From toddler to adolescent, each age group has special needs when receiving respiratory care. By understanding these needs, RTs can provide effective care and achieve positive outcomes.

 Four-year-old Jamal has been in the emergency department (ED) for 6 hours being treated for an asthma exacerbation. The respiratory therapist enters the room to give a nebulizer treatment before the child is admitted and says, “I’m going to give you some more mist before you get on the stretcher to go to the floor.” Jamal’s eyes widen and he begins to cry, calling for his mother. His respiratory rate increases and retractions worsen.

Respiratory care practitioners are experts at managing pediatric respiratory conditions from asthma to cystic fibrosis to preventing postoperative complications. That technical expertise is not always accompanied by an understanding of childhood development and age-appropriate care, however. Jamal’s therapist, for example, did not understand that preschoolers take words literally, and upon hearing the term stretcher, Jamal thought he was going to be stretched on a machine. Telling him he was going to the floor meant, to Jamal, that he would have to be on those hard tiles under everyone’s feet. When children are afraid or upset, they cry, which increases respiratory rate, oxygen demand, and work of breathing. This article provides respiratory care practitioners with an overview of cognitive and psychosocial development and recommendations for working with children of all ages most effectively. Keep in mind that the categories used here overlap and individual children may be slightly ahead or behind the age-specific norms described.

Toddlers: Exploring the World Around Them
Toddlers, 1 to 3 years of age, are experiencing a stage of rapid physical and psychosocial development. Their thinking is concrete, and they interpret words literally. They have not yet learned to share toys, and if you say, “I’m going to take your temperature,” they will often react negatively, thinking you are taking something away from them. Separation from caregivers is very stressful, and this dependency increases during times of illness. Allow the parent or guardian to stay with the child during respiratory care treatments; ideally, provide therapy while the child is on a familiar caregiver’s lap. Toddlers have yet to develop a sense of danger, and they are very curious, so raising side rails on the crib after a treatment is essential to prevent a fall. Toddlers also value their newly developed mobility, so avoid holding them down unless absolutely necessary for safety, such as when drawing an arterial blood sample.

Use simple terms when talking with a toddler, such as saying, “Your lungs are sick and need medicine,” before giving an aerosol treatment. Similarly, if you need to give instructions, give one direction at a time, such as “Sit up,” rather than “Sit up so I can listen to your lungs.” Spend a little time talking with toddlers before you touch them, since most are wary of strangers, especially when they are overwhelmed with the many caregivers in the hospital or ED. It is always best to auscultate lungs of a child who is quiet rather than those of one who is crying loudly. Be playful whenever possible so as to be less threatening to the child.

Let toddlers handle equipment such as your stethoscope or a nebulizer before you use it clinically, and bring an extra disposable item such as a mask for the child’s teddy bear or doll to make the equipment less threatening. Do not tell a toddler the treatment will take only 5 more minutes, because most toddlers have not yet developed a sense of time.

Play Activities for Respiratory Care

  • Blow bubbles with commercial bubble mix and wand.
  • Blow bubbles with a straw under water.
  • Blow into a noise-making device such as a kazoo or harmonica; give it to the child as a reward.
  • Blow on a toy that will move and provide visual feedback, perhaps a pinwheel or feathers.
  • Make pictures by blowing paint through a straw.
  • Create games such as blowing Ping-Pong balls across a table or across the surface of a tub of water.
  • Use syringes to squirt decorations on cookies or to squirt watercolor paint to create a picture. This will make them less threatening.
  • Use a paper cup with stickers in the bottom instead of a face mask; run large-bore aerosol tubing from the nebulizer to the bottom of the cup, and hold the cup to the child’s face. Allow the child to draw on the cup to make it their own.

Preschoolers: Transition to Independence
Preschoolers, 3 to 5 years old, are in a transitional phase in which they retain many of the toddler’s characteristics while becoming more independent and self-sufficient. Preschoolers are very magical thinkers, and this often leads to misunderstandings when adults use words and phrases that can easily be misinterpreted by the child, such as when Jamal thought a stretcher was a device that would stretch his body. Adults often do not realize that even phrases that seem simple can frighten children. If you talk about a CAT scan, they may worry about felines. Or they may hear the term IV and think it is a leafy, green plant. It is easy for clinicians to overestimate a preschooler’s comprehension because they have quite good verbal skills and ask lots of questions.

Preschoolers believe they can make things happen by wishing. This can be terrifying if they wished a sibling would go away the day before the family is in an auto accident and the children are separated in the ED, for example. They may also believe that an injury or illness is punishment for something they did or thought about doing. When you care for a preschooler, tell him the treatment is not a punishment. Ask children if they feel happy or sad, scared or mad, and praise them when they try to cooperate with care. Be careful not to tell a child that being good means showing no emotion, and try to avoid using the word bad because children of this age will have a hard time understanding that a bad cough does not mean they are themselves a bad person. Never threaten dire consequences for not “behaving” under the stress of a hospitalization or medical treatment or a procedure. Exasperated parents sometimes say, “If you don’t behave, the nurse will give you a shot,” which makes care very complicated if an injection is then required.

Bandages are very important to preschoolers because they typically think any break in the skin can allow their “insides to leak out.” Bandages are seen as protective and are very comforting. Thus, any time you draw blood, focus on applying an adhesive bandage after the procedure even if it is not medically indicated.

As with the toddler, allow the preschooler to become familiar with equipment by allowing them to handle it and by treating a favorite doll or stuffed animal. Children at this age will respond well to games and treatments that incorporate play. For 5-year-old Emily, who has just been admitted to the pediatric unit after having abdominal surgery, try this approach, “I brought this pinwheel with me. See how pretty it is when I blow on it? Now I want you to make it spin.”

