ear, mouth, throat).
Position of Comfort
Example
Assess the infant's abdomen while the child sits on the mother's lap rather than on an exam table.
Examining the infant or toddler while sitting on the parent's lap to reduce fear and maintain the child's sense of security.
Diagrams to know
- Sequence of paediatric physical exam (least to most invasive)
- Apical pulse location by age
- Positioning techniques for different age groups
Vital Signs: Age-Specific Technique
Common values
Value
110–160 bpm (up to ~180 when crying)
Symbol
HR
Quantity
Newborn (0–1 month) Heart Rate
Value
30–60 breaths/minute
Symbol
RR
Quantity
Newborn (0–1 month) Respiratory Rate
Value
~60–90 mmHg
Symbol
SBP
Quantity
Newborn Systolic BP
Value
90–160 bpm
Symbol
HR
Quantity
Infant (1–12 months) Heart Rate
Value
30–53 breaths/minute
Symbol
RR
Quantity
Infant Respiratory Rate
Value
~70–100 mmHg
Symbol
SBP
Quantity
Infant Systolic BP
Value
80–140 bpm
Symbol
HR
Quantity
Toddler (1–3 years) Heart Rate
Value
22–37 breaths/minute
Symbol
RR
Quantity
Toddler Respiratory Rate
Value
~80–110 mmHg
Symbol
SBP
Quantity
Toddler Systolic BP
Value
80–120 bpm
Symbol
HR
Quantity
Preschool (3–5 years) Heart Rate
Value
20–28 breaths/minute
Symbol
RR
Quantity
Preschool Respiratory Rate
Value
~80–110 mmHg
Symbol
SBP
Quantity
Preschool Systolic BP
Value
70–120 bpm
Symbol
HR
Quantity
School-age (6–12 years) Heart Rate
Value
18–25 breaths/minute
Symbol
RR
Quantity
School-age Respiratory Rate
Value
~85–120 mmHg
Symbol
SBP
Quantity
School-age Systolic BP
Value
60–100 bpm
Symbol
HR
Quantity
Adolescent (13–18 years) Heart Rate
Value
12–20 breaths/minute
Symbol
RR
Quantity
Adolescent Respiratory Rate
Value
~95–120 mmHg
Symbol
SBP
Quantity
Adolescent Systolic BP
Important facts
- APICAL PULSE is taken for a FULL MINUTE in children under ~2 years; location: 4th intercostal space, midclavicular line in infants.
- RESPIRATIONS are counted by watching ABDOMINAL MOVEMENT in infants; count for a FULL MINUTE (infants breathe irregularly).
- BP CUFF BLADDER must cover ~2/3 of the upper arm; too-small cuff falsely raises reading.
- BLOOD PRESSURE is routinely measured from ~3 years of age onwards.
- TEMPERATURE: avoid rectal routes when possible; use axillary or tympanic for routine assessment in young children.
- As the child GROWS, HR and RR DECREASE, and BP INCREASES.
- FEVER raises both HR and RR.
- TACHYCARDIA is the EARLIEST sign of shock in children; hypotension is a LATE and ominous sign.
Key definitions
Apical Pulse
Example
Place the stethoscope diaphragm at the 4th intercostal space at the midclavicular line in an infant and count beats for a full minute.
Heart rate measured by auscultating directly over the apex of the heart; the most accurate method in infants and young children.
Blood Pressure Cuff Selection
Example
For a toddler with a 15 cm arm circumference, use a cuff with a bladder width of ~10 cm.
The cuff bladder must encircle approximately 2/3 of the upper arm; a cuff that is too small falsely elevates the reading.
Axillary Temperature
Example
Place the thermometer bulb in the centre of the axilla and hold the arm against the body for 3–5 minutes.
Temperature measured in the axilla (armpit); preferred non-invasive route in young children to avoid rectal trauma.
Diagrams to know
- Normal vital sign ranges by age group (table format)
- Apical pulse assessment technique
- Blood pressure cuff sizing guide
Communication by Developmental Stage
Important facts
- INFANTS: respond to soft voice, holding, rocking; keep primary caregiver present; use consistent caregivers.
