28_McClure_28.indd 1008 11/14/2012 3:38:56 PM ASSESSMENT BY SOCIAL CARE 1009 that can be downloaded called \200\230Protecting children and young people: the responsibi lities of all doctors \200\231 (2011). \200 Information can be disclosed without consent in cases of serious crime (including child abu se). If information is not disclosed the doctor should be prepared to justify their decisio n. In the absence of consent, con \201 dential medical information about parents or third parties should be shared when relevant and necessary to protect the safety and welfare of t he child. The more sensitive this information is, the greater the child \200\231s needs mus t be to justify disclosure. Normally permission from parents should be obtained unless it i s reasonable to conclude that this would hinder enquiries or place the child at greater ris k. 28_McClure_28.indd 1009 11/14/2012 3:38:56 PM CHAPTER 28 Child protection 1010 Prevention strategies Most children referred to social care will be those in need, rather t han those requiring protection. Children in need are de \201 ned as those whose vulnerabil ity is such that they are unlikely to reach or maintain a satis- factory level of health or development without the provision of support services. The role of social care in preventi on is to undertake an initial core assessment and to implement a plan to maximize the child \200\231s health and development, including: \200 Referral to universal support services, e.g. health visitors, parenting groups, school nurs es, nursery placement, home support. Referral to specialist services, e.g. mental health (a dult or child), pediatrics. Further reading Department of Education (2010). Working Together to Safeguard Children: A guide to inter-ag ency working to safeguard and promote the welfare of children. London: DoE. Available at: h ttps://www. education.gov.uk/publications/standard/publicationdetail/page1/DCSF-00305-2010. NICE (2009). When to suspect child maltreatment. NICE guideline CG89. London: NICE. Availab le at: M http://www.nice.org.uk/CG89 The physical signs of child sexual abuse RCPCH (2008) (see http://www.rcpch.ac.uk/csa where an updated 2012 summary can be downloaded and the hardcopy ordered). 28_McClure_28.indd 1010 11/14/2012 3:38:56 PM 1011 Chapter 29 Pharmacology and therapeutics Prescribing for children 1012 Adverse drug reactions 1014 Pharmacokinetics 1016 Drug metabo lism 1017 Pain management 1018 Sedation 1019 Fever 1019 29_McClure_29.indd 1011 11/14/2012 3:39:11 PM CHAPTER 29 Pharmacology and therapeutics 1012 Prescribing for children Licensing Many medicines used in children are not licensed for suc h use. This does not mean that they should not be used, but that the pharmaceutical com- pa ny has not sought a license from the regulatory authorities. Hence, many medicines in child ren are used off label, i.e. they are used at a dif- ferent dose, route, age, or indication than speci \201 ed within the product license. It is important that medicines are used in children in relation to the scienti \201 c evidence available. In certain circumstances t his may involve off label use. Disease states Certain diseases, e.g. cystic \201 brosis, or clinical conditions, e.g. sh ock, may affect drug metabolism. Both liver and renal failure delay drug elimination, and s o require dosage reduction. Breastfeeding Most medicines taken by a breastfeeding mother are safe for her infant. Mothe rs should not be discouraged from breastfeeding because of uncer- tainty about possible tox ic effects. The British National Formulary (BNF) for children gives detailed information re garding which medicines to avoid.1 Medication errors Medication errors are a signi \201 cant problem in children. In particul ar, ten- fold errors have been associated with signi \201 cant mortality and morbidity, es pecially in the very young. All health professionals will commit a medica- tion error durin g their career! Medication errors include: \200 Incorrect dose: commonest error and also the type most likely to be associated with a fatal ity. Knowledge of the child \200\231s actual weight and checking of dose calculation is vit al, especially on the neonatal unit and with parenteral medicines. Incorrect with signi \201 cant fatalities. Incorrect procedure for specialists and great care should be taken wh en drugs are to be given this way! Other and administration of the drug to the wrong patien t. drug: second most common type of error and also associated route: this is a particular problem with IT drugs. This is a errors: include incorrect rate of administration, duplicate dosing, Reference 1 RCPH (2009). The British National Formulary for Children. BMJ Publishing Group Ltd, RPS Publishing, RCPCH Publication Ltd. 2009 29_McClure_29.indd 1012 11/14/2012 3:39:11 PM PRESCRIBING FOR CHILDREN 1013 29_McClure_29.indd 1013 11/14/2012 3:39:11 PM CHAPTER 29 Pharmacology and therapeutics 1014 Adverse drug reactions One in 10 children in hospital and one in 100 attending outpatients will experience an adverse drug reaction (ADR). 