Consultations with children
General Practioner Laindon, UK
E-mail: pfhbk{at}tiscali.co.uk
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Abstract |
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 TOP Abstract Standards set by the...Aims of the consultationChild-friendly premisesThe consultationBehaviour problemsMaking an action planPrescribing for childrenConsultations with special...References |
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Patients under 15 years of age comprise around 20% of the average GP list and account for one in four GP consultations. School children visit the GP between two and three times a year, but this figure is doubled in the under fives (who visit the GP an average of 6 times per year). The under fives also have more home visits than any other group except the elderly. Children form an important part of a GP's workload and this article aims to give the GP in training a strategy with which to approach their assessment in the community.
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Standards set by the National Service Framework for Children |
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TOPAbstractStandards set by the...Aims of the consultationChild-friendly premisesThe consultationBehaviour problemsMaking an action planPrescribing for childrenConsultations with special...References |
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National service frameworks (NSFs) are long-term strategies for improving specific areas of care. The NSF for children, young people and maternity services sets out a list of standards in the care of children and young people that NHS services should strive to meet (Box 2). Many of these standards do apply to general practice.
| What the GP curriculum says about consultations with children A GP must be able to develop and apply the primary care consultation to bring about an effective doctor, patient, family relationship. It is important for children and young people to be involved and supported routinely in making informed decisions and choices about their care (taking into account their age and development, increasing autonomy with age, and the need for confidentiality balanced with the parents' need for information). A GP must enable parents or carers to participate in their children's care planning and delivery, noting that the role of fathers in parenting their children and teenagers is frequently overlooked – all GPs should have the skills for engaging with fathers as well as mothers. A GP must understand the problems with transitions from child to adolescent, and from adolescent to adult, and be able to support young people with a chronic disease negotiate these transitions.
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Aims of the consultation |
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TOPAbstractStandards set by the...Aims of the consultationChild-friendly premisesThe consultationBehaviour problemsMaking an action planPrescribing for childrenConsultations with special...References |
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When assessing a child in primary care, the objectives are to:
- Establish a constructive relationship with the child and carers to enable effective communication and serve as the basis for any subsequent therapeutic relationship
- Determine whether the child has a physical or behavioural problem and, if so, what that is
- Find out (where possible) what caused that problem
- Assess the child's and family's emotions and attitudes towards the problem, and
- Establish how it might be treated
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Child-friendly premises |
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TOPAbstractStandards set by the...Aims of the consultationChild-friendly premisesThe consultationBehaviour problemsMaking an action planPrescribing for childrenConsultations with special...References |
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Children are much easier to assess if they feel comfortable in their environment. This starts before the child has even been seen by the doctor. Have a look at your surgery reception and waiting room. Is it child-friendly? Is there access for prams and pushchairs? Are there some toys or books available for children to play with whilst they are waiting? Are there books and magazines suitable for older children? If not, speak to your practice manager and ask if anything can be done to improve the reception and waiting area for children.
Safety is another important issue when considering child-friendly premises. Small children are naturally inquisitive. Ensure that sharps boxes and anything else that is potentially dangerous are kept well out of reach. Sharp corners at head level are another potential hazard that it is easy to safeguard against. Plastic corner protectors are cheap and can be bought from most DIY stores.
| Box 1. Diploma in Child Health The Diploma in Child Health is designed to give recognition of competence in the care of children to associates in training for general practice, clinical medical officers and trainees in specialties allied to paediatrics. Administered by the Royal College of Paediatrics and Child Health (RCPCH). Further details are available at website www.rcpch.ac.uk
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The consultation |
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TOPAbstractStandards set by the...Aims of the consultationChild-friendly premisesThe consultationBehaviour problemsMaking an action planPrescribing for childrenConsultations with special...References |
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Whenever you have a consultation with a child, check the relationship between the child and the accompanying adult. The first goal is to find out why you are seeing the child. Use open questions at the start becoming more directive as necessary. Clarify, reflect, facilitate and listen. Include the child and encourage him or her to contribute to the history when old enough to do so. Consider seeing adolescents alone as well as with their accompanying carers. Points to include in the history are listed in Figure 1.