- TODDLERS: limited language, think concretely; PREPARE JUST BEFORE the procedure (short sense of time); use simple words, allow CHOICES, tolerate rituals and comfort objects.
- TODDLERS: expect NEGATIVISM ('NO!') and REGRESSION; do not take it personally.
- PRESCHOOLERS: have MAGICAL THINKING and fear BODILY HARM/MUTILATION; use NON-THREATENING concrete words; reassure procedure is NOT punishment.
- PRESCHOOLERS: fear of 'insides leaking out' — USE BANDAGES; allow MEDICAL PLAY with dolls/equipment.
- Avoid threatening phrases: say 'the cuff will hug your arm' not 'take your blood pressure'; 'medicine' not 'shot'; 'poke' not 'injection'.
- SCHOOL-AGE: wants EXPLANATIONS and REASONS; likes to know how equipment works; give HONEST, FACTUAL info; respect MODESTY and PRIVACY.
- ADOLESCENTS: treat with RESPECT and HONESTY; ensure PRIVACY and CONFIDENTIALITY; interview SEPARATELY from parents for sensitive topics; allow CONTROL and PARTICIPATION.
- GENERAL RULE: The YOUNGER the child, the CLOSER to the event you prepare them.
- ALWAYS tell the TRUTH; never say 'it won't hurt' if it will.
- Be at EYE LEVEL; use the child's NAME.
Key definitions
Magical Thinking
Example
A preschooler may believe that their bad behaviour caused their fever and hospitalization.
The preschooler's belief that thoughts and wishes can cause events; leads to interpretation of illness or injury as punishment.
Concrete Thinking
Example
Saying 'we'll take your temperature' can be frightening because the child thinks you will remove their body temperature.
The toddler and young preschooler interpret words literally; unable to understand abstract or symbolic language.
Regression
Example
A 5-year-old who was toilet-trained may resume bed-wetting during hospitalization.
Return to earlier developmental behaviours (thumb-sucking, bed-wetting, baby talk) during stress or illness.
Diagrams to know
- Developmental communication strategies by age
- Inappropriate vs. appropriate phrases to use with children
- Preparation timeline by developmental stage
The Child's Response to Hospitalization
Important facts
- SEPARATION ANXIETY is the MAJOR STRESSOR for TODDLERS (not preschoolers or school-age).
- Separation anxiety has THREE stages: PROTEST → DESPAIR → DETACHMENT (most serious).
- PROTEST is HEALTHY; do NOT punish or restrain the child.
- DETACHMENT is the MOST DANGEROUS because it signals the child has given up — parents often misinterpret it as 'adjustment'.
- LOSS OF CONTROL is a stressor for ALL children, especially toddlers and adolescents.
- FEAR OF BODILY INJURY AND PAIN is the major stressor for PRESCHOOLERS.
- MANAGEMENT: encourage ROOMING-IN and LIBERAL PARENTAL VISITING; keep COMFORT OBJECTS at bedside; maintain HOME ROUTINES and RITUALS; assign CONSISTENT CAREGIVERS.
- REGRESSION during hospitalization is NORMAL — reassure parents; do NOT shame the child.
- Allow the child as much INDEPENDENCE and CHOICE as safe to restore sense of control.
Key definitions
Separation Anxiety
Example
A 18-month-old first cries and searches for mother (Protest), then becomes withdrawn and sad (Despair), and finally appears content with staff but ignores the mother on visits (Detachment).
The major stressor for toddlers; progresses through Protest → Despair → Detachment.
Protest (First Stage)
Example
An 2-year-old frantically searches the room when the mother leaves, refusing comfort from nurses.
The child cries, screams, clings, searches for the parent, and rejects strangers; this is a HEALTHY response.
Despair (Second Stage)
Example
The toddler sits silently in the crib, refusing toys and showing no interest in visitors.
Withdrawn, sad, quiet, uninterested in play or food; appears 'settled' but is actually depressed.
Detachment/Denial (Third Stage)
Example
The toddler smiles at the nurse but seems indifferent when the mother visits; this signals emotional withdrawal.