71 in 8 will be severe. ADRs are responsibl e for almost 2% of children admitted to hospital. ADRs in children can be as varied as in a dults. Children, because of growth and development, also suffer speci \201 c ADRs. Differe nces in drug metabolism make certain ADRs a greater problem in children, e.g. valproate hep ato- toxicity, or less of a problem, e.g. paracetamol hepatotoxicity following an overdose. The mechanisms of ADRs speci \201 cally affecting children are illustrated with examples below. Mechanisms of ADRs Impaired drug metabolism Chloramphenicol, when \201 rst used in neonat es, led to the development of the gray baby syndrome (vomiting, cyanosis, cardiovascular co llapse, and in some cases death). The newborn infant metabolizes chloramphenicol more slowl y than adults and so only requires a lower dose of the antibi- otic. Reduction in the dosag e prevents gray baby syndrome. Children, particularly neonates, are more likely to have a reduced capac- ity to metabolize drugs than adults. Therefore, lower doses are usually required. Altered drug metabolism Children may have reduced activity of the major hepatic enzymes ass oci- ated with drug metabolism. To compensate for this, they may use other enzyme pathways. This is thought to be one of the factors contributing to the increased risk of hepatotoxic ity in children under the age of 3 years who receive sodium valproate. This risk is raised by the concurrent use of other anticonvulsants which may cause enzyme induction of certain metabolic pathways. Sodium valproate should not be used as a \201 rst-line anticonvulsant in children under t he age of 3yrs. Protein-displacing effect on bilirubin The use of the sulphonamide sulphisoxazole in ill ne onates in the 1950s was associated with the development of fatal kernicterus due to drug di s- placement of protein bound bilirubin into the blood because of its higher binding af \201 nity to albumin. Ceftriaxone also is highly protein bound and will displace bilirubin in sick neonates. The protein-displacing effect of medicines should be considered in sick preterm neonates. Percutaneous absorption Percutaneous toxicity can be a signi \201 cant prob- lem in the ne onatal period due to their higher surface area to weight 29_McClure_29.indd 1014 11/14/2012 3:39:11 PM ADVERSE DRUG REACTIONS 1015 ratio than that of both children and adults. An example of this is the use of antiseptic ag ents such as hexachlorophene that have been associated with neurotoxicity. Drug interactions Ceftriaxone and calcium containing solutions when used together in neonat es may result in the precipitation of ceftriaxone \200\224 calcium salt in the lungs. This drug interaction can result in fatalities and therefore ceftriaxone should be avoided in ne onates. Ceftriaxone should be avoided in neonates. Unknown There are several examples of major ADRs that occur in children for which we do not understand the mechanism. Salicylate given during the presence of a viral illness increase s the risk of the development of Reye \200\231s syndrome in children of all ages. Since the use of salicylates has been avoided in chil- dren the incidence of Reye \200\231s syndrome has dramatically reduced. Propofol has minimal toxicity when used to induce general anesth esia. Used as a sedative in critically ill children, however, it has been associated with t he death of over 10 children in the UK alone. The propofol infusion syn- drome is thought t o be related to the total dose of propofol infused, i.e. high dose or prolonged duration is more likely to cause problems. Propofol should not be used as a sedative in critically ill children Suspect ADRs One should always consider the possibility of an ADR being responsible for a c hild \200\231s symptoms. Table 29.1 lists some of the seri- ous ADRs associated with widely used medicines. Table 29.1 Serious ADRs associated with medicines Drug ADR Corticosteroids Adrenal insuf \201 ciency/sepsis Cytotoxics Neutropenia Carbamazepine Stevens \200\223Johnson syndrome NSAIDs (including ibuprofen) GI hemorrhage Opiates Respiratory depression Sodium valproate Hepatotoxicity Preventing ADRs Recognizing which patients are at greater risk of ADRs can help reduce the overall incidence. Health professionals should follow guidelines. Reporting ADRs Suspected ADRs should be reported to the regula- tory authorities. In the UK the yellow card scheme i s in operation. 