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Caring for children – safe and effective practice
EDITORIAL
Caring for children – safe and effective practice
to children’s mental health, undermining the development of resilience (the ability to cope with life’s ups and downs).5 Every professional interaction with children should aim to promote resilience, a key life skill for all children.
Heather Payne
Child safeguarding Although the vast majority of parents are able to protect and prioritise their child’s needs, this is not so in every case. Any professional working with children must have basic safeguarding skills,6 with the ability to recognise and refer possible abuse. Child abuse tragedies are regularly reported in the media, despite repeated review findings7 that underline the need for direct observation of and listening to the child, and careful interagency working. When the child’s rights conflict with the adult’s (such as the need to disclose confidential information about a parent to help protect the child) then child protection considerations justify disclosure.8
This edition of The Foundation Years deals with the common acute presentations in children. Many young doctors who have not yet had the profound learning experience of having their own offspring will find the prospect of treating children the more frightening the smaller the patient. The presenting complaint may be non-specific – crying, bad tummy, off their food, or more confusing still, a parent saying ‘he’s just not right, Doctor’. Children can get ill worryingly fast, and may recover equally quickly. The consequences of missed severe illness are rare but devastating. The question seems to be how to find a needle in a haystack: which of the febrile,1 vomiting children presenting this evening will be fine tomorrow morning, and which few may have meningitis or some other treatable condition, which must be identified to prevent death or disability? Careful attention to the concerns of the parents or carers is essential. Parents are experts in their child and will be able to give detailed information with the right prompts and questions. When their child is ill, they will be far more upset and worried than an adult patient, and need patience and understanding (although within firm boundaries including zero tolerance of aggression or violence). Use of the evidence base is essential. NICE guidelines2 should be used wherever possible (issued or under consultation in many relevant areas, including the febrile child, diarrhoea and vomiting, self harm and investigation of suspected child abuse). The importance of careful clinical physiological observations cannot be overstated, especially heart and breathing rate, temperature and skin turgor in the acute situation, growth and head circumference in the longer term.
Conclusions Children (under the age of 18) make up about a quarter of the UK population and represent greater than this proportion of consultations in primary care. Many adults who consult a doctor are parents of children under 18, who may be affected by their parent’s illness; so it is unlikely that any doctor can justifiably say, ‘I don’t need to know how to deal with children’. Safe medical care for children requires the doctor to be thorough and careful, to listen and respond to the patient and the family, to use the evidence base and to consult senior or paediatric specialist colleagues for advice. When dealing with acute illness, it is essential to maintain a high index of suspicion of possible sepsis, which may have potentially catastrophic consequences (death or permanent disability), which are avoidable through early identification and treatment. A process of active learning, focused diagnostic questions, access to just-in-time knowledge bases and careful reflection (ideally captured in a reflective note for your learning portfolio)9 will serve any doctor well. The foundation years are the ideal opportunity, like childhood, to develop the good habits that will stand you in good stead for the rest of your life. ◆
The specific needs of children and respecting rights
References 1 National Library for Health. Best bets: the febrile child. Also available at: http://www.bestbets.org/database/browse-by-topic. php?CategoryID=17. 2 National Institute for Clinical Excellence. Also available at: http:// www.nice.org.uk. 3 DCA website archive. FAQ on Human Rights Act 1998. Also available at: http://www.dca.gov.uk/peoples-rights/human-rights/faqs.htm. 4 DCSF. UN convention on rights of the child; UK report 2007. Every child matters. Also available at: http://www.everychildmatters.gov. uk/strategy/uncrc/ukreport/. 5 Grotberg EA. Guide to promoting resilience in children: strengthening the human spirit. The International Resilience Project. Also available at: http://resilnet.uiuc.edu/library/grotb95b. html, 1995.
All of us have human rights, now legally enforceable.3 Children are more vulnerable, and are afforded extra protection enshrined in the UN Convention on the Rights of the Child.4 Knowing the child’s family context is also vital, as the child’s life and daily routine is determined by their family. Promotion of positive mental health is a parent’s daily role, in affectionate interaction, support, encouragement and positive discipline. There is good evidence that a home displaying low warmth and high criticism is harmful
Heather Payne MBBS DCH IHM FRCPCH ILTM is Senior Lecturer within the Department of Child Health and Associate Dean of the Postgraduate School at the Wales College of Medicine, Cardiff University, UK. Conflicts of interest: none declared.
THE FOUNDATION YEARS 5:2
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© 2009 Elsevier Ltd. All rights reserved.
EDITORIAL
8 GMC. 0–18 Years - guidance for all Doctors. Also available at: http://www.gmc-uk.org/guidance/archive/GMC_0-18.pdf, 2007. 9 Kaufman DM. ABC of learning and teaching in medicine - applying educational theory in practice. BMJ 2003; 326: 213–216. Also available at: http://www.bmj.com/cgi/content/full/326/7382/213.
6 RCPCH. Safeguarding children and young people - roles and competences for health care staff. Also available at: http://www. rcpch.ac.uk/Publications/Publications-list-by-title, 2006. 7 Statement of Ed Balls, Secretary of State for Children, Families and Schools. Also available at: http://www.independent.co.uk/news/uk/ politics/baby-p-ed-balls-statement-in-full-1044023.html, 1 Dec 2008.
THE FOUNDATION YEARS 5:2
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© 2009 Elsevier Ltd. All rights reserved.