The MOST SERIOUS stage; child appears to have adjusted, becomes friendly with staff, shows LITTLE INTEREST in the parent — signals resignation, not true adjustment.
Diagrams to know
- Three stages of separation anxiety (Protest → Despair → Detachment)
- Age-specific stressors of hospitalization
- Nursing interventions by stressor type
Paediatric Pain Assessment
Common values
Value
0–10 (0–3 = no/minimal pain; 4–6 = mild–moderate; 7–10 = severe)
Symbol
FLACC
Quantity
FLACC Total Score Range
Value
0–10 (0 = no hurt; 2 = hurts little bit; 4 = hurts little more; 6 = hurts even more; 8 = hurts a whole lot; 10 = hurts worst)
Symbol
FACES
Quantity
Wong-Baker FACES Scale Range
Value
0–10 (0 = no pain; 10 = worst pain imaginable)
Symbol
NRS
Quantity
Numeric Rating Scale (NRS) Range
Important facts
- Pain is the FIFTH VITAL SIGN; assess in every child at every visit.
- INFANTS and YOUNG CHILDREN CANNOT VERBALISE pain — use age-appropriate BEHAVIOURAL and PHYSIOLOGIC CUES.
- Pain behavioural cues: CRYING, GUARDING, GRIMACING, TENSENESS, WITHDRAWAL, AGGRESSION.
- Pain physiologic cues: ↑HR, ↑BP, ↑RR, PALLOR, DIAPHORESIS, PUPIL DILATION.
- INFANTS DO FEEL PAIN (old myth that they don't is FALSE); untreated pain has physiologic consequences.
- FLACC is STANDARD for INFANTS and NON-VERBAL children (~2 mo–7 yr); evaluate every 4–6 hours and after interventions.
- FACES/Wong-Baker scale: appropriate ~3 years and older; child POINTS to matching face.
- NUMERIC 0–10 scale: appropriate ~7–8 years and older; school-age and adolescents can reliably self-report.
- NIPS/CRIES: for neonates; use when child cannot self-report at all.
- Reassess pain AFTER EVERY intervention (medication, distraction, positioning) and document response.
Key definitions
FLACC Scale
Example
A crying infant with clenched fists, rigid body, and inconsolable crying scores high on FLACC.
Face, Legs, Activity, Cry, Consolability (0–2 points each; total 0–10); used for infants and non-verbal children ~2 months to 7 years.
Wong-Baker FACES Scale
Example
A 4-year-old post-op points to the third face (moderate hurt) after analgesia is given.
Six faces from smiling (0 = no hurt) to crying (10 = worst hurt); child points to the face matching their pain; appropriate ~3 years and older.
Numeric Rating Scale (NRS)
Example
A 9-year-old with a fracture rates pain as 7/10 before medication and 3/10 after.
Child rates pain on a 0–10 scale (0 = no pain, 10 = worst pain); appropriate ~7–8 years and older.
NIPS / CRIES Scales
Example
A newborn post-circumcision shows increased heart rate, crying, and facial grimacing on the NIPS scale.
Neonatal pain scales using behavioural and physiologic indicators (crying, facial expression, heart rate, saturation, breathing); for neonates unable to self-report.
Diagrams to know
- Pain assessment tool selection by age
- FLACC scale scoring criteria
- Wong-Baker FACES scale with numerical equivalents
- Behavioural vs. physiologic pain indicators
Pain Management in Children
Formulas
Paracetamol: 10–15 mg/kg/dose PO/PR every 4–6 hours
Meaning
mg/kg = dose per kilogram of body weight; PO = by mouth; PR = rectal; total daily maximum = ~75 mg/kg/day; single-dose adult ceiling = ~1,000 mg
Watch out
Do NOT exceed 75 mg/kg/day or single adult dose of 1,000 mg; hepatotoxicity risk if overdosed; always calculate based on child's ACTUAL WEIGHT in kg.
When to use
First-line antipyretic and analgesic; safest choice; no anti-inflammatory effect; no GI/bleeding risk.
