physiotherapy; occupational therapy. 27_McClure_27.indd 988 11/14/2012 3:36:33 PM SPECIFIC LEARNING DIFFICULTIES 989 Box 27.2 Presenting features and signs of DCD Presentation \200 \200 \200 \200 \200 \200 Poor motor skills Dif \201 culty using cutlery Dif \201 culty dressing and riding bike Po or attention and organization Problems with school progress (reading, copying, math) Behavi or problems (disruptive, low self-esteem) Signs \200 \200 \200 \200 \200 \200 Muscle tone may be low \200\223normal Poor balance Poor co-ordination Excess of over \202 ow movement on effort Persistence of primitive re \202 exes Associated sensory dif \201 c ulties: hypo/hypersensitive to touch, sound, light, taste, smell 27_McClure_27.indd 989 11/14/2012 3:36:33 PM CHAPTER 27 Community child health 990 Chronic fatigue syndrome Chronic fatigue syndrome (CFS) is de \201 ned as generalized fati gue persist- ing after routine tests and investigations have failed to identify underlying cause. The fatigue in CFS may be associated with other symptoms: \200 \200 \200 Dif \201 culty in concentrating; cognitive dysfunction. Disturbed sleep. Fatigue (both men tal and physical) exacerbated by effort. The diagnosis should be made as soon as it is clear that the symptoms are causing functiona l impairment and no alternative explanation has been found (3mths in children). Investigation Routine investigations need to be undertaken to rule out plausible alterna- t ive causes. Second-line investigations are only undertaken if symptoms/ signs or investigat ions suggest a particular diagnosis. Investigations for chronic fatigue syndrome \200 \200 \200 \200 \200 \200 \200 FBC and \201 lm, ESR Glucose, biochemistry, CK (muscle), liver function test Thyroid test s Urine to exclude renal disease Screening tests for gluten sensitivity Assessment of ferri tin levels EBV or viral tests only if history indicates recent infection An assessment of psychological well-being is essential and psychiatric dis- orders need to be excluded. Psychological morbidities such as anxiety and depression are common and import ant to recognize. Management There is no one single approach for all patients with CFS, but as a mini- mum th e following should be addressed. Activity management. Establish baseline level and gradually increase as appropriate. Referr al to physiotherapy and occupational therapy to supervise program and treat symptoms. It is widely assumed that the correct approach is the use of graded activity and CBT, as support ed by the literature in adults. However, some patients \201 nd it unacceptable to use psy chological treat- ments and have found that any exercise is to be avoided. Parental men- ta l illness, especially depression and anxiety, should be assessed. Treating these presentati ons may be important in a holistic treatment plan. Other management \200 \200 \200 Symptomatic treatment Dietary advice Treatment psychiatry team. for pain, sleep. (e.g. poor appetite or weight gain due to immobility). for depression and mood disorders \200\224need referral to child 27_McClure_27.indd 990 11/14/2012 3:36:33 PM ABSENCE FROM SCHOOL 991 CFS and education CFS causes signi \201 cant disruption to school. The length of absence f rom school depends on severity and will range from part time attendance to home tuition for many years. Liason with the school is essential in order to formulate a plan for return. S upport in school may be needed for mobility or learning, and for some a statement of specia l educational needs will be required. If the child is too unwell to attend school, home tui tion can be organized with support from the pediatrician but the maximum per week is usuall y a few hours and the child \200\231s needs should be monitored closely. Prognosis Severe or very severe CFS (house bound or bedridden for 3mths) on rare occasions requires admission to hospital. Some cases the condition may persist for many years. Genera lly, though, outcome is favorable.1 Reference 1 NICE (2007). NICE guidelines for chronic fatigue, No. 53. London: NICE. Absence from school This may be due to long-term illness (710%). In many situations the abs ence from school may be the result of poor provision of extra support in class and/or infor mation and training of the school staff. CFS is an important cause of school absence (see b p.990). Absence due to school refusal has a wide range of contributory factors (see Box 27 .3). Box 27.3 Factors contributing to refusal to go to school \200 \200 School phobia Anxiety concerning: \200 peers (bullying) \200 teachers \200 dif \201 culties with home life \200 emotional problems Poor academic progress whatever reason Tru ancy and antisocial behaviors Distressing symptoms such as soiling or wetting \200 \200 In most cases a thorough medical assessment is needed to ascertain the cause of chronic or recurrent school absence. When it is thought appro- priate, home tuition can be provided un til the child returns to school. 