How patients change with age

1. You findAn infant has a heart rate and breathing rate far above adult values.You doJudge against the age, not against an adult. Infants normally run fast. They also breathe through the nose in the first weeks, breathe with the diaphragm so the belly moves more than the chest, and tire quickly in respiratory distress.
2. You findYou look at the soft spot on top of an infant's head.You doRead it. A sunken fontanelle suggests dehydration. A bulging fontanelle in an infant who is not crying suggests increased pressure inside the skull.
3. You findAn infant or toddler panics when you move them away from the parent.You doKeep the parent close, even holding the child. Separation anxiety is normal at this age and gets in the way of your assessment.
4. You findA preschooler is frightened and seems to think being sick is their fault.You doBe reassuring and keep explanations simple. Magical thinking is normal at this age, and a preschooler may believe an illness or injury is a punishment.
5. You findA school-age child wants to know what you are doing.You doTell them, and involve them in their own care. Children of 6 to 12 can understand explanations.
6. You findA teenager gives short, guarded answers in front of parents or friends.You doGive them privacy. Adolescents may not answer honestly in front of others. Stay alert for signs of eating disorders, self-harm and depression.
7. You findAn older adult is confused, or has a fast heart rate.You doDo not assume confusion is normal aging; look for a cause. A fast heart rate is tolerated less well in late adulthood, and the risk of falls is high.

• Two things change with age: physiologic development (the body, the vital signs, motor ability) and psychosocial development (trust, independence, identity).
• Eight stages: infancy (birth to 1 year), toddler (12 to 36 months), preschool (3 to 5 years), school age (6 to 12), adolescence (13 to 18), early adulthood (19 to 40), middle adulthood (41 to 60) and late adulthood (61 and up).
• The trend to remember: as age goes up, heart rate and breathing rate go down and blood pressure goes up. You need a feel for normal at each age, not every number.
• Infants grow fast. Birth weight doubles by 6 months and triples by 12 months, and the head is about a quarter of the body weight.
• Fontanelles close with age: the posterior by about 2 to 3 months, the anterior by 9 to 18 months.
• Newborn reflexes. Moro: when startled, the arms fly out, the fingers spread, then grab. Palmar: grasps a finger placed in the palm. Rooting: turns toward a touch on the cheek. Sucking: starts sucking when the lips are stroked.
• Infant psychology. Crying is the main way an infant communicates. Bonding is the infant's sense that its needs will be met, and a consistent, responsive environment builds trust.
• Puberty is the point where CPR guidelines switch from pediatric to adult.
• Adults. Physical condition peaks between 19 and 26, and accidents are a leading cause of death in early adulthood. Middle adulthood brings vision changes, cholesterol and cancer concerns, and menopause. Late adulthood brings a less efficient heart, declining lungs and a slower metabolism.

The wrong idea: Confusion is just part of getting old, so in an elderly patient it is not an important finding.

What is actually true: Confusion is never assumed to be normal for age. In an older adult it is treated as a change in mental status that needs a cause, the same as in any other patient.

Patients change in two ways with age: the body and its vital signs, and the mind and its social needs. Across the eight stages of life the heart rate and breathing rate fall and the blood pressure rises, so normal depends on age. Infants breathe fast, through the nose and with the belly, and their fontanelles are a window on dehydration and intracranial pressure. Keep parents close to infants and toddlers, reassure preschoolers in simple words, explain things to school-age children, give adolescents privacy and watch for self-harm and eating disorders. In older adults, never write confusion off as age, and remember that a fast heart rate is poorly tolerated and falls are common.

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