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When examining a child, a minute or two playing (for example, pretending to examine teddy or allowing a child to play with your stethoscope) may be well worth it to gain the child's co-operation (Box 3). Young children may be best examined on the carer's lap. Some children are reluctant to be undressed. Be flexible. Adequate examination is often possible without completely undressing the child. Leave any unpleasant parts of the examination (for example ear, nose and throat examination or anything that might be painful) until the end.
Start by taking a general look at the child. Does the child appear ill? Is the child breathless, struggling to breath or breathing faster than normal? Is the child particularly pale or flushed? Is the child unkempt or dirty? Does the child interact normally with you? If there is any suggestion of infection, check temperature. If the child appears sick or is breathless, check respiratory rate and pulse rate (Box 4). Then tailor your examination to confirm or refute the diagnoses suggested by the history (Figure 1).
| Box 3. Putting children at ease: "They always used to sort of tickle his tummy while they was listening to him and say silly things, doctor's looking in his ears, they used to say ‘Oh we’ve carrots growing today.... or ‘Have you cleaned you ears?’ They always used to play with him and ask him what he’d been doing either at nursery or at school. Ask him about his home life and his food and ‘Have you been to MacDonald’s?’ and ‘Where are you going on holidays?’ and ‘What are you doing today?’ " "They always had plenty of time for X which is, I think really important to build a relationship and it felt like we’d got a relationship with the doctors rather than just going to see a doctor"
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Patient experience is reproduced from the DIPEx patient experience database (www.dipex.org.uk)
Always remember:
Parents know their children best - take any concerns seriously. NICE recommends:
- Urgent referral when a child or young person presents three or more times with the same problem, but with no clear diagnosis.
- That persistent parental anxiety is sufficient reason for referral, even where a benign cause is considered most likely.
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Behaviour problems |
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TOPAbstractStandards set by the...Aims of the consultationChild-friendly premisesThe consultationBehaviour problemsMaking an action planPrescribing for childrenConsultations with special...References |
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GPs are commonly asked to ‘sort out’ behaviour problems of children by parents at their wits ends. Between 2% and 10% of all children are said to have behaviour problems depending on how the problems are defined and measured. Differentiation between normal behaviour and behavioural problems can be difficult, especially if you do not know the child or family well. A significant problem is more likely:
- when the behaviour is frequent and chronic
- when more than one problem behaviour occurs, and
- if behaviour interferes with social and/or cognitive functioning
A feature of child psychiatry is that the child should be seen in the context of a family - any problems are an interaction between child, family and environment (figure 2). The history is usually taken from the parents but it is helpful if the child can contribute. Older children may prefer to be seen alone.
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Important questions to explore from the start:
- Who is most worried about the child?
- Why are they presenting now?
- What do they think should be done about the problem?
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Making an action plan |
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TOPAbstractStandards set by the...Aims of the consultationChild-friendly premisesThe consultationBehaviour problemsMaking an action planPrescribing for childrenConsultations with special...References |
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When you have finished assessing the child, summarize the history and your findings back to the child and carers. Include children in the discussion if they are old enough, and explain in terms the child and carer can understand. Give an opportunity for the child or carer to fill in any gaps. Ask if the child or carers have any ideas about what is wrong. Next draw up a problem list. Establish and negotiate what the child and family want you to do about each problem. Finally draw up a management plan. Management plans should include setting a review date if appropriate and/or safety netting. For example, if a child presents with ear ache, and the examination shows acute otitis media, but the child has only had symptoms for a day, it is reasonable to agree that treatment is with paracetamol and fluids, but important to state that if symptoms worsen, or the child is no better in 2–3 days time, the child should be brought back for review.