Ibuprofen: 5–10 mg/kg/dose PO every 6–8 hours
Meaning
mg/kg = dose per kilogram of body weight; PO = by mouth; maximum single dose usually 400 mg; total daily maximum = ~40 mg/kg/day
Watch out
GIVE WITH FOOD to reduce GI upset; AVOID in dehydration/renal failure/GI bleeding; do NOT use in viral illness context without consideration; always verify age ≥6 months.
When to use
Anti-inflammatory analgesic; appropriate from ~6 months of age; for mild–moderate pain and fever.
Common values
Value
10–15 mg/kg
Symbol
Dose
Quantity
Paracetamol per-dose range
Value
~75 mg/kg/day
Symbol
Max daily
Quantity
Paracetamol maximum daily dose
Value
~1,000 mg
Symbol
Max single dose
Quantity
Paracetamol single-dose adult ceiling
Value
5–10 mg/kg
Symbol
Dose
Quantity
Ibuprofen per-dose range
Value
~60 minutes
Symbol
Onset
Quantity
EMLA application time before procedure
Value
2 mL of 24% solution
Symbol
Standard dose
Quantity
Oral sucrose for neonatal pain
Important facts
- NON-PHARMACOLOGIC measures are FIRST-LINE ADJUNCTS: distraction, positioning, holding, swaddling, non-nutritive sucking, ORAL SUCROSE (neonates).
- DISTRACTION: use TV, music, games, stories, or parental presence to redirect attention away from pain.
- POSITIONING: hold infant upright or in position of comfort; avoid supine restraint when possible.
- EMLA (topical anaesthetic): apply ~60 MINUTES BEFORE needle stick (must be on intact skin); cover with occlusive dressing.
- PARACETAMOL (acetaminophen): 10–15 mg/kg/dose q4–6h; MAX 75 mg/kg/day; SAFEST antipyretic; NO anti-inflammatory; NO GI/bleeding risk.
- IBUPROFEN: 5–10 mg/kg/dose q6–8h (age ≥6 months); GIVE WITH FOOD; anti-inflammatory; AVOID in dehydration/GI bleed.
- OPIOIDS (e.g., morphine): for moderate–severe pain; weight-based titration; monitor for RESPIRATORY DEPRESSION, SEDATION, and CONSTIPATION.
- NEVER give ASPIRIN to a child with VIRAL ILLNESS (varicella, influenza) — RISK OF REYE'S SYNDROME.
- ALWAYS calculate weight-based doses using child's MOST RECENT WEIGHT in KILOGRAMS.
- DOUBLE-CHECK high-alert calculations with a SECOND NURSE.
- REASSESS pain AFTER every intervention; document response.
- Oral sucrose (24% solution, 2 mL) is evidence-based for procedural pain in neonates and young infants.
Key definitions
Non-Pharmacologic Pain Management
Example
During a heel stick, wrap the newborn, provide a pacifier dipped in sucrose, and have a caregiver hold and talk softly to the infant.
First-line adjuncts to medication: distraction, positioning, holding/cuddling, swaddling, non-nutritive sucking, and oral sucrose (for neonates/young infants).
EMLA (Eutectic Mixture of Lidocaine and Prilocaine)
Example
Apply EMLA under an occlusive dressing to the IV insertion site 1 hour before the procedure to numb the area.
Topical anaesthetic cream applied to intact skin ~60 minutes before needle sticks to reduce procedural pain.
Weight-Based Dosing
Example
A 10 kg toddler receiving ibuprofen at 5 mg/kg = 50 mg per dose.
Medication dose calculated using the child's weight in kilograms; the standard in paediatric practice to ensure safe, appropriate dosing.
Reye's Syndrome
Example
Avoid aspirin in any child with chickenpox or flu; use paracetamol or ibuprofen instead.
Rare but life-threatening acute encephalopathy and hepatic dysfunction associated with aspirin use in children with viral illness (varicella, influenza).
Diagrams to know
- Non-pharmacologic pain management techniques by type
- Analgesic dosing by age and type
- Pain assessment and management algorithm
Atraumatic Care & Safe Restraint
Important facts
- PERFORM PAINFUL PROCEDURES IN A 'TREATMENT ROOM' — NOT in the child's bed or PLAYROOM.