27_McClure_27.indd 991 11/14/2012 3:36:34 PM CHAPTER 27 Community child health 992 Constipation and soiling See also b p.306. This is a common problem in childhood.1 Critical periods occur around the time of infant weaning, toilet training, and starting school. Con stipation may follow a period of dehydration leading to hard stools that become painful to pass. The child therefore holds on to stool. Secondary soiling (over \202 ow) is common an d leads to anxiety at school that may lead to school refusal. It is important to review the past medical history for pos- sible underlying reasons and causes of constipation. Taking the history Find out when problem \201 rst arose. In infants ask about: \200 \200 \200 Delay in passage of meconium Abdominal distension in early infancy Explosive stools These are possible indicators of underlying HSD or short segment bowel Also ask about: Possible precipitants Current diet and \202 uid intake Psychological fact ors \200 \200 \200 \200 \200 \200 coercive or chaotic toilet training fear of toilet parental neglect/discord /illness enviro nmental stressors Examination and investigations Examination \200 Inspect anus for: \200 \200 \200 \200 Palpate abdomen General examination of child including growth: rarely presentation of hypothyroidism \201 ssures infection skin disease \200\224excoriation/ \201 stula dilatation \200 Investigations \200 AXR (to demonstrate fecal loading) \200\224not routinely needed for diagnosis Bloods: \200 FBC \200 TFT 27_McClure_27.indd 992 11/14/2012 3:36:34 PM CONSTIPATION AND SOILING 993 Management Throughout this time parents and child will need considerable support from the n ursing team (i.e. health visitor/school nurse/specialist nurse). Short-term constipation with no soiling \200 \200 , lactulose or docusate. Soften retained stool, e.g. oral Movicol Colonic stimulant orally, e.g. oral senna. Continu e until bowel pattern regular and then decrease. Long-term and soiling \200 Soften retained stools for at least a week, e.g. lactulose/ docusate/ Movicol ). Oral colo nic stimulant, e.g. senna, single daily dose until stool passed. If no stool passed conside r using: \200 \200 \200 \200 oral bowel evacuation preparation; enema; manual evacuation as a last resort (necessary if evidence of impaction). Maintenance treatment \200 \200 \200 \200 \200 \200 Increase dietary \201 bre and \202 uid. Regular bulk laxative. Regular colonic stimulan t. Persist with medication for at least 6mths. Behavior management may be needed to establi sh toilet routine. Assessment by a clinical psychologist and family therapist if there is a degree of family discord. In resistant cases treatment will need to be continued for longe r. Reference 1 NICE (2010). NICE guidelines constipation in childhood. No. 99. London: NICE. 27_McClure_27.indd 993 11/14/2012 3:36:34 PM CHAPTER 27 Community child health 994 Enuresis Enuresis is the involuntary emptying of the bladder. Although children may \200 \230wet \200\231 themselves by day or night, the term enuresis is applied to nocturnal enur esis. When it occurs during the day, while awake, it is known as diur- nal enuresis. Noctur nal enuresis is more common. In order to learn bladder control the young child needs to overcome the infant automatic pa ttern of voiding. For the young child, conscious awareness of fullness and the ability to p ostpone voiding by suppressing the urge to void are not perfect. This response is \201 rs t learned for day- time control. Eventually, bladder control becomes automatic and does not require a conscious act. Night-time bladder control requires that the brain, during sleep, suppress the automatic emptying re \202 ex. Learning blad- der control at night occurs gr adually, and in some children and families takes much longer than average. Girls achieve bladder control earlier than boys. Enuresis is de \201 ned as the continued wetting in girls beyond the age of 5yrs, and in boys beyond the age of 6yrs. Enuresis may be primary, with children not having established an appro- priate period of ad equate bladder control in early childhood, or secondary occurring after a period of establi shed bladder control. Primary enuresis \200 \200 \200 A strong family history. Boys more commonly than girls (ratio 2:1). 