Big Head, Little Body Syndrome: What EMS Providers Need to Know

From the first EMS classes we attended, we were taught that "children are not small adults." This is true in many ways: physically, psychologically and emotionally. One of the most significant differences between children and adults can be termed "Big Head, Little Body Syndrome." Compared to the adult population, children have big heads and little bodies. Our ability to provide optimal care during pediatric emergencies, whether medical or traumatic, often hinges on how well we understand the importance of those anatomical proportion differences. This article will review unique ABCDE factors that are impacted by this "syndrome" and their implications for EMS providers.

A Is for Airway

The basis for all emergency resuscitation treatment begins with establishing an adequate airway. If you lay a young child flat on a stretcher or spine board, his/her big head can cause potentially serious airway problems by forcing the chin onto the chest in an exaggerated downward-facing position. This is especially true for children under age eight, due to the prominent occiput.1¡V3

Basic resuscitation courses teach that after asking the patient if he is okay, the next action is to open the airway by gently tilting the head back and/or performing a jaw thrust. Until recently, it was commonly taught that extremes of head position (flexion or extension) actually closed or crimped the trachea.1,4,5 Subsequent studies have shown that this is not necessarily the case, demonstrating that airway compromise may not be due to a "squished" trachea. The problem probably arises from the way the relaxed tongue and hypopharnyx can obstruct the airway.6¡V9 A simple remedy for this situation is to provide adequate padding, such as a folded diaper (for infants), small towel roll (for older kids), or a commercially available adjustable pad, under the shoulders to place the airway in a more neutral position (see Figures 1¡V2).

B Is for Burns

Big head, little body makes a difference when treating burns. Scalds resulting from sudden immersion into too-hot water, or from pulling things down from stove tops, constitute a high percentage of pediatric burn injuries.1,10¡V12 Much like the ABCs of resuscitation, EMS providers are taught the "Rule of 9s" for emergency burn care. Often described as distinguishing the big parts from the little parts, the Rule of 9s (see Figure 3) says that little parts of the body represent 9% of the body surface area (BSA) while the big parts are twice that, or 18%. In an adult, the entire head is a "little part" and therefore accounts for just 9% of BSA. In young children, the big head is proportionally larger and therefore it is a "big part" that represents 18% of the body.1,10¡V12

C Is for Cervical Spine and Car Seats

Just as all resuscitation efforts begin with ABC, all trauma efforts should include recognizing the commonly held EMS precept that "everyone has a broken neck until proven differently." Placing a young child who requires spinal immobilization on a traditional spine board is not a pretty picture. Despite the fact that we usually don't want anything on the board "but their butt," there are special interventions to consider for spinal immobilization of patients with "big head, little body syndrome."3,13,14

As described earlier, placing a towel roll or diaper under the shoulders of the pediatric patient can better position the head and airway. This applies to spinal immobilization as well.1,7,11,13,15,16 There is a new pediatric pad that can be placed on a conventional spine board to help with big head positioning.16,17¡V19 In addition, this new pad is color-coded to match the popular Broselow-Luten tape, which makes it of great value in managing initial resuscitation of the child.