- The CHILD'S BED and PLAYROOM must remain SAFE SPACES.
- Use THERAPEUTIC HOLDING / POSITIONS OF COMFORT (child upright, hugged by parent) instead of forced supine restraint when possible.
- Keep the PARENT as a COMFORTER, not the one who restrains the child.
- RESTRAINTS are a LAST RESORT, used only for SAFETY/PROCEDURE and with an order.
- If restraint is necessary: CHECK CIRCULATION regularly; REMOVE/REPOSITION frequently; NEVER tie a restraint to a MOVABLE bed part.
- MUMMY/PAPOOSE RESTRAINT: use BRIEFLY for scalp-vein IV, throat, eye/ear procedures; wrap the infant snugly but not so tight as to restrict breathing.
- TELL THE TRUTH; give choices without offering a choice that doesn't exist ('Would you like the medicine in a cup or a syringe?' — but the medicine is NOT optional).
- PRAISE COOPERATION afterward.
- Always EXPLAIN the procedure in DEVELOPMENTALLY APPROPRIATE language BEFORE starting.
Key definitions
Atraumatic Care
Example
Performing an IV insertion in a designated treatment room (not the crib) keeps the crib a 'safe' space for sleep and comfort.
Minimizing physical and psychological distress during procedures through preventing separation, promoting control, and minimizing pain.
Therapeutic Holding / Position of Comfort
Example
Hold the infant in an upright position with the head resting against a parent's chest during a procedure, rather than strapping the child down.
Positioning the child upright or in a comfortable position, often with a parent providing comfort, rather than supine restraint.
Mummy (Papoose) Restraint
Example
Wrap a newborn in a blanket in a swaddled position for a brief throat examination to prevent flailing.
A blanket or device that wraps the infant's arms and legs to briefly immobilise the child for scalp-vein IV, throat, or eye/ear procedures.
Treatment Room
Example
Blood draws and IV insertions are done in the treatment room so the child's bed remains a 'safe' place.
A designated room where painful or invasive procedures are performed; distinct from the child's bed or playroom to preserve safety associations.
Diagrams to know
- Procedure room setup vs. child's bed/playroom
- Therapeutic holding positions by age
- Mummy restraint technique (visual steps)
- Decision tree: when to use restraint vs. comfort positioning
Medication Administration by Age
Important facts
- IM SITE: VASTUS LATERALIS (anterolateral thigh) is PREFERRED/SAFEST for INFANTS and YOUNG CHILDREN; largest muscle, no major nerves/vessels.
- IM SITE: VENTROGLUTEAL is safe once the child is WALKING WELL.
- IM SITE: AVOID DORSOGLUTEAL in children under ~3 years / until WALKING WELL (small muscle, sciatic nerve risk).
- IM SITE: DELTOID is used mainly for small volumes/vaccines in OLDER CHILDREN.
- ORAL MEDICATIONS: use a CALIBRATED ORAL SYRINGE or DROPPER (NOT a needle syringe).
- ORAL MEDICATIONS: aim toward SIDE/BACK OF CHEEK (not centre of mouth) to prevent aspiration.
- ORAL MEDICATIONS: give SLOWLY to prevent aspiration.
- NEVER MIX MEDICATION into a FULL BOTTLE of FORMULA or ESSENTIAL FOOD (child may not finish it; creates food aversion).
- ALWAYS VERIFY WEIGHT-BASED DOSES using child's MOST RECENT WEIGHT in KILOGRAMS.
- DOUBLE-CHECK high-alert calculations (especially opioids, insulin) with a SECOND NURSE.
- ALWAYS DOCUMENT the medication, dose, route, time, and child's response in the medical record.
Key definitions
Vastus Lateralis Site
Example
Give an infant IM medication in the middle third of the outer thigh, perpendicular to the thigh, avoiding medial and posterior surfaces.
The anterolateral thigh; the PREFERRED and SAFEST IM injection site for infants and young children due to largest muscle mass and no major nerves/vessels.
Ventrogluteal Site
Example
Once a toddler is confidently walking, the ventrogluteal site can be used for IM medications.