15% of 5-yr-olds, 5% of 10-yr-olds, and 1% of 16-yr-olds have not established total bladder control and will wet t he bed once a week or more. Majority of cases have no underlying organic cause and it is th ought to be due to delayed maturation of bladder control mechanisms. Secondary enuresis Needs careful history and investigations because of probable organic cau se. Possible organic causes of secondary enuresis \200 \200 \200 \200 \200 Renal tract: Neurological: Endocrine: Behavioral problems Abuse urinary tract infection spina bi \201 da diabetes mellitus, diabetes insipidus Daytime wetting is usually caused by bladder detrusor instability. 27_McClure_27.indd 994 11/14/2012 3:36:34 PM ENURESIS 995 History and investigations History Assess pattern and types of drink consumed: \200 \200 \200 Voiding habits: \200 \200 \200 Often limited \202 uid in the day Drink after school and evening May have sugary drinks Infrequent (<4 daily) Frequent (>7 daily) Dysfunctional/inappropriate place of voiding Investigations \200 Urine testing: \200 culture \200 urinalysis US of the renal tract : \200 \200 assess pre- and post-micturition bladder urine residual volume underlying anatomical abnorm alities Treatment Primary (nocturnal) enuresis \200 \200 Encourage regular drinks (water), but restrict in last hour before bed. Give drinking/voidi ng chart. If primary nocturnal enuresis is associated with arousal from sleep or disturbance, then an enuresis alarm should be considered. This requires careful discussion with families. Compl iance is often an issue and the fam- ily and child need to be motivated. If enuresis associ ated with a small bladder, \200\230bladder training \200\231 exercises is \201 rst-line approach. Also consider using bladder-stabilizing drugs, e.g. oxybutynin. If nocturnal enur esis and urine output exceeds bladder capacity consider using desmopressin (anti- diuretic hormone) and limit \202 uid intake 1hr before bedtime. If the problem is resistant to the above treatments, other pathologies need to be considered: \200 \200 \200 \200 Urinary out \202 ow obstruction in boys. Chronic constipation. Neurodevelopmental problems . Psychological problems. 27_McClure_27.indd 995 11/14/2012 3:36:34 PM This page intentionally left blank 997 Chapter 28 Child protection De \201 nitions 998 Illness fabricated or induced by carers 999 Physical abuse 1000 Sexual abuse 1002 Emotional abuse 1003 Medical involvement in child protection 1004 Referrals to other agencies 1005 Medical assessment 1006 Assessment by social care 1008 Prevention strat egies 1010 Further reading 1010 28_McClure_28.indd 997 11/14/2012 3:38:54 PM CHAPTER 28 Child protection 998 De \201 nitions Child protection The decisive action taken to safeguard children from harm . Child abuse This is de \201 ned as either: \200 \200 . Deliberate in \202 iction of harm to a child Failing to prevent harm to a child. Children may be abused in the family home, in an institutional setting, or, occasionally, b y a stranger. Most young people who are abused know their abuser. It is estimated that 1 \200\2232 children die each week due to abuse. Child abuse may be categorized as: neglect; physical ( sexual ( emotional ( \200 \200 \200 b p.1000); b p.1002); b p.1003) Neglect This is de \201 ned as a persistent failure to meet a child \200\231s basic physic al or psy- chological needs that is likely to result in serious impairment of the child \200\231s health and development. Neglect may occur during pregnancy as a result of materna l substance abuse. Once a child is born it may involve: \200 \200 \200 \200 Failing to provide adequate food. Failing to protect from physical harm or danger. Failure to access appropriate medical care or treatment. Failure to ensure adequate supervision Presentation \200 \200 \200 \200 Failure to thrive. Consistently unkempt and dirty appearance. Repeated failure by carers to prevent accidental injury. Lack of social responsiveness and/or developmental delay when t here are other concerns about the environment at home. Medical advice is not sought, which compromises the health of the child, including if they are in ongoing pain. 28_McClure_28.indd 998 11/14/2012 3:38:55 PM ILLNESS FABRICATED OR INDUCED BY CARERS 999 Illness fabricated or induced by carers This is an unusual form of child abuse. It was prev iously referred to as Munchausen syndrome by proxy (MSbP). The salient feature is that the child is harmed by being presented for medical attention with symptoms or signs that have b een falsi \201 ed by the carer. \200 The child is the victim of the abuse and the perpetrator is the person who fabricates the i llness. Existing mental health dif \201 culties in the perpetrator (child \200\231s natura l mother in 90% of cases) have been described, but are not essential for the diagnosis. Presentation There is a wide spectrum of severity of presentation of harm: \200 \200 False medical story. Fabrication of signs, e.g. blood on clothing or nappy, or sugar in uri ne specimen. The most serious