29_McClure_29.indd 1015 11/14/2012 3:39:11 PM CHAPTER 29 Pharmacology and therapeutics 1016 Pharmacokinetics Pharmacokinetics de \201 nes the relationship between the dose of a drug and its concentration in different parts of the body (usually plasma) in relation to time. This relationship is measured and de \201 ned numerically. Knowledge of several key terms is needed to understand pharmacokinetic principles. \200 Absorption: stream. If a drug is given orally, usually only a fraction is absorbed and the term bioavailability is used to describe the percentage of the drug administered that reach es the systemic circulation. Absorption is often reduced following oral administration in t he neonatal period. Volume of distribution (V): this is not a physiological volume but rath er an apparent volume into which the drug would have to distribute to achieve the measured concentration. Water-soluble drugs, such as gentamicin, have a V that is similar to the ext racellular \202 uid volume. Drugs that are highly bound to plasma proteins have a low V. Children differ from adults because of their body composition (neonates and young children have a higher proportion of body water) and lower plasma protein concentrations. Clearance: de \201 ned as the volume (usually of plasma) that is completely cleared of drug in a giv en time. In adults, clearance is described in relation to volume/time (mL/min). In children , clearance is also described in relation to body weight (mL/min/kg). Clearance is usually reduced in the neonatal period but may actually be higher in infants and young children tha n in adults. Elimination half-life: this is the time taken for the concentration of a drug (usually plasma) to fall to half the original value. It is inversely related to clearance. Therefore, 50% of the dose will be eliminated in 1 half-life; 97% of a drug will be elimina ted after 5 half-lives. This is also the time required for steady state to be achieved foll owing initial administration of the drug. if a drug is given IV, 100% of the dose enters the blood describes the removal of a drug from the body and is Mathematical formulas are available in standard texts that describe the interrelationship b etween clearance, volume of distribution, and elimina- tion half-life. 29_McClure_29.indd 1016 11/14/2012 3:39:12 PM DRUG METABOLISM 1017 Drug metabolism The major pathways involved in drug metabolism are divided into phase I (ox idation, reduction, hydrolysis, and hydration) and phase II (glucuronida- tion, sulphation, methylation, and acetylation) reactions. As a general rule, the clearance of drugs in the neonatal period is reduced. For many drugs adult clearance values are reached by the age of 2yrs. Phase I pathways The major pathway is oxidation which involves the cytochrome P450 enzymes (CYP). The major CYP enzymes are CYP3A4 and CYP1A2. \200 this is responsible for the meta bolism of many drugs (e.g. CYP3A4: midazolam, ciclosporin, fentanyl, nifedipine). CYP3A4 activity is reduced in the ne onatal period and early infancy. Enzyme activity between individuals varies considerably le ading to a large range of plasma concentrations after the same dose of an affected drug. CY P1A2: and theophylline are metabolized via the CYP1A2 pathway. Enzyme activity is reduced i n the neonatal period, but increases rapidly such that by the age of 6 months activity appr oaches that of older children and adults. accounts for 13% of total enzyme activity in the liver. Caffeine Phase II pathways Glucuronidation and sulphation are two major pathways. Glucuronidation is reduced in the neonatal period and there is compensa- tory sulphation. The development of glucuronidation varies for different drugs. For example, children who are 2yrs old have rat es of glucuronida- tion for morphine similar to those in adults, whilst for paracetamol adu lt rates of glucuronidation are not reached until puberty. the 29_McClure_29.indd 1017 11/14/2012 3:39:12 PM CHAPTER 29 Pharmacology and therapeutics 1018 Pain management See also b pp.691, 890. Assessment Always consider the possibility of a child being in pain, either as a result of their disease or the interventions that are required. Accurate assessment requires an age-a ppropriate validated pain assessment scale. Self-reporting is the ideal, but the child need s to be (cid:2)3yrs old to be able to do this. Do not use pain scales validated for acute p ain to assess chronic pain. \200 Self-report scales: usually involves the child pointing to a photograph of a child in pain (the Oucher) or a diagram of a child in pain (Bieri Faces Pain Scale or Wong \200\223Baker Faces Pain Scale). The Oucher has been validated in children as young as 3yrs of age, where as the Bieri Faces Pain Scale has only been validated in children aged (cid:2)6yrs. The Won g \200\223Baker Faces Pain Scale is more reliable in children aged 8 \200\22312yrs than in the 3 \200\2237-yr age group. The Adolescent Pediatric Pain Tool is for children between th e ages of 8 and 17yrs. Behavioral