The gluteal area between the anterior superior iliac spine and posterior iliac crest; safe for IM injection once the child is walking well.
Dorsogluteal Site
Example
Do NOT use the dorsogluteal site in infants or toddlers; reserve for older children and adults.
Upper outer quadrant of the buttock; AVOIDED in children under ~3 years / until walking well due to small muscle mass and risk of sciatic nerve injury.
Calibrated Oral Syringe
Example
Draw up 5 mL of liquid paracetamol in a calibrated oral syringe and administer toward the side/back of the child's cheek.
A syringe marked with mL or mg measurements (NOT a needle attached); used to accurately measure and administer liquid oral medications.
Diagrams to know
- IM injection sites by age
- Correct vastus lateralis technique (visual steps)
- Oral medication administration technique
- Needle gauge and length recommendations by age and site
Must remember
- SEQUENCE THE EXAM LEAST-TO-MOST DISTRESSING: observe and auscultate heart/lungs/abdomen FIRST; do ears/mouth/throat LAST; examine infants/toddlers ON THE PARENT'S LAP.
- VITAL SIGNS BY AGE: newborn HR 110–160 / RR 30–60; as child grows, HR and RR DECREASE, BP INCREASES. Count apical pulse and respirations for a FULL MINUTE in infants; tachycardia is the EARLIEST sign of shock; hypotension is LATE.
- SEPARATION ANXIETY (TODDLER MAJOR STRESSOR): progresses Protest → Despair → Detachment (most serious). Manage with rooming-in, comfort objects, consistent caregivers, home routines.
- REGRESSION during hospitalization is NORMAL — reassure parents; do NOT shame the child.
- COMMUNICATION BY AGE: toddlers—prepare just before, use simple words, allow choices; preschoolers—fear mutilation/punishment, use non-threatening words, allow medical play; school-age—want explanations, respect privacy; adolescents—treat with respect, ensure confidentiality.
- PAIN ASSESSMENT: FLACC (infant/non-verbal ~2 mo–7 yr) → FACES/Wong-Baker (~3 yr+) → NUMERIC 0–10 (~7–8 yr+). INFANTS DO FEEL PAIN; untreated pain has physiologic consequences.
- PARACETAMOL (SAFEST antipyretic): 10–15 mg/kg/dose q4–6h; MAX ~75 mg/kg/day, single-dose adult ceiling ~1,000 mg. IBUPROFEN: 5–10 mg/kg/dose q6–8h (age ≥6 mo); give WITH FOOD. NEVER ASPIRIN in viral illness (Reye's syndrome risk).
- NON-PHARMACOLOGIC pain measures FIRST: distraction, positioning, holding, swaddling, non-nutritive sucking, ORAL SUCROSE (neonates). EMLA (topical anaesthetic) ~60 minutes before needle stick.
- ATRAUMATIC CARE: perform procedures in TREATMENT ROOM (not bed/playroom); use positions of comfort, not restraint; keep parent as comforter, not restrainer. MUMMY RESTRAINT: brief, only for scalp-vein IV/throat/eye/ear procedures.
- IM INJECTION: VASTUS LATERALIS (anterolateral thigh) is PREFERRED for infants; avoid DORSOGLUTEAL until ~3 years/walking well. ORAL MEDS: use calibrated syringe, aim toward SIDE/BACK of cheek, NEVER hide in formula. ALWAYS calculate weight-based doses using ACTUAL WEIGHT in kg; double-check with second nurse.
Last minute tips
- Memorize the vital sign ranges by age — this is REPEATEDLY tested on the NLE. Newborn HR 110–160 / RR 30–60; infant HR 90–160; toddler HR 80–140; school-age HR 70–120; adolescent HR 60–100. Remember the TREND: rates DECREASE with age.
- When you see a hospitalization question about a TODDLER, think SEPARATION ANXIETY and the three stages (Protest → Despair → Detachment). Detachment is often the exam's 'trick answer' because parents misinterpret it as adjustment when it's actually the MOST SERIOUS stage.