presentations include fabrication of illness induced by poisoning or suffo cation. Symptoms Children may present with one or more of a range of symptoms: \200 b p.527). \200 \200 \200 \200 \200 \200 Seizures, collapse, coma ( b p.48). Apnoea ( Vomiting and diarrhea ( Failure to thrive ( Po lyuria and polydipsia ( Purpura ( Recurrent fever ( b pp.300, 302). b p.308). b p.350). b p.632). b p.702). Diagnosis \200 It is important to realize that the medical profession may potentially harm children becaus e unnecessary investigations are undertaken. The diagnosis can be established when the chil d is separated from the perpetrator and should be considered when other investigations are persistently normal. Very careful attention should be paid to the medical history, particul arly as to who witnessed events and when they occurred. Seek an opinion from an experienced colleague, who should arrange a strategy meeting betwee n health-care professionals to decide on what further action is necessary. 28_McClure_28.indd 999 11/14/2012 3:38:55 PM CHAPTER 28 Child protection 1000 Physical abuse Physical abuse involves any activity that causes physical harm to a child, e .g. hitting, shaking, burning, suffocating. Fabricated illness is also usually included in this category (see b pp.527, 758, 999). Typical presentations of physical abuse Any serious or unusual injury with an absent or unsuitable explanation Bruises \200 \200 Symmetrical bruised eyes Bruising of soft tissues of the face, especially in small babies. Pre- mobile babies should not get bruises or other injuries Bruising of mouth or ears Finge r marks on legs, arms, or chest (the latter may have associated rib fractures) Bruising of different ages Linear bruising on buttocks or back Distinct patterns of bruising, e.g. hand print marks, implements, kicks Uncommon sites for accidents, e.g. stomach, chest, genitalia , neck \200 \200 \200 \200 Burns or scalds \200 Typically with clear outlines or shape of an implement, e.g. cigarette burns, iron Soft tis sue areas that are unusual, e.g. backs of hands, soles of feet Forced immersion, e.g. glove and stocking distribution \200 Fractures It is rare for a child <1yr of age to sustain an accidental fracture. Bone disord ers, e.g. osteogenesis imperfecta (see b p.762), are rare. Consider the following: \200 \200 \200 Long bones (arms/legs) in infants or non-mobile children; ribs Multiple fractures in variou s bones \200\224almost always abuse Fractures of different ages Bite marks Adult or child bite marks can be determined by forensic dentistry Scars Especially if concurrent bruising present Poisoning This may be accidental, as a consequence of neglect, or deliberate (as in fabrica ted illness). An example of deliberate poisoning is salt intoxica- tion, which may prove fa tal. This should be considered when severe, recurrent symptoms or signs, such as coma, seiz ures, or severe GI upset (vomiting or diarrhea) remain unexplained. 28_McClure_28.indd 1000 11/14/2012 3:38:55 PM PHYSICAL ABUSE 1001 Investigations Skeletal survey and other imaging Infants do not localize pain; hence, injur ies of differing ages may be missed. X-rays must be carefully planned with the radiology te am and the correct views carried out. This may need repeating if inconclusive. Alternativel y, consider a radioisotope bone scan. \200 X-rays: children. Bone scan: metaphyseal or skull fractures. CT or MRI scan of brain: irrit ability or coma. particularly in children aged <18mths and for some older if X-rays inconclusive. Useful for rib fractures but not for in infants and young children who present with Clotting screen Perform tests if extensive or unusual bruising, or unexplained cerebral hem orrhage. \200 If there is evidence of physical abuse, such as hand marks or marks from implements. Should be done if child presents with petechiae or bizarre marks. Ophthalmology examination by experienced ophthalmologist to look for evidence of retinal he morrhages. The latter are suggestive of non- accidental head injury (see b p.923). 