Provide explanations in terms of the child’s senses, such as “You’ll feel this medicine like a feather on your face, and it will make a funny noise” before a nebulizer treatment. Use simple analogies such as comparing blowing in a peak flow meter to blowing out birthday candles. Offer choices when you can, but do not accept unnecessary delays of more than 2 minutes if a preschooler stalls for time.

School-Age Children: A Sense of Accomplishment
School-age children, ages 6 to 11 years, are developing a sense of accomplishment as they master new skills. Experiencing success helps them develop a sense of self-esteem. At about age 7, children move from the magical thinking of preschoolers to more logical thought. They no longer see illness or injury as punishment and can begin to understand cause and effect, such as “If you take two puffs every morning, your lungs will stay healthy.” You can provide more complex instructions, such as “We’ll help you hold your arm still, but it’s okay if you need to cry,” when drawing an arterial blood sample.

School-age children understand time since their days are scheduled at school. Be sure to tell a child how much time is left in a procedure or treatment, and offer to count the time down for the child. These children can also understand longer-term consequences of illness, and, for the first time, they understand that death is irreversible. Toward the older ages, school-age children have a better knowledge of anatomy and understand more complex explanations, such as “The breathing tubes in your lungs are squeezing closed, so I need to give you medicine to open them up.”

At this age, children are afraid of losing control, of being separated from others their age, and of becoming more dependent on parents again. You can offer them the choice of having a caregiver present when you are with them; being able to take a treatment without a parent present may be important for the child’s self-esteem. You can also support school-age children by asking them to be your helper, such as opening the plastic bag that holds a piece of equipment and handing the equipment to you.

Children of this age are becoming more sensitive to privacy and may want to be covered up when you listen to their lungs, for example. They tend to hide their thoughts and feelings and act brave to protect themselves from their fears, so offer them the opportunity to talk about how they feel. They may not want to admit they do not know something, so open the door to questions by offering an explanation such as “Would you like to know how this nebulizer makes a mist?”

Child Life Specialists
Child life specialists (CLSs) are professionals who are specially trained to help children and their families cope with hospitalization. Their training covers human growth and development, education, psychology, and counseling. Clinicians can collaborate with the CLS to develop a plan of care and an approach to children and their families that will help them understand the hospitalization, provide emotional support, and create therapeutic medical play activities to facilitate care. While CLSs were once exclusively hospital-based, their expertise is now being used in all pediatric settings, including emergency departments, clinics, and outpatient centers. Respiratory care practitioners can consult with these specialists to help prepare children for procedures or surgery and to develop approaches to care that will reduce a child’s anxiety and promote his cooperation.

Child Life Council. Available at:   Accessed November 16, 2004.

Adolescents: Not Adults Yet
Adolescents are often treated like adults, but to provide the most appropriate care, clinicians should be aware of their developmental needs. Adolescents are most fearful of changes to their physical appearance and threats to their emerging independence. Their relationships with other teens are very important, and encouraging peer visitation will help support a teen’s self-esteem during a hospitalization.

Adolescents can be very moody and are particularly insulted when treated like a child or hospitalized on a pediatric unit with much younger children, particularly if they have to share a room with a child. If possible, offer to give treatments in a day room or other area of the teen’s choosing. Be sure to provide privacy, and ask permission before you examine a teen. When you talk with a young adult, try to avoid interruptions or distractions and pay attention to nonverbal cues.

Explain treatments and procedures in detail. When possible and factual, reassure adolescents that they can fully recover, whether it is from an asthma exacerbation or a traumatic injury. Do not dismiss the teen’s concerns about scarring or changes in physical appearance, even if the changes are barely noticeable to you. Discuss your assessment and emphasize the normal findings to provide reassurance. Work with adolescents to problem-solve so they can adapt treatments to their everyday lives. For example, many teens are reluctant to carry a metered-dose inhaler with them because it is big and bulky in their pocket, and visible to others at a time when the teen wants to look exactly like his or her peers. An inhaler that fits into one’s pocket may be more acceptable since it is easier to conceal, or better yet, a leukotriene modifier pill may be the best option for a teen’s asthma management.

Unfortunately, adolescents with chronic illnesses such as asthma or diabetes may completely abandon their daily treatment during a time of rebellion and frustration about being different from their peers. This behavior can lead to potentially life-threatening exacerbations. It is important to assess the teen without placing blame during initial treatment so you can get as much truthful information as possible to guide initial care. Once the crisis passes, you can explore the teen’s motivation for stopping treatment and help develop a plan the teen can follow on discharge.

Pediatric respiratory care can be fun and rewarding. By understanding the psychosocial needs of these young patients, you can provide effective age-appropriate care to achieve the most positive outcomes.

Patricia Carroll, RRT, RN, maintains a clinical practice as an emergency nurse at Manchester Memorial Hospital, Manchester, Conn.

Further Reading
1. Emergency Nursing Pediatric Course Provider Manual. 3rd ed. Des Plaines, Ill: Emergency Nurses Association; 2004.
2. Hockenberry MJ. Wong’s Clinical Manual of Pediatric Nursing. 6th ed. St Louis: Mosby; 2000.
3. Johnson DL. Preparing children for visiting parents in the adult ICU. Dimens Crit Care Nurs. 1994;13(3):152-154,157-165.
4. LeRoy S, Elixson EM, O’Brien P, Tong E, Turpin S, Uzark K. Recommendations for preparing children and adolescents for invasive cardiac procedures. Circulation. 2003;108:2550-2564.