- For pain assessment, the exam loves testing FLACC for infants (~2 mo–7 yr) and Wong-Baker FACES for ~3 years+. Know what each assesses: FLACC = behavioural observation; FACES = child self-report. If the question mentions 'non-verbal' or 'infant', think FLACC.
- Paracetamol dosing (10–15 mg/kg/dose) is SAFE and FIRST-LINE; ibuprofen (5–10 mg/kg/dose, age ≥6 mo) is stronger but requires food. NEVER give aspirin to a child with a viral illness — the exam will likely have this trap question. Default answer is always paracetamol or ibuprofen.
- For exam questions about procedures, remember ATRAUMATIC CARE basics: 'treatment room' vs. 'safe spaces' (bed/playroom), positions of comfort instead of restraint, parent as comforter not restrainer. If the answer choice says 'restrain the child supine', it's usually WRONG unless it specifies a specific mummy restraint for a brief procedure.
Comparison tables
Pain Assessment Tools by Age
| Tool Name | Age Range | How It Works | Scoring Range | Best For | |
|---|---|---|---|---|---|
| FLACC | Face, Legs, Activity, Cry, Consolability | ~2 months – 7 years | Nurse observes 5 behaviours; score 0–2 for each | 0–10 total | Infants and non-verbal children |
| Wong-Baker FACES | FACES scale with numeric equivalents | ~3 years and older | Child POINTS to the face matching their pain | 0–10 (6 faces shown) | Preschool and early school-age |
| Numeric Rating Scale (NRS) | 0–10 pain scale | ~7–8 years and older | Child RATES pain on a 0–10 number line | 0–10 scale | School-age and adolescent |
| NIPS / CRIES | Neonatal Infant Pain Scale / Crying, Requires oxygen, Increased vital signs, Expression, Sleepless | Neonates (first few days of life) | Nurse assesses crying, facial expression, vital signs, body tone | Varies by scale (typically 0–13) | Neonates unable to self-report |
Developmental Communication Strategies
| Age Group | Cognitive Level | Key Fears / Concerns | Communication Strategy | Preparation Timing |
|---|---|---|---|---|
| Infant (0–12 mo) | Sensorimotor; learns through senses | Separation from caregiver | Keep caregiver present; use soft voice, holding, rocking; consistent caregivers | Just before or during (minimal advance notice) |
| Toddler (1–3 yr) | Preoperational; concrete thinking; egocentric | Separation, loss of control, pain | Prepare JUST BEFORE; use simple words; allow choices and rituals; tolerate comfort objects | Minutes to <1 hour before |
| Preschooler (3–5 yr) | Preoperational; magical thinking; fears mutilation | Bodily harm, mutilation, punishment | Use concrete, non-threatening words (not 'cut', 'shot', 'take'); reassure NOT punishment; allow medical play; use bandages | A few hours to 1 day before |
| School-age (6–12 yr) | Concrete operational; understands logic; wants explanations | Loss of control, modesty, separation from peers | Give honest, factual explanations; answer questions; respect privacy and modesty; involve in care | 1–7 days before |
| Adolescent (13–18 yr) | Formal operational; abstract thinking; peer-oriented | Loss of control, privacy/confidentiality, peer separation | Treat with respect and honesty; ensure privacy; interview separately from parents; allow control and participation | Variable; respect their need for information |
Separation Anxiety: Three Stages
| Stage | Behaviour / Appearance | Emotional State | Nursing Interpretation | Management |
|---|---|---|---|---|
| Protest | Cries, screams, clings, searches for parent, rejects strangers | Angry, frightened | HEALTHY response; child recognizes parent absence | Encourage parental presence; reassure parent that crying is normal; do NOT punish; comfort child |
| Despair | Withdrawn, quiet, sad, uninterested in play or food, appears 'settled' | Depressed, resigned | Child is actually distressed, not adjusted; at risk for poor outcomes | Increase parental visits; use comfort objects; maintain home routines; provide consistent, warm caregiving |