28_McClure_28.indd 1001 11/14/2012 3:38:55 PM CHAPTER 28 Child protection 1002 Sexual abuse See also b pp.576, 801. This involves forcing or enticing a child or young per son to take part in sexual activities whether or not the child is aware of what is happen- ing. This may include physical contact, and penetrative or non-penetrative acts. It may als o involve non-contact activities, such as looking at or being involved in pornographic or o ther sexual activities, and includes abuse via the Internet. Presentation Children who have been victims of sexual abuse may present in a number of ways , including: \200 Sexually transmitted infections: vaginalis. Pregnancy. Vaginal bleeding in prepubertal girl s Genital or peri-anal injury with an absent or unsuitable explanation. Behavioral changes: \200 \200 \200 \200 \200 Disclosure by the child. gonorrhea; Chlamydia; Trichomonas \200 \200 \200 self-harm; withdrawal; aggression; sexualized behavior; unexplained deteriorating school pe rformance. s \200 wetting and/or fecal soiling. Signs Few signs are diagnostic and there may be no \201 ndings in 50 \200\22390%. Acute signs \200 Girls: area; and \200\230hand \200\231 grip marks. Boys: Anal signs may disappear rapidly. acutely \200\224tears in hymen; vaginal bleeding; bruising around genital \200 bruising to genital area; urethral injury; torn frenulum of penis. signs: anal \201 ssure ; gaping anus; swelling of anal margin. Note: these Chronic signs \200 \200 These signs are more dif \201 cult to interpret. In girls the following that may be sugges tive of previous, repeated penetrative trauma: \200 \200 \200 In both sexes: excluded . scar in posterior fourchette; old tear or scar of the hymen; complete absence of tissue at posterior hymen anal \201 ssure and scars when other causes have been 28_McClure_28.indd 1002 11/14/2012 3:38:55 PM EMOTIONAL ABUSE 1003 Emotional abuse Persistent, emotional ill-treatment of a child that results in severe impai r- ment in emotional development. This may involve: \200 \200 \200 \200 Conveying to children that they are worthless or unloved. Imposing age or developmentally i nappropriate expectations. Causing children to frequently feel frightened and threatened. S eeing or hearing the ill-treatment of another as in domestic violence. This form of abuse often co-exists with other forms of ill treatment. Presentation This is almost always gradual and dif \201 cult to diagnose. Symptoms are lar gely behavioral and may include: \200 \200 \200 \200 \200 Being excessively clingy. Attention-seeking behavior. Overly anxious. Overly serious. Being anxious to please. Parental behaviors are a clue to the diagnosis. Any of these must be per- sistent and sever e, and have a major impact on the child in order to reach the threshold for emotional abuse : \200 Persistently \200\223ve view of the child. \200 Inconsistent and unpredictable responses. \200 Expectations that are very inappropriate. \200 Induction of a child int o bizarre parental beliefs. 28_McClure_28.indd 1003 11/14/2012 3:38:55 PM CHAPTER 28 Child protection 1004 Medical involvement in child protection All health professionals have a role in ensuring th at children and families receive the care, support, and services they need in order to prom ote child health and development. It is likely that health professionals will be the \201 rst to have contact with children or families in dif \201 culty. Participation in child p rotection encompasses a range of activities. \200 Recognizing children in need of support or protection, and parents who may need extra help in bringing up their children. Contributing to enquiries about a child or family. Assessing the needs of children and the capacity of parents to meet their children \200\231s needs. Planning and providing support for vulnerable children and families. Participating in child protection conferences. Planning support for children at risk of signi \201 cant harm. Pr oviding therapeutic help to abused or neglected children and parents under stress(usually t he remit of the child and adolescent mental health team) Contributing to case reviews. \200 \200 \200 \200 Initial concerns Where there are concerns about a child, and when there is reasonable belie f that a child is at serious risk of immediate harm, doctors should act immediately to prot ect the interests of the child, and this will almost always involve contacting one of the t hree statutory bodies with respon- sibilities in this area: \200 \200 \200 Social care. Police. National Society for the Prevention of Cruelty to Children (NSPCC). A full report of concerns will be required. The precise action taken should be governed by the procedures set out by the Local Safeguarding Children Boards (see also b pp.1005 \200 \2231010, 1042). 