The Hands-on Guide to Practical Paediatrics

Rebecca Hewitson is Paediatrics Specialist Trainee, London Deanery, The Whittington Hospital and Royal Free Hospital, London   Caroline Fertleman is Consultant Paediatrician, The Whittington Hospital Site Sub-Dean and Honorary Senior Lecturer, University College London Medical School Training Programme Director, School of Paediatrics, London Deanery Honorary Consultant, Great Ormond Street Hospital, London

Preface xi

Acknowledgements xii

About the Companion Website xiii

1 Getting started 1

Who’s who? 1

Breastfeeding advisor 1

Child protection nurse 1

Clinical support worker 1

Dietitian 1

Health visitor 2

Healthcare assistant 2

Midwife 2

Nursery assistant 2

Nursery nurse 3

Occupational therapist 3

Orthoptist 3

Pharmacist 3

Pharmacy technician 3

Physician assistant 3

Physiotherapist 4

Play specialist 4

Psychologist 4

School teacher 4

Specialist nurse 5

Social worker 5

Speech and language therapist 5

Staff nurse 5

Ward clerk 6

Ward sister 6

What happens where? 6

Playroom 6

Teenage room 6

Treatment room 6

School room 7

Parents’ room 7

Sensory room 7

Day care unit 7

Milk room 7

Postnatal ward 7

Paediatric emergency department 7

Be prepared 8

Jargon buster 9

2 Child development 19

What can a child of this age normally do? 19

Six weeks 20

Six to eight months 21

Twelve months 21

Eighteen months 21

Two years 22

Three years 22

School 22

Developmental delay and children with disabilities 22

Support for children with disabilities and their families 25

Growth 26

Obesity 28

Immunisations 29

The UK vaccination schedule 31

3 Communication with children and their parents 37

How to communicate with a baby or toddler 39

How to communicate with an infant school child (4–6 years) 40

How to communicate with a school-age child (7–12 years) 40

How to communicate with a teenager 41

How to communicate with a child using alternative communication 45

How to communicate with anxious parents 46

How to communicate with an expert parent or patient 47

Breaking bad news 49

Cultural sensitivity 54

Illiteracy 56

Consent 56

Parental responsibility 57

At what age can children consent for themselves? 57

4 Child protection and safeguarding 60

Different forms of abuse 60

Physical abuse 60

Fabricated or induced illness (FII) 62

Emotional abuse 64

Neglect 66

Sexual abuse 66

Maternal substance abuse in pregnancy 69

Female genital mutilation 70

Forced marriage and honour violence 70

Which children are most vulnerable to abuse? 72

What to do if you suspect child abuse 73

What should I say to the parents? 75

What to do if you suspect sexual abuse 75

Child protection medicals 77

Working with social care, education and the police 77

Social care 78

Police 78

I’ve made a referral to social services; what happens next? 83

What if you are worried about the immediate safety of the child? 83

What is a section 17 investigation? 84

Who is a child in need? 84

Who is a looked-after child? 84

What happens after it is decided that a child is in need? 84

What is a strategy discussion? 84

What is a section 47 enquiry? 85

What is a child protection conference? 85

What is a child protection plan? 85

What is a child protection review conference? 85

What is the child protection register? 85

What stops us from considering the possibility of abuse? 85

5 Common paediatric emergencies 88

Basic Life Support 88

Danger 88

Response 88

Shout for help 88

Airway 90

Breathing 91

Circulation 91

Choking child 92

History 93

Symptoms 93

Signs 93

Immediate management 93

Advanced Life Support 95

Airway management 97

Breathing management 97

Circulation management 99

Emergency drugs 99

ABCDE approach 101

A – Airway 101

B – Breathing 105

c – Circulation 108

d – Disability 110

E – Exposure 112

Reassess 113

Take a brief history 113

Anaphylaxis 113

History 113

Symptoms 114

Signs 114

Immediate management 114

Further management 115

Long-term management 115

Acute asthma 115

History 116

Symptoms 116

Signs 116

Immediate management 116

Further management 118

Long-term management 118

Drowning 119

History 119

Signs 119

Immediate management 119

Further management 120

Sepsis 121

History 121

Symptoms and signs 121

Immediate management 122

Further management 122

Meningococcal septicaemia 123