| Detachment (Denial) | Superficially friendly with staff, little interest in parent, appears content | Withdrawn, emotionally disconnected | MOST SERIOUS; signals resignation and loss of trust — NOT true adjustment; parents often misinterpret as 'doing well' | Urgent: increase parental presence; provide emotional support; reassess parental involvement; watch for long-term emotional impact |
Analgesic Dosing in Children: Key Medications
| Medication | Dose (by weight) | Frequency | Maximum Daily Dose | Key Advantages | Key Cautions |
|---|---|---|---|---|---|
| Paracetamol (acetaminophen) | 10–15 mg/kg/dose | Every 4–6 hours | ~75 mg/kg/day (single-dose adult ceiling ~1,000 mg) | SAFEST antipyretic; no anti-inflammatory; no GI/bleeding risk | Hepatotoxicity if overdosed; calculate carefully; verify actual weight |
| Ibuprofen | 5–10 mg/kg/dose | Every 6–8 hours | ~40 mg/kg/day (max single dose ~400 mg) | Anti-inflammatory; more effective than paracetamol for fever with inflammation | Age ≥6 months only; GIVE WITH FOOD; avoid in dehydration, GI bleed, renal failure |
| Morphine (opioid) | Weight and age-dependent; typically 0.1–0.2 mg/kg/dose IV/IM | Every 2–4 hours or per protocol | Per protocol (patient-controlled analgesia in older children) | Effective for severe pain; can be titrated | MONITOR for respiratory depression, sedation, constipation; opioid-naive dosing lower; assess risk for abuse in adolescents |
| Aspirin | NOT recommended in children | N/A | N/A | N/A | CONTRAINDICATED in viral illness (varicella, influenza) — RISK OF REYE'S SYNDROME; use paracetamol or ibuprofen instead |
Vital Signs: Age-Related Trends
| Age Group | Heart Rate (bpm) | Respiratory Rate (breaths/min) | Systolic BP (mmHg) | Key Point |
|---|---|---|---|---|
| Newborn (0–1 mo) | 110–160 (up to ~180 crying) | 30–60 | ~60–90 | HIGHEST rate; count for FULL MINUTE; apical pulse preferred |
| Infant (1–12 mo) | 90–160 | 30–53 | ~70–100 | Rates still high; apical pulse for full minute; watch abdominal breathing |
| Toddler (1–3 yr) | 80–140 | 22–37 | ~80–110 | Rates decreasing; HR/RR more variable; BP starts measurable |
| Preschool (3–5 yr) | 80–120 | 20–28 | ~80–110 | Rates approach school-age; routinely measure BP from ~3 years |
| School-age (6–12 yr) | 70–120 | 18–25 | ~85–120 | Rates approaching adolescent range; individual variation increases |
| Adolescent (13–18 yr) | 60–100 | 12–20 | ~95–120 | Similar to adult ranges; consider adult norms for older adolescents |
Diagrams
Paediatric Physical Assessment: Exam Sequence
Step-by-step flowchart showing the least-to-most distressing sequence of paediatric exam: observe and auscultate heart/lungs/abdomen first, then palpate/percuss, assess extremities, and ears/mouth/throat LAST. Emphasizes comfort and the importance of removing distressing components to the end.
Pain Assessment & Management by Age
Mind map showing paediatric pain assessment tools by age, non-pharmacologic strategies, medication options, and critical red flags. Emphasizes that pain is the 5th vital sign and that infants DO feel pain; treatment must be age-appropriate and always weight-based.
Developmental Communication & Preparation
Decision tree showing age-appropriate communication and preparation timing for each developmental stage. Illustrates how preparation timing decreases with age (infants: just before; preschoolers: hours before; school-age: days before) and the specific communication strategies for each group.
Separation Anxiety: Three-Stage Progression
State diagram showing the three-stage progression of separation anxiety in hospitalized toddlers. Protest is healthy; Despair indicates depression; Detachment (most serious) signals emotional resignation. Understanding this progression is critical for exam success because questions often test whether students recognize Detachment as the most dangerous stage, not a sign of adjustment.
Pain Medication Dosing Decision Tree
Decision tree for paediatric pain medication selection based on pain level, age, and presence of inflammation. Emphasizes weight-based dosing, the critical contraindication of aspirin in viral illness (Reye's syndrome risk), and the importance of reassessing pain after intervention.