pain scales: rely on assessment of the child \200\231s be havior. Validated for children aged 1 \200\2235yrs. Examples include the Toddler \200\224 P reschooler Postoperative Pain Scale (TPPPS) and the CHEOPS. The FLACC has been validated fo r children aged 2 months \200\2237 years. Neonatal pain scales: examples include CRIES, NFC S, NIPS, and PIPP. These rely on behavioral observation and, in some, measurements of pulse , BP, and O2 saturation. It is important to use one that has been validated for the gestati on of the infant, e.g. is it valid only in full-term neonates? Management It is best to consider pain as being mild, moderate, or severe. \200 Mild line drug to be used for mild pain in all ages. Moderate to paracetamol should receive either a NSAID, such as ibuprofen or diclofenac. Alternatively, codeine or dihydrocodeine can be administered orally. Severe pain: morphine is the drug of choice. It can be given IV (including patient-controlled analgesia (PCA)), intranasally, or orally. pain: for certain painful procedures, e.g. dressing change Procedural in burns patients, it may be better to use inhaled entonox. This is an effective and safe analgesic with a short duration of acti on, which the child can control themselves. pain: paracetamol is the safest analgesic available and is the \201 rst- pain: children who are unresponsive (or unlikely to respond) 29_McClure_29.indd 1018 11/14/2012 3:39:12 PM SEDATION 1019 Sedation There are two main areas where sedation is required \200\224during procedures and whilst receiving pediatric intensive care. Procedural sedation There are many sedative agents available. All sedative agents decrease conscious level and, thereby, can have signi \201 cant toxicity. The choice of sedative ag ent depends upon local experience and how quickly and for how long sedation is needed. If a child is likely to be dif \201 cult to sedate, then consider whether a short-acting gener al anesthetic, administered by a pediatric anesthetist, is safer and kinder to the child. Prolonged sedation (critical care) The purpose of sedation in the pediatric intensive care unit (PICU) is to help the child not the health professional. IV midazolam is the drug of c hoice on admission. Subsequently, once NG feeds are tolerated, chloral hydrate and prometha zine have been shown to be more effective than midazolam. Propofol is contraindicated for u se in the PICU, with the exception for procedures, in view of the risk of a fatal ADR. Fever Fever is a sign of an underlying illness. It is more important to treat the underlyin g illness than the fever itself. Fever is reduced to make the child more comfortable. The t wo most used antipyretics (paracetamol and ibu- profen) are also analgesics (see b p.701). Management Paracetamol is the drug of choice. It is less likely to be associated with a sig ni \201 cant ADR than ibuprofen. Ibuprofen is appropriate to use as an antipyretic agent i f paracetamol has failed. Although the safest of all NSAIDs, it should not be used in child ren with gastroenteritis or other GI symptoms. 29_McClure_29.indd 1019 11/14/2012 3:39:12 PM This page intentionally left blank 1021 Chapter 30 International health and travel Child survival: world health 1022 World health: childhood illness 1023 Taking children on h oliday 1024 Illness after international travel 1026 Further reading 1028 30_McClure_30.indd 1021 11/14/2012 3:39:31 PM CHAPTER 30 International health and travel 1022 Child survival: world health Worldwide, almost 9 million children aged <5yrs still die ever y year. Child mortality rates vary between world regions, and these differences are large a nd increasing. Some examples are: \200 1990 . There were 180 deaths per 1000 live births in sub-Saharan Africa, but only 9 per 100 0 in industrialized countries \200\224a 20-fold difference. 1990 \200\2232000 . This 20-fold gap increased to almost a 30-fold difference. United Nations response The United Nations set several development goals in September 2000, revised in September 2010: \200 Target: rate of children under 5yrs. reduce by two-thirds, between 1990 and 2015, the mortality Since 1990 \200 The number of children in developing countries who died before they reached the age of 5 dr opped from 100 to 72 deaths per 1000 live births between 1990 and 2008. The highest rates o f child mortality continue to be found in sub- Saharan Africa, where, in 2008, one in seven children died before their \201 fth birthday. Of the 67 countries de \201 ned as having high child mortality rates, only 10 are currently on track to meet the Millennium Developm ent Goals target. 