History 123

Symptoms 123

Signs 123

Initial management 124

Burns and scalds 124

History 124

Symptoms 124

Signs 125

Immediate management 125

Further management 126

Ongoing management 126

Seizures 128

History 128

Immediate management 128

Further management 130

Poisoning 131

History 131

Symptoms and signs 131

Immediate management 131

Further management 132

Diabetic ketoacidosis 135

History 135

Symptoms 135

Signs 135

Immediate management 135

Further management 136

Trauma 138

Catastrophic external haemorrhage 138

Airway and cervical spine control 138

Breathing 139

Circulation with haemorrhage control 140

Disability and assessment of head injury 141

Critical care transfer services 141

North West England 141

North East England 142

West Midlands 142

East Midlands 142

South East England and London 142

South Central and South West England 142

North Wales 142

East Scotland 143

West Scotland 143

Northern Ireland 143

6 Practical procedures 144

Setting up 144

Cannulation 145

Taking blood (including heel prick sampling) 148

Heel prick sampling 148

Venepuncture in babies 151

Capillary blood gas 152

How to measure a spun bilirubin (SBR) 153

How to measure packed cell volume 154

Intraosseous access 154

Nasogastric tube 158

Lumbar puncture 161

Urinary catheter insertion 166

Suprapubic urine sample 169

Mantoux test 171

Injecting tuberculin 171

‘Reading’ the Mantoux test results 173

Peak flow 173

Hand-held spirometry 174

Setting up a nebuliser 175

Inhaler technique and using a spacer 175

Intramuscular injections (for immunisations) 176

How to use an Epipen/Anapen 177

Changing a nappy 177

7 Prescribing in children 179

General principles 179

Getting children to actually take what you prescribe 181

Fluids 181

Maintenance fluids 182

Replacement therapy 182

Analgesia 186

Step 1 – mild pain 187

Step 2 – moderate pain 187

Step 3 – severe pain 188

Controlled drugs 188

Blood products 188

When to give CMV-negative products 188

When to give gamma-irradiated products 189

Packed red cells 189

Platelets 189

Fresh frozen plasma (FFP) 190

Drug level monitoring 190

8 Teenagers 192

Taking a history from a teenager 192

Mental health problems 193

Deliberate self-harm and suicide 193

Eating disorders 196

Substance abuse 197

Sexual health 198

9 Neonates 200

Neonatal life support at birth 200

Stimulate and airway manoeuvre 204

Reassess 204

Give five inflation breaths 205

Reassess 205

Consider oxygen saturation monitoring 205

Further inflation breaths or regular breaths 205

Calculating Apgar scores 206

Newborn baby checks 207

Newborn examination 210

Prematurity 210

Resuscitation at birth for premature babies 211

Extreme prematurity and resuscitation decisions 213

The law in the United Kingdom 214

Best interests 214

Parental responsibility 214

Euthanasia is illegal 214

Intending relief of distress is normally legal 214

Withdrawing or withholding treatment is the same in the eyes of the law 215

Some useful ethical frameworks and guidance 215

Intravenous fluids in infants 215

Neonatal nurses 216

10 Looking after yourself 218

Dealing with upsetting situations 218

Short-term coping mechanisms 218

Long-term coping mechanisms 221

Bullying and harassment 223

Practising paediatrics when you have your own children 224

Emotional impact 224

Not enough hours in the day 224

Feeling isolated 225

Nobody’s perfect: dealing with mistakes 226

Avoiding making mistakes 227

Pitfall 1: Communication 227

Pitfall 2: Being distracted at a critical moment 229

Pitfall 3: Failure to follow protocol 230

Pitfall 4: Acting beyond your competence 230

Organisation 231

Night shifts 232

11 Developing your career 234

Specialist training structure for paediatrics 234

Opportunities for research 237

Academic training programme 237

Out-of-programme research (OOPR) 237

Completing research projects alongside regular training 237

College exams 238

Written papers 238

Clinical exam 239

How to boost your CV 240

CV building for medical students 241

CV building for Foundation trainees 243

CV building for specialist trainees 245

Clinical governance – more than just audit 246

Service improvement projects 246

Patient safety 249

Less than full-time training 250

Teaching and training 252

Work-based assessments and e-portfolios 254

Index 257