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Prescribing for children |
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TOPAbstractStandards set by the...Aims of the consultationChild-friendly premisesThe consultationBehaviour problemsMaking an action planPrescribing for childrenConsultations with special...References |
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Children differ from adults in their response to drugs and the doses of them that they require. Particular care is needed in first 30 days of life. Before prescribing any medication for a child, weigh the risks against the benefits. The more dangerous the medicine, and the flimsier the evidence-base for treatment, the more difficult it is to justify the decision to prescribe. Consult the British National Formulary (BNF), BNF for Children or Paediatric Vade Mecum before prescribing unfamiliar drugs and always check drug doses carefully. Information on drugs used to treat rare paediatric conditions is available from Alder Hey Children's Hospital (telephone 0151 252 5381) or Great Ormond Street Hospital (telephone 020 7405 9200).
All children under 16 years of age (and those under 18 years if in full-time education) are entitled to free prescriptions everywhere in the UK. Prescriptions for children under 12 must include the child's age or date of birth. If a child needs an ongoing medication in more than one place (for example, school and home, or if the parents are separate and the child spends part of the week with each parent), prescribe sufficient quantity to keep a supply at both locations.
Consider the formulation of the medicine. Small children generally prefer syrups or suspensions. However, most paediatric suspensions contain large amounts of sugar. For long-term use, or children having frequent prescriptions, consider sugar-free versions. Oral syringes are supplied by pharmacies if the dose prescribed is less than 5mls, but they can also be useful for administering larger doses to reluctant children. Never advise adding medicines to infant feeding bottles. The drug may react with the contents and the dose of drug received will be reduced if not all the contents are drunk. For older children, consider tablets or capsules. These are often tolerated well and are easier to transport and administer if a dose needs to be taken at school. Ask the child if he or she has a preference.
| Advise parents and carers to keep all medicines out of the reach of children - and preferably in a locked cupboard.
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Prescribing outside licence
In the UK, the Medicines Act (1968) makes it essential for anyone who manufactures or markets a drug for which therapeutic claims are made, to hold a licence. Although doctors usually prescribe according to the licensed indications, they are not obliged to. Many drugs are not licensed for use with children, but children sometimes need these drugs and there may not be a licensed alternative. In these circumstances, drugs are often prescribed ‘off-licence’. Before prescribing off-licence, remember that the person signing the prescription is legally responsible. Never prescribe unlicensed drugs unless you have experience of and can justify their use (e.g. there is an evidence base for their use or established drug texts like the BNF advocate use). If in doubt, refer for a specialist opinion.
When prescribing licensed drugs for unlicensed indications:
- Inform the child and/or carers of what you are doing and why and obtain consent for the drug's use in that way.
- Explain that the patient information leaflet (PiL) will not have information about the use of the drug in these circumstances.
- Record in the patients notes your reasons for prescribing outside the licensed indications for the drug.
Suspected adverse reactions
Suspected adverse reactions in children to any therapeutic agent (whether over-the-counter, herbal medicine, other alternative medicines, new or established medicines prescribed by a doctor) should be reported to the Medicines and Healthcare products Regulatory Agency (MHRA - CSM Freepost, London SW8 5BR). Forms ("Yellow cards") are available from that address or in the back of the BNF. Alternatively report online at www.mhra.gov.uk.
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Consultations with special groups |
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TOPAbstractStandards set by the...Aims of the consultationChild-friendly premisesThe consultationBehaviour problemsMaking an action planPrescribing for childrenConsultations with special...References |
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Sick infants
Assessing sick children, particularly those too young to tell you what is wrong, can be very difficult. Infants under 6 months of age can be particularly difficult to assess and may deteriorate rapidly over a short period of time. Physical signs are often absent or deceptive. One approach is to exclude ‘alarm’ symptoms and signs (Box 5) which might point to serious illness.
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If any alarm symptoms or signs are present, then arrange for specialist paediatric review. If there are no alarm symptoms or signs, then management will depend on whether a cause for the symptoms can be found. If you find a possible cause (e.g. otitis media), then treat the cause. If you cannot find the cause, then consider the possibility of urinary tract infection. In both cases, if the child is not being admitted, either arrange for a review within a few hours, or ask the child's carers to contact you again if there is any deterioration or if they have any other worries about the child.