30_McClure_30.indd 1022 11/14/2012 3:39:31 PM WORLD HEALTH: CHILDHOOD ILLNESS 1023 World health: childhood illness Worldwide, half of the deaths in children aged <5yrs are du e to: \200 \200 \200 \200 pneumonia; diarrhea; malaria; measles. Under-nutrition is a major factor contributing to these deaths. Two-thirds could be prevent ed by interventions already available and feasible today for implementation in low-income c ountries. In fact, we have the knowl- edge and instruments to reduce child mortality, but c hildren continue to die because effective interventions are not reaching them. For example, Haemophilus in \202 uenzae type b vaccine coverage is universally low and, with few excep tions, insecticide-treated net coverage rates in malarial areas are well below 5%. There are also clear indications in the developed world of health ine- qualities. Infant mo rtality rates show an excess associated with social dep- rivation and ethnic minorities. The infant mortality rate in England and Wales of 4.7 deaths per 1000 live births in 2009 w as the lowest ever recorded in England and Wales and has fallen by 64% since 1978 In sub-Sa haran Africa the equivalent rate in children under 1yr was 81 deaths per 1000 live births, 39 in Asia and 19 in Latin America and the Caribbean. In the UK, the rate varies by socio- economic status, being 69% higher in the \200\230routine and manual \200\231 group com- pa red with the \200\230managerial and professional group \200\231. In 2003, data showed also that: Excess infant mortality also occurs in children of Asian pa rents \200\2248.3 per 1000 live births born to mothers whose country of birth was Banglades h, India, or Pakistan died. Babies born to mothers whose country of birth was Pakistan had an infant mortality rate of 10.5 per 1000 live births. The factors associated with excess i nfant mortality include low birth weight, ethnicity, poverty, maternal cigarette smoking, t he delivery of health care, and consanguinity. 30_McClure_30.indd 1023 11/14/2012 3:39:31 PM CHAPTER 30 International health and travel 1024 Taking children on holiday Parents will often ask advice about taking their child on holida y. Here are some general guidelines to consider in well children. If a child has a chronic illness (e.g. diabetes, cystic \201 brosis, CHD), consider whether they will re- quire ac cess to special health needs and provide details of a local expert. Your local specialist s hould be able to help. Travel vaccinations International travel with babies and children has the added dimension o f considering the right immunizations long before you go: \200 Babies in the UK receive r outine immunization (see \200 Exotic places usually means exotic diseases and therefore t he need for immunization. Check with the National Travel Health Network and Center (at M ww w.nathnac.org/pro/index.htm), country by country, in the travel itinerary. Babies under the age of 6mths and many immunosuppressed children cannot be given yellow fever injection. Ba bies under the age of 2mths can take antimalarial tablets if the family need to travel to a n area requiring prophylaxis. Just as important for very young travelers are the use of a c ot mosquito net, and other measures to prevent mosquito and other insect bites. b p.728). Flying with babies Most international travel will require an airline \202 ight. Mothers w ill not be allowed to \202 y if they: \200 \200 have given birth in the last 48hr; had a Cesarean section in the last 10 days. Families may choose to \202 y after the baby \200\231s 6-wk check. Modern commer- cial ai rcraft maintain ambient air pressure equivalent to 8000 ft (2500m) or less, even during \202 ight at altitudes above 13km (43,000 ft). Healthy babies should tolerate this \200 \230altitude \200\231 well, although children with respiratory dis- ease may need specialis t consideration even if they do not usually require supplementary oxygen at home Common medical problems encountered on holiday Sunburn This problem can be limited by the u se of sun suits, hats, high-protection sunscreen, and being disciplined about exposure (see Box 30.1). See also b p.819. 30_McClure_30.indd 1024 11/14/2012 3:39:31 PM TAKING CHILDREN ON HOLIDAY 1025 Box 30.1 Advice to parents about avoiding sunburn It is important to be protected from the sun \200 \200 \200 \200 Too much exposure is harmful Protection prevents painful sunburn Protection reduces the ris k of skin cancer in later life Some children are sensitive and will develop a rash Protection entails the following \200 \200 \200 Keep infants out of direct sunlight especially in the middle of the day Use high-protection , water-resistant sunscreen Wear sun suits If sunburn occurs \200 \200 seek medical advice (cid:1) If there is blistering or a rash Cool the sunburnt area, but do not let the child get cold Prickly heat This \201 ne, red rash with tiny pimples is centered around imma- ture sweat glands. It can blister and be uncomfortable. Diarrhea This can be serious in the very young if dehydration occurs (see b p.90). Children returning from abroad should be investigated with stool samples for bacteria, viruses and parasites if the diarrhea is severe enough to present to hospital or has been present for m ore than 7 days. This is because some pathogens that require treatment with antimicrobial a gents are more common in those returning from abroad (Giardia lamblia, Shigella and some Sa lmonella). (See NICE guideline).1 Reference 1 NICE guideline on \200\230Diarrhea and vomiting in children \200\224Diarrhea a nd vomiting caused by gastroenteritis: diagnosis, assessment and management in children you nger than 5yrs \200\231; M http:// www.org.uk/guidance/CG84/NICEGuidance 30_McClure_30.indd 1025 11/14/2012 3:39:31 PM CHAPTER 30 International health and travel 1026 Illness after international travel Approximately 3% of people traveling internationally hav e fever for a short period. Children will require a full assessment of fever as discussed i n b Chapter 19 (b pp.696 \200\223703). When a history of recent travel is known, the additi onal information needed in your assessment should include: \200 \200 \200 \200 \200 \200 review of travel itinerary; exposure history; duration of fever; likely incubation period; immunization state; use or non-use of antimalarial chemoprophylaxis. Incubation period Determining an approximate incubation period is particularly helpful when you are trying to \200\230rule-out \200\231 possible causes of fever. It is also useful t o con- sider causes according to key features. For example, is the fever: \200 \200 \200 \200 \200 \200 Non-speci \201 c? Associated with hemorrhage? Associated with central nervous system invol vement? Associated with respiratory symptoms? Associated with exposure to blood? Associated with eosinophila? The following subsection summarizes the likely causes by incubation period and key features . It can be used to guide your history. For example, if fever began more than 21 days after returning from international travel then dengue, rickettsial infections, and viral haemorr hagic fever (e.g. yel- low fever, Lassa fever) are excluded, irrespective of the history of expo- sure. Once the travel exposure and likely duration of symptoms have been identi \201 ed, your investigations could include: \200 \200 \200 \200 \200 \200 \200 b Chapter 19 (b p.723) discusses some of the infections discussed below. Peripheral blood \201 lm for malaria. FBC and differential WCC. LFTs. Urinalysis. Culture of blood, stool, and urine. CXR. Speci \201 c serology based on the likely incubation per iod. Causes of fever according to incubation period and key features Fevers with incubation peri od <14 days \200 Non-speci \201 c fever: \200 malaria (Plasmodium spp.) \200\224 regions; tropics, subtropics, and temperate 30_McClure_30.indd 1026 11/14/2012 3:39:31 PM ILLNESS AFTER INTERNATIONAL TRAVEL 1027 \200 \200 \200 \200 dengue (virus serotypes 1 \200\2234) \200\224 Rickettsial spotted fever scrub virus leptosp irosis Campylobacter developing countries; typhoid fever East African trypanosomiasis tropics, subtropics; \200\224worldwide; \200\224Asia, Australia; \200\224tropics; , Salmonella, Shigella \200\224developed or more commonly \200 Fever with hemorrhage: \200 meningococcaemia, leptospirosis, bacterial infection, malaria; \200 viral haemorrhagic fever. Fever with CNS involvement: \200 \200 \200 \200 \200 \200 \200 \200 Fever with respiratory \201 ndings: \200 \200 \200 \200 \200 \200\224developing countries; \200\224sub-Saharan East Africa. meningococcal meningitis; bacteria and viral meningitis and encephalitis; malaria, typhoid, and typhus; rabies \200\224 arbovirus encephalitis: worldwide; eosinophilic meningitis; po liomyelitis; East African trypanosomiasis. Africa, Asia, and Latin America; in \202 uenza legionellosis acute histoplasmosis acute coccidioidomycosis Q fever \200\224widespread, seasonal; \200\224widespread; \200\224widespread; \200\224Americas; \200\224worldwide. Incubation period 14 \200\22355 days \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 Malaria. Typhoid fever. Hepatitis A: Hepatitis E: Acute schistosomias. Amoebic liver absces s. Leptospirosis. HIV acute seroconversion. East African trypanosomiasis. Viral haemorrhagi c fever. Q fever. widespread. widespread. Incubation period >55 days \200 \200 \200 \200 \200 \200 \200 Malaria Tuberculosis: Hepatitis B and E: Visceral leishmaniasis: Lymphatic \201 lariasis. Schistosomiasis: tropics. Amoebic liver abscess. worldwide. worldwide. Africa, Asia, S. America, Mediterranean basin. 