Caring for children – safe and effective practice
to children’s mental health, undermining the development of resilience (the ability to cope with life’s ups and downs).5 Every professional interaction with children should aim to promote resilience, a key life skill for all children.
Heather Payne
Child safeguarding Although the vast majority of parents are able to protect and prioritise their child’s needs, this is not so in every case. Any professional working with children must have basic safeguarding skills,6 with the ability to recognise and refer possible abuse. Child abuse tragedies are regularly reported in the media, despite repeated review findings7 that underline the need for direct observation of and listening to the child, and careful interagency working. When the child’s rights conflict with the adult’s (such as the need to disclose confidential information about a parent to help protect the child) then child protection considerations justify disclosure.8
This edition of The Foundation Years deals with the common acute presentations in children. Many young doctors who have not yet had the profound learning experience of having their own offspring will find the prospect of treating children the more frightening the smaller the patient. The presenting complaint may be non-specific – crying, bad tummy, off their food, or more confusing still, a parent saying ‘he’s just not right, Doctor’. Children can get ill worryingly fast, and may recover equally quickly. The consequences of missed severe illness are rare but devastating. The question seems to be how to find a needle in a haystack: which of the febrile,1 vomiting children presenting this evening will be fine tomorrow morning, and which few may have meningitis or some other treatable condition, which must be identified to prevent death or disability? Careful attention to the concerns of the parents or carers is essential. Parents are experts in their child and will be able to give detailed information with the right prompts and questions. When their child is ill, they will be far more upset and worried than an adult patient, and need patience and understanding (although within firm boundaries including zero tolerance of aggression or violence). Use of the evidence base is essential. NICE guidelines2 should be used wherever possible (issued or under consultation in many relevant areas, including the febrile child, diarrhoea and vomiting, self harm and investigation of suspected child abuse). The importance of careful clinical physiological observations cannot be overstated, especially heart and breathing rate, temperature and skin turgor in the acute situation, growth and head circumference in the longer term.
Conclusions Children (under the age of 18) make up about a quarter of the UK population and represent greater than this proportion of consultations in primary care. Many adults who consult a doctor are parents of children under 18, who may be affected by their parent’s illness; so it is unlikely that any doctor can justifiably say, ‘I don’t need to know how to deal with children’. Safe medical care for children requires the doctor to be thorough and careful, to listen and respond to the patient and the family, to use the evidence base and to consult senior or paediatric specialist colleagues for advice. When dealing with acute illness, it is essential to maintain a high index of suspicion of possible sepsis, which may have potentially catastrophic consequences (death or permanent disability), which are avoidable through early identification and treatment. A process of active learning, focused diagnostic questions, access to just-in-time knowledge bases and careful reflection (ideally captured in a reflective note for your learning portfolio)9 will serve any doctor well. The foundation years are the ideal opportunity, like childhood, to develop the good habits that will stand you in good stead for the rest of your life. ◆
The specific needs of children and respecting rights
References 1 National Library for Health. Best bets: the febrile child. Also available at: http://www.bestbets.org/database/browse-by-topic. php?CategoryID=17. 2 National Institute for Clinical Excellence. Also available at: http:// www.nice.org.uk. 3 DCA website archive. FAQ on Human Rights Act 1998. Also available at: http://www.dca.gov.uk/peoples-rights/human-rights/faqs.htm. 4 DCSF. UN convention on rights of the child; UK report 2007. Every child matters. Also available at: http://www.everychildmatters.gov. uk/strategy/uncrc/ukreport/. 5 Grotberg EA. Guide to promoting resilience in children: strengthening the human spirit. The International Resilience Project. Also available at: http://resilnet.uiuc.edu/library/grotb95b. html, 1995.
All of us have human rights, now legally enforceable.3 Children are more vulnerable, and are afforded extra protection enshrined in the UN Convention on the Rights of the Child.4 Knowing the child’s family context is also vital, as the child’s life and daily routine is determined by their family. Promotion of positive mental health is a parent’s daily role, in affectionate interaction, support, encouragement and positive discipline. There is good evidence that a home displaying low warmth and high criticism is harmful
Heather Payne MBBS DCH IHM FRCPCH ILTM is Senior Lecturer within the Department of Child Health and Associate Dean of the Postgraduate School at the Wales College of Medicine, Cardiff University, UK. Conflicts of interest: none declared.
THE FOUNDATION YEARS 5:2
41
© 2009 Elsevier Ltd. All rights reserved.
EDITORIAL
8 GMC. 0–18 Years - guidance for all Doctors. Also available at: http://www.gmc-uk.org/guidance/archive/GMC_0-18.pdf, 2007. 9 Kaufman DM. ABC of learning and teaching in medicine - applying educational theory in practice. BMJ 2003; 326: 213–216. Also available at: http://www.bmj.com/cgi/content/full/326/7382/213.
6 RCPCH. Safeguarding children and young people - roles and competences for health care staff. Also available at: http://www. rcpch.ac.uk/Publications/Publications-list-by-title, 2006. 7 Statement of Ed Balls, Secretary of State for Children, Families and Schools. Also available at: http://www.independent.co.uk/news/uk/ politics/baby-p-ed-balls-statement-in-full-1044023.html, 1 Dec 2008.
THE FOUNDATION YEARS 5:2
42
© 2009 Elsevier Ltd. All rights reserved.