General rules for safe practice:
- Always arrange for a sick baby who has not responded to simple measures (such as paracetamol and fluids) to be reviewed by a doctor.
- Always trust the mother's instinct.
- Always perform a full examination. Localizing signs might be absent (for example, tonsillitis is a frequent cause of vomiting in small children). A petechial rash under a nappy can be easily missed.
- The younger the baby - the lower the threshold for seeking a paediatrician's opinion.
Adolescents
Adolescents visit their GP on average 2–3 times per year but their needs are often poorly addressed. Access to the primary care team can be a problem for teenagers - especially about issues that they do not want to tell their parents about. Ensure reception staff welcome teenagers when they come to the surgery without their parents. Listen to what teenagers say they want from the practice and try to be as accommodating as possible in providing those facilities and services. Provide leaflets and display posters using language and presented in ways that are attractive for teenagers. Teenage clinics outside school hours can help improve access for this group.
The choice of doctor is also important for adolescents. Gender of the doctor is especially important for sexual health matters, and often teenagers do not want to see the doctor that they have seen since being a small child, or the doctor that their mother or another family member sees. The attitude of the doctor is crucial. Teenagers often push the boundaries. They will not consult for help if they know that they will be judged when they go too far or make mistakes. Try to keep an open mind. Listen, offer support, advice, practical help and treatment without imposing your views.
Worries about confidentiality are particular barriers to teenage health care. Posters and/or leaflets in the surgery about confidentiality of medical information can boost confidence. Ensure that teenagers do not have their confidentiality breached when making appointments (for example, ensure receptionists do not insist that a teenager gives a reason for an appointment being booked on the telephone) and when telephoning the teenager's home about results, appointments or prescriptions. Breaching confidentiality includes discussing a child with another health professional not involved currently with that child's care. Only in exceptional cases and with justification can confidentiality be breached. Examples of cases in which breach of confidentiality is allowed are investigations for child abuse (social services may request information under Section 47 of the Children's Act); suicidal intent in a teenager; adverse drug reactions (routine reporting to the MHRA is allowable without consent); notifiable diseases (this is a statutory duty). Frequently asked questions about competence to consent can be found in box 6.
Consent to treatment is another contentious issue in this age group. Consent implies willingness of a patient to undergo examination, investigation or treatment. It may be expressed (i.e. the patient specifically says yes or no, or signs a consent form) or implied (i.e. the patient complies with the procedure without ever specifically agreeing to it). For consent to be valid, the person giving consent must be competent to make that decision, must have received sufficient information to take that decision, and must not be acting under duress. For children of less than 16 years, consent can only be given by a parent or other individual or local authority with parental responsibility, the child if he or she is judged competent, or a Court.
A competent child is able to understand the nature, purpose and possible consequences of a proposed procedure, as well as the consequences of not undergoing that procedure. This is termed ‘Frazer competence’ (previously and still occasionally referred to as ‘Gillick competence’). In particular competent children have a right to:
- Accept treatment - although, if treatment is refused, in England and Wales (but not Scotland) a parent or court may authorize procedures in the child's best interests
- Request to be seen alone without a parent
- Withhold permission for their parents to have access to medical information about them
- Make their own decisions about disclosure of their health information, and
- Apply for access to their own medical records
Children with chronic illness or disability
Chronic disability, due to a wide range of causes and of varying degrees, affects up to 10% of children in the UK. GPs are team members in the care of these children. Sometimes they are the key workers who co-ordinate care, on other occasions they are peripheral members of the team with the bulk of care being delivered by secondary care services. Chronic disability or illness may have effects on the child (such as discomfort, loss of independence, physical differences from peers, inability to do things other children do, etc.) and put additional strains on the family (grieving for the loss of the ‘ideal child’, financial strain, additional time commitments, neglect of siblings, etc.). Even if the child does not consult for a reason relating to the underlying condition, always consider the problem in the context of that condition and take each consultation as a chance for review of the child and family as a whole (Box 7).
| Box 6. Frequently asked questions about competence to consent Who determines whether a child is competent? It is the responsilbility of the treating doctor to decide whether a child is competent to consent. How can I decide if a child is competent to consent to treatment? A competent child should be able to understand in simple terms:
In addition, chldren must:
If a child is deemed competent once, is that child always competent? No – competence varies according to what the treatment proposed is. For example, a teenager may be competent to decide to take contraception but not to consent to major surgery.
