Hospitalization is a crisis for children and families. Children have fewer coping skills, limited understanding of illness, and depend on routines and caregivers. The main stressors are separation, loss of control, and fear of bodily injury and pain; how a child reacts depends on age, previous experiences, and the support available.

Two guiding frameworks:

• Family-centered care — the family is the constant in the child's life; parents are partners in care, decision-making, and comfort
• Atraumatic care — minimize physical and psychological distress: prevent or reduce separation, promote a sense of control, and prevent or minimize pain

Separation anxiety (most intense from about 6 months through the preschool years) typically has three phases:

Reactions by developmental stage

Physical assessment on admission

• Weight in kilograms (and height) — basis for all medication and fluid calculations
• Vital signs with age-appropriate technique; baseline pain score
• Respiratory status in infants: rate for a full minute, work of breathing (nasal flaring, retractions, grunting, head bobbing), breath sounds (wheezes, crackles), oxygen saturation, color, feeding tolerance — assessed together, not as single items
• Allergies (drugs, foods, latex), immunization status, developmental level, usual routines (nicknames, comfort objects, feeding, toileting words)
• Fall risk and skin risk

Relevant tools rather than a single test:

Pain assessment scales

Use the same scale consistently, reassess after every intervention, and trust a child's self-report when it is available.

• Pediatric fall-risk tools (e.g., Humpty Dumpty Falls Scale) guide prevention level
• Pediatric early warning scores in many hospitals trigger escalation of care

Medication safety — the highest-risk area in pediatrics

• Doses are weight-based (mg/kg); calculate the safe dose range and compare the ordered dose before every administration. Many errors are tenfold (decimal point) errors
• Use weight in kg only; independent double-check for high-alert drugs (insulin, opioids, heparin, electrolytes, chemotherapy)
• Doses are verified against a pediatric drug reference in practice
• Oral: use an oral syringe (not household spoons); give into the side of the cheek, small amounts at a time; do not mix with essential foods (e.g., formula in a full bottle) — the child may refuse them later or not take the full dose
• Intramuscular sites: vastus lateralis for infants and toddlers; deltoid once muscle mass is adequate (about 3 years, sometimes earlier); ventrogluteal is acceptable in older infants and children
• IV therapy: use an infusion pump and often a volume-control chamber to prevent fluid overload; check the site at least hourly for infiltration; secure well but keep the site visible

Procedures

• Perform painful procedures in a treatment room, not the child's bed — the bed and playroom stay "safe places"
• Topical anesthetics (lidocaine–prilocaine or liposomal lidocaine creams) applied before venipuncture per product timing; oral sucrose with non-nutritive sucking for brief procedures in young infants; distraction, positioning for comfort (child held upright by parent rather than lying flat)
• Opioid and non-opioid analgesics are weight-based; monitor sedation and respiratory rate with opioids (keep naloxone available); ibuprofen is not given with dehydration or active bleeding, and it is generally not used under 6 months; acetaminophen doses from all products must be added up (hepatotoxicity) — usual oral dose 10–15 mg/kg every 4–6 hours; do not exceed 75 mg/kg/day or 4 g/day

Listed in priority order.

1. Airway, breathing, circulation — recognize respiratory distress early; children compensate well, then deteriorate quickly
2. Safe medication administration — weight-based dose check, right patient (two identifiers; ID band), independent double-checks
3. Fall and injury prevention, using several measures together:
   • Crib side rails fully up whenever the nurse steps away; crib tops (bubble or net tops) for climbers
   • Bed in lowest position, call light in reach, non-skid footwear, adequate lighting
   • Accompany high-risk children to the bathroom; educate parents
   • Keep small objects, latex balloons, and medications out of reach
4. Pain assessment and management — age-appropriate scale, pharmacologic and non-pharmacologic measures, reassess
5. Minimize separation: encourage parents to stay (rooming-in) and to participate in care; keep familiar objects (blanket, favorite toy), home routines and rituals; consistent nurse assignment
6. Give control: offer real choices ("Which arm?" "Juice or water after your medicine?"), not choices that do not exist ("Do you want your shot?")
7. Prepare for procedures by developmental level
   • Toddler: explain just before the procedure, simple words, let them handle safe equipment
   • Preschooler: therapeutic play with dolls and real equipment; short, concrete explanations; use bandages (fear of "leaking"); avoid words like "cut" or "take your blood"
   • School-age: explain in advance with diagrams, allow questions, involve in care tasks
   • Adolescent: explain directly, protect privacy, involve in decisions, allow peer contact
8. Therapeutic communication: acknowledge and name the child's feelings ("You are scared of being alone") and invite them to talk; do not shame ("Big kids don't cry"), bribe, or dismiss
9. Temperature support for small infants: incubator or radiant warmer set by weight and age; skin probe temperature about 36.5 °C (97.7 °F); never use hot-water bottles or heated gloves (burn risk)
10. Specific care examples
    • Chemotherapy-related mucositis: gentle mouth care with a soft toothbrush or soft sponge if the gums bleed, bland rinses (saline or sodium bicarbonate) as ordered, prescribed topical analgesic agents, avoid hot, spicy, and acidic foods
    • Restraints only when needed for safety or a procedure: least restrictive type, explain to child and parent, check circulation and skin often, release and reassess per policy
11. Assent and consent: parents give consent; seek the child's assent (agreement) from about school age; respect adolescents' growing autonomy
12. Discharge planning — start at admission; teach medications with return demonstration

• Parents: expected regression is temporary; respond with patience rather than punishment
• Honest explanations — do not promise that something will not hurt if it will
• Teach parents to use the oral syringe and measure doses in mL, never in teaspoons
• Home safety of medications: locked storage; poison control number
• Siblings may feel neglected or guilty; involve them when possible

• Medication errors (tenfold overdose, wrong concentration) — stop, assess, notify, follow reporting policy
• IV infiltration or extravasation in infants: swelling, coolness, blanching — stop infusion immediately
• Falls from cribs, beds, or while carried
• Signs of deterioration: rising early warning score, tachypnea, grunting, altered responsiveness, poor perfusion
• Unmanaged pain (causes long-term fear of health care) and oversedation with opioids
• Prolonged despair or detachment behaviors; severe regression
• Device-related pressure injuries (oximeter probes, tubing, casts) in small children

• Main stressors: separation, loss of control, fear of injury and pain
• Separation anxiety phases: protest → despair → detachment; peaks in toddlers
• Preschoolers see illness as punishment and fear mutilation — use bandages and therapeutic play
• Acknowledge feelings and let the child talk; no bribes, no shaming
• Weight-based dose check is the most important medication safety step
• Infants' IM site: vastus lateralis; IV fluids via pump, site checked hourly
• Treatment room for procedures — keep the bed a safe place
• Pain scales: FLACC for non-verbal young children, FACES from about 3 years, numeric from about 8 years
• Fall prevention is multi-component: rails up, low bed, supervision, non-skid socks
• Never use hot-water bottles to warm infants
• Seek assent from school-age children; involve adolescents in decisions