30_McClure_30.indd 1027 11/14/2012 3:39:31 PM CHAPTER 30 International health and travel 1028 Further reading United Nations millennium goals. Available at: M http://www.un.org/millenni umgoals/pdf/MDG_ FS_4_EN.pdf UNICEF Statistics. Available at: M http://www.unicef.org/sowc2011/pdfs/Table-1-Basic-Indica tors_ 02092011.pdf 30_McClure_30.indd 1028 11/14/2012 3:39:31 PM 1029 Chapter 31 Pediatrics, ethics, and the law Ethics 1030 Common law 1031 Recognition of ethical issues in everyday clinical practice 103 2 Clinical case study 1033 The doctor \200\223child relationship 1034 Parental responsibili ty 1035 The doctor \200\223parent relationship 1035 Assent and consent 1036 Con \201 denti ality and disclosure 1038 Withholding or withdrawing treatment in children 1040 Good ethica l and legal practice in suspected child abuse 1042 Serious case reviews 1043 Legal aspects of international adoption 1044 31_McClure_31.indd 1029 11/14/2012 3:40:31 PM CHAPTER 31 Pediatrics, ethics, and the law 1030 Ethics The development of ethical frameworks has a history as long as medicine itself. Toda y, ethical traditions can be broadly categorized into three tradi- tions: \200 \200 \200 virtue ethics; deontology; consequentialism. More recently, principlism has been proposed as a unifying approach. \200\230Virtue ethics \200\231 Often associated with the tradition of Aristotle and emphas izes the char- acter and moral behavior of the person or agent. Aristotle proposed nine key virtues: wisdom; prudence; justice; fortitude; courage; liberality; magni \201 cence; mag nanimity and temperance. \200\230Deontology \200\231 Most commonly associated with Immanuel Kant who formulated the con- cept of the categorical imperative. The tradition emphasizes individual dig- nity, tr uth telling, non-male \201 cence, bene \201 cence, and autonomy. The good will and motive of the individual determine the rightness of the act. \200\230Consequentialism \200\231 In contrast to deontology, emphasizes that the rightness of an action is determined by its consequences. The tradition is often associated most wit h the utilitarians such as Jeremy Bentham. \200\230Principlism \200\231 Traces its origins to the Nuremberg Code (1948), the Declarat ion of Helsinki (1964), and the Belmont Report (1979) all of which focus on research on hum an subjects. Beauchamp and Childress have championed moral decision-making in medicine base d on principlism emphasizing four moral attributes: autonomy, non-male \201 cence, bene \201 cence, and justice. 31_McClure_31.indd 1030 11/14/2012 3:40:31 PM COMMON LAW 1031 Common law In England, the United States, Canada, Australia, India, and many other countrie s the law has mainly developed from judges through case law or precedent, rather than statu te or executive action. This system is known as \200\230common law \200\231. In an idealiz ed form, common law should mean similar cases are decided consistently and that the law wil l evolve when new circumstances require precedent to be created. Dif \201 culties can pres ent when two or more precedents suggest con \202 icting courses of action. We all function within the legal framework of the state in which we live, and we will also have our own personal ethical views and ideas. All of these will have an impact on the way that doctors relate to their patients, colleagues, and everybody else with whom they intera ct in their profes- sional lives. As a pediatrician you will need to do the following: \200 Identify the legal and ethical problems involving patients that clinicians face most freque ntly. When might one anticipate the circumstances in which clinicians may require particula r care in deciding a course of action? Identify clinician have when faced with a moral or e thical problem that affects the care for a patient? Bring expert guidance, wisdom and prece dent in complex situations. What resources can clinicians use to try to resolve legal and e thical problems effectively so that the care of the patient can be continued or altered app ropriately? clearly the clinicians \200\231 obligations in each case. What duties does a 31_McClure_31.indd 1031 11/14/2012 3:40:31 PM CHAPTER 31 Pediatrics, ethics, and the law 1032 Recognition of ethical issues in everyday clinical practice The key areas and issues that a rise frequently in pediatric practice are summarized in Box 31.1. Box 31.1 Key issues in pediatric practice Consent (b pp.1007, 1036) \200 Age and Gillick/ Fraser competence \200 Parental consent or refusal \200 Proxy consent \200 Refusal of treatment \200 Insistence on treatment Best interests (b p.1040) \200 Aggressive treat ment \200 Resuscitation and do-not-resuscitate orders \200 Refusal of treatment by doct ors \200 Cultural factors (e.g. circumcision, blood transfusion in Jehovah \200\231s Witn ess) Con \201 dentiality (b p.1038) \200 \200 \200 \200 Neonatal and pediatric intensiv e care (b p.1040) \200 \200 Child protection (b p.1042) \200 \200 b p.1035) The doctor \200\223patient relationship ( Rights of minors with or without competence ( Rig hts of the child versus the family Rights of parents