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Box 7. Checklist of areas to cover when looking after children with chronic disability or illness
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| Information and support for parents: Green Toddler Taming: A parent's guide to the first four years (2000) Vermilion ISBN: 0091875285 Green Beyond Toddlerdom: Every Parent's Guide to the 5-10s (2000) Vermilion ISBN: 0091816246 Parentline Tel: 0808 800 2222 Website: www.parentlineplus.org.uk Information and support for children: Childline 24 h confidential counselling service Tel: 0800 1111 Website: www.childline.org
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References |
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TOPAbstractStandards set by the...Aims of the consultationChild-friendly premisesThe consultationBehaviour problemsMaking an action planPrescribing for childrenConsultations with special...References |
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Van Dorp F, Simon C. Oxford GP Library: Child Health (2007) OUP ISBN: 0199215685.
Kendrick T, Simon C. Oxford GP Library: Mental Health (2006) OUP ISBN: 0198570570.
Social Trends 34: Consultations with an NHS GP by sex and age. 2001/02 Available from: http://www.statistics.gov.uk/StatBase/ssdataset.asp?vlnk=7401&Pos=&ColRank=1&Rank=272 [date last accessed 29.11.07].
Department of Health National Service Framework for Children. young people and maternity services. Available from http://www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/ChildrenServices/Childrenservicesinformation/index.htm [date last accessed 29.11.07].
RCGP Curriculum Statement 8: Care of children and young people. Accessed via: http://www.rcgp-curriculum.org.uk/extras/curriculum/statementDetails.aspx?id=15 [date last accessed 29.11.07].
NICE. Referral guidelines for suspected cancer (2005) Available from : http://www.nice.org.uk/guidance/index.jsp?action=byID&o=10968 [date last accessed 29.11.07].
Drugs and Therapeutics Bulletin. Prescribing unlicensed drugs or using drugs for unlicensed applications (1992) 30:97–9.[Medline]
Morley CJ, Thornton AJ, Cole TJ. Baby Check: a scoring system to grade the severity of acute systemic illness in babies under 6 months old. Archives of Disease in Childhood (1991) 66:100–5.
NICE. Feverish illness in children: assessment and initial management in children under five years (2007) Available from: http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11010 [date last accessed 29.11.07].
McPherson A. Adolescents in primary care. British Medical Journal (2005) 330:465–7.
Gilbert & Tripp. Consent, rights and choices in healthcare for children and young people. BMJ Books (2001) ISBN: 0727912283.
British Medical Association - accessed at: www.bma.org.uk.
• Consent toolkit. http://www.bma.org.uk/ap.nsf/AttachmentsByTitle/PDFconsenttk3/$FILE/ConsentToolKit.pdf.
• Confidentiality and people under: 16. http://www.bma.org.uk/ap.nsf/Content/Confidentialityunder16?OpenDocument&Highlight=2,Confidentiality,people,under,16 [date last accessed 29.11.07].
•Access to health records by patients General Medical Counci. http://www.bma.org.uk/ap.nsf/Content/accesshealthrecords?OpenDocument&Highlight=2,Access,to,health,records,by,patients [date last accessed 29.11.07].
• Seeking patients' consent: the ethical considerations. http://www.gmc-uk.org/guidance/current/library/consent.asp [date last accessed 29.11.07].
• Guidance on good practice - confidentiality. http://www.gmc-uk.org/guidance/current/library/confidentiality.asp#28 [date last accessed 29.11.07].
• 0-18 years: Guidance for all doctors' GMC. (2007) http://www.gmc-uk.org/guidance/archive/GMC_0-18.pdf [date last accessed 29/11/2007].
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