This set is about children between about six and twelve. It is the first age group where
the patient can tell you what is wrong, and the first where they might decide not to.
The tiers map roughly onto the three phases of a six-year medical programme — the science, then
the clinical reasoning, then what you will actually be expected to do with your own hands. Read the one
that fits, and glance at the one above it. If you are on a rural clinical school placement with us, all
three are fair game on a ward round.
Tier one
The science of an almost-adult
Phase 1 — the foundational years, and anything called Beginnings, Growth and Development
The airway is nearly thereAdenotonsillar tissue peaked at two to six and is regressing. The larynx has descended, and by about eight the vocal cords rather than the cricoid ring are the narrowest point — which is why cuffed tubes are now standard and why the cuff pressure is something you check rather than guess.
But it is still smaller than yoursPoiseuille has not been repealed. Resistance still varies inversely with the fourth power of the radius, so a millimetre of oedema costs a nine-year-old more than it costs you. This is the physiology behind the asthma that fills the unit at this age.
The circulation finally behavesStroke volume is no longer close to fixed, so output is not substantially rate-dependent any more. Systemic resistance and blood pressure are climbing towards adult values. The consequence is that this child compensates better than a toddler — and therefore decompensates later and faster.
Where the numbers are agreed, and where they are notFrom twelve years there is consensus on a mean arterial pressure of at least 65. Below twelve there is still no agreed target, which is worth knowing before you are asked to defend one.
Dose, fluid and surface areaMaintenance on the 4-2-1 rule, resuscitation at 10 mL/kg rather than the adult litre, and everything per kilogram until puberty. Weight estimation is more reliable at this age than at three, and body habitus varies enormously, so weigh them if you possibly can.
The immune system has met the worldPassive maternal antibody is long gone and they have been at school for years. That changes the organisms: Mycoplasma and Streptococcus pneumoniae rather than the viruses of the nursery, and a broadly competent response that can nonetheless overshoot.
If you take one thing: the physiological gap between this child and an adult has
nearly closed, and the psychological one has opened. Everything difficult about this age group is on the
second side of that.
Likely to be examined as: a short answer on why airway resistance rises so steeply
with mucosal oedema, or on how the determinants of cardiac output change with age. A common viva opener
is at what age does a child stop being rate-dependent, and why does that matter?
Tier two
Taking a history from someone who has learned to be brave
Phase 2 — the clinical years, integrated clinical studies, and the ICE
You can take a history — and it will be incompleteFor the first time the patient is a witness. They can localise pain, describe onset, and tell you what happened. They will also minimise, omit anything embarrassing, and say they are fine, because being brave is what they understand the job to be.
Send the parent out — and know where the guidance startsPaediatric bodies recommend routine one-on-one time from about eleven, and the evidence that it improves disclosure comes from adolescents. Below that it is a judgement rather than a rule: offer it when the question is a private one — ingestion, self-harm, fear, what they think is happening — and not otherwise. If you suspect abuse, ask as little as possible and refer. A detailed interview by an untrained questioner can contaminate a forensic account; that is a specialist’s job.
Explain before you touch, in orderThey are concrete thinkers. Say what will happen, in sequence, without metaphor — “a little scratch” means nothing, and “we will put you to sleep” means something you did not intend. Offer the choices that are real (which arm) and do not offer the ones that are not.
Examine the hip of every child with a sore kneeReferred pain is the trap of this age group. Perthes disease and slipped upper femoral epiphysis both present as knee pain in a child who cannot localise reliably, and both are missed by examining the knee.
Count the respiratory rate, and then look at the workRate alone is a poor discriminator by this age. Accessory muscle use, the ability to speak in sentences, and posture tell you far more. A child sitting forward and refusing to lie down has told you something before you touch them.
Ask what they are usually likeParents describe change with real precision if you ask for change rather than for worry. “He is normally the loudest one in the house” is a clinical observation.
And still look at the whole childUndress them. Bruising in unusual places, marks that do not fit the story, and injuries at odds with what a child of this age can physically do all still matter — the pattern changes at school age but the obligation does not.
If you take one thing: at this age the examination gets easier and the history gets
harder. The information you need most is the information they have decided not to volunteer.
Likely to be examined as: a long or short case where the marks are in how you
approach the child rather than in the findings. Examiners watch whether you address the child before the
parent, whether you explain before you touch, and whether you examine the hip of a child complaining of a
knee.
Tier three
What you will be expected to do
Phase 3 — the final clinical years, the pre-internship term, and your first nights on call
Asthma is the one that will kill somebody on your watchThis is the peak age for admission and for preventable death. Salbutamol by spacer unless they are too unwell to use it, ipratropium early in severe disease, then magnesium, then an infusion by local policy. Ask about previous intensive care, previous intubation and recent oral steroids — those three answers change your threshold.
A quiet chest is the emergencyThe wheeze was evidence that air was moving. Silence in a tiring child, a rising carbon dioxide, or a child who has stopped fighting you means the situation has changed. Escalate before you are certain.
Diabetic ketoacidosis: follow the protocol exactlyOften the first presentation of type 1 diabetes at this age, and it may arrive dressed as abdominal pain or as a chest infection. Cerebral oedema is rare and is what kills — headache, falling conscious state, bradycardia and hypertension, which is the opposite of shock. This is not a place to improvise the fluids.
In trauma, look for the injuries you cannot seeHandlebar to the epigastrium means pancreas and duodenum with a deceptively soft abdomen. A seatbelt mark means bowel, mesentery and a Chance fracture until excluded. And a normal blood pressure is not a normal circulation — they compensate, then crash.
Ask about self-harm, directlyAt the top of this age band ingestions stop being accidental. Every deliberate ingestion needs a mental health assessment and not just a paracetamol level, and the question has to be asked privately and more than once.
Analgesia is planned, not rescuedLet them score their own pain and believe the number. Withholding opioids from a child with abdominal pain is a dogma that outlived its evidence decades ago.
Know the numbers cold, and check them anywayFluid 10 mL/kg. Adrenaline 10 microgram/kg. Defibrillation 4 J/kg. Glucose 2 mL/kg of ten per cent. Cuffed tube, age over four plus three and a half. Verify every one against your own formulary before you use it.
Call earlyIn New South Wales that is NETS on 1300 36 2500. Nothing is lost by a phone call that gets stood down, and a great deal is lost by the one that comes an hour late.
If you take one thing: the commonest error at your stage is not the wrong drug. It
is waiting — for more information, for the consultant to arrive, for the child to declare
themselves. Notice early, do the simple things well, and call somebody.
Likely to be examined as: an OSCE or viva on the acute asthmatic, the child in
ketoacidosis, or a deliberate ingestion. You will be marked on structure and escalation rather than on
obscure knowledge — say aloud what you are doing and when you would call for help.
Over to you
Which tier did you read — and what did I leave out that you needed?
Tell me your year, which tier fitted, and what was missing, too basic or too advanced. If there is a
topic you are struggling with, say that too and I will build the next one around it.