b p.1036) Resuscitation Withholding and withdrawing treatment and end-of-life decisions Duties of the doctor and breaching con \201 dentiality Con \202 icts of interest: general practitioner \200\231s duties to the family 31_McClure_31.indd 1032 11/14/2012 3:40:31 PM CLINICAL CASE STUDY 1033 Clinical case study During clinical practice, as a postgraduate trainee or an undergradu- a te medical student, there are many opportunities to consider some of the common ethical and legal issues at the core of pediatrics and child health. In order to help with consolidati ng this aspect of your learning we suggest that you undertake this clinical case study. Fir st, identify a case that has caused you to think. There are then 4 steps. In the \201 rst two you note your initial thoughts. Step 3 is completed after a case discussion conference with your team and other learners. Step 4 is for your re \202 ec- tion. Write down a summ ary of each step \200\224it will help to clarify your thoughts and you shouldn \200\231t ne ed more than 250 words for each of the sections in Box 31.2. Box 31.2 Steps in a clinical case study Step 1. Clinical vignette Describe the key issues in your patient or scenario: \200 \200 \200 \200 \200 \200 The medical facts? Contextual factors? The patient \200\231s capacity? The child \200\231s preferences? Surrogate decision makers? Competing interests? Step 2. Medical, ethical, and legal issues \200 \200 What problems are posed by the case or scenario? What options were there for resolution? Step 3. Clinical goal-setting and decision-making After you have had an opportunity to disc uss steps 1 and 2 in a group: \200 \200 \200 Write down what you discussed in the group Was there an answer or resolution to the problem ? How was this achieved and what options or interventions were considered? Step 4. Implementation and evaluation \200 \200 \200 How was the matter dealed with? Comment on whether the plan of action worked In retrospect, do you think the problem could have been avoided or improved, etc.? 31_McClure_31.indd 1033 11/14/2012 3:40:32 PM CHAPTER 31 Pediatrics, ethics, and the law 1034 The doctor \200\223child relationship Involving children in decision-making about their own care presents some problems. The law in England is not clear and relies on the clinician e xer- cising clinical judgment. In general, consider: \200 \200 \200 Doctors should act in partnership with children whenever possible. The Children Act (1989) states that children \200\231s views should be heard. United Nations Convention on the Righ ts of the Child indicates that The clinicians should give \200\230due weight to the views of the child according to age and maturity \200\231. The Children Act 1989 The legal framework within which action takes place to safeguard chil dren. The key principles of this act include: \200 \200 The welfare of the child is paramount. Children are best brought up in their own home and a gencies should seek to work in partnership with parents. The social services authority has a duty to investigate the circumstances of individual children where there are reasonable g rounds to believe that the child is at risk of suffering or suffers \200\230signi \201 ca nt hardship \200\231. Note the following: \200 \200\230Harm \200\231 is de \201 ned as ill-treatment (i.e. all forms of abuse) or impair ment of health or development. \200\230Signi \201 cant \200\231 is not de \201 ned in th e Act, but means considerable, noteworthy, or important. The Children Act 1989 was added to in The Children Act 2004 which gave legal underpinning t o \200\230Every Child Matters: Change for Children \200\231 (2004) and meant that from Apr il 2006, education and social care services for children have been brought together under a director of children \200\231s serv- ices in each local authority. Closely linked to the Children Act are: Protection of Children Act 1999. Safeguarding Vulne rable Groups Act 2006. The Children and Young Person Act 2008. \200 \200 The Human Rights Act 1998 Public authorities must act consistently with the European Conven tion on Human Rights. Most relevant are the following. \200 \200 \200 \200 The right to life. The right to respect for private and family life. The right to liberty a nd security of person. That no one shall be subjected to torture or inhuman or Article 2: Article 8: Article 5: Article 3: degrading treatment or punishment. 31_McClure_31.indd 1034 11/14/2012 3:40:32 PM PARENTAL RESPONSIBILITY 1035 Parental responsibility This is de \201 ned as \200\230all the rights, duties, powers, re sponsibilities, and author- ity which by law a parent has in relation to the child and his property \200\231. Parental responsibility (PResp) is allocated as follows. PResp is automatically given to th e mother. The father has PResp if: \200 \200 \200 