28_McClure_28.indd 1004 11/14/2012 3:38:55 PM REFERRALS TO OTHER AGENCIES 1005 Referrals to other agencies An experienced/senior member of the medical team must be involv ed when there are child protection concerns. Agencies \200 \200 Social care: Police service: when criminal prosecution is likely. lead agency for investigation of child abuse. frequently involved in the initial joint investigation or Referral procedure \200 \200 \200 \200 \200 Inform parents unless likely to result in further harm to the child. Referral does not need parental permission. Speci \201 c concerns should be clearly stated. Telephone referrals should be con \201 rmed in writing. All referrals should be followed up if no acknowledgem ent is received or action taken. The child \200\231s safety is of equal importance with their medical treatment. If hospitalization for medical treatment is not indicated they should not be discharged wit hout a clear plan and decision about place of safety and future follow-up. This will be the joint decision and responsibility of the multidisciplinary agencies (medical, social care, and police). The police should be immediately informed if the parents/carers attempt to re move the child from hospital before these decisions are made. 28_McClure_28.indd 1005 11/14/2012 3:38:55 PM CHAPTER 28 Child protection 1006 Medical assessment See also b p.1004. The purpose of the medical assessment is to: \200 Assess whether the child has been injured and/or whether there are any other medical or dev elopmental concerns. Provide appropriate investigations and treatment for the child. Provid e an opinion about possible cause. \200 When assessing a child who may have been the victim of child abuse it is important to infor m and involve your senior colleagues at an early stage. The assessment should be carried ou t (along with an experienced/ senior colleague, if possible) in an environment that provide s a suf \201 cient degree of comfort for the child and their parents/carers, as well as su f- \201 cient access and lighting for examination. It is good practice to have a nurse or other health professional present at the time of history taking and examination. History \200 \200 A thorough history is required. The presenting problem should be documented chronologically , outlining the sequence of events and circumstances leading up to presentation and referra l. The family history, past medical history (e.g. clotting defects, bone disorders, psychia tric), and social history should be detailed. Examination This should include a general examination of all the systems. \200 Weight, head circumference, and height should be plotted on a growth chart. Neurodevelopmen tal assessment is appropriate in infants/toddlers. External injuries should be recorded in detail, including their location, size/dimensions, and appearance. Photographs should be ta ken (see \200 b p.1007). Examination of children with suspected sexual abuse should only be undertaken by designated /trained professionals (e.g. the named child pro- tection lead or police-surgeon). Child protection plan \200 Where there are concerns about a child enquires should be made to social care. There is a c on \201 dential list of names of children subject to a child protection plan within a loca l authority area who are believed to be at continuing risk of signi \201 cant harm. This i s maintained by the local authority within the social care department, every local authorit y is required to hold one. A child protection plan is drawn up by professional staff workin g together with the parents, carers, and the child (where old enough). Children with a chil d protection plan have a social worker who is responsible for co-ordinating work with the c hild and the family. 28_McClure_28.indd 1006 11/14/2012 3:38:55 PM MEDICAL ASSESSMENT 1007 The family must have a clear understanding of the planned outcomes and that they are willin g to work to these within a speci \201 ed time frame. A child will be the subject of a chi ld protection plan until it is believed that the child is safe from any future harm. Regula r meetings are held with the parents/carers and child to review the work being done and pro gress made. If a child moves out of one area, if they are the subject of a child protection plan, the information must be passed on to the new local authority area. Consent This is an important consideration that needs to be taken into account before proce eding with the medical assessment of any child. If the child is deemed to have suf \201 ci ent understanding to make an informed decision, consent should be obtained from them. This principle is commonly re- ferred to as \200\230Gillick competency \200\231, although now w e think in terms of Fraser competency (see b p.1036). Children of suf \201 cient understan ding cannot be medically examined without their consent even when an emergency protection o rder has been made (see b p.1042). Gillick competency This is named after the ruling of the House of Lords (Gillick v. West Norfolk and Wisbech Area Health Authority [1985]). It stat ed that the parental right to determine whether or not a child below the age of 16yrs will or will not have medical treatment terminates if and when the child achieves suf \201 cien t understanding and intelligence to enable him to under- stand fully what is proposed (see also b p.1037). This term has now been replaced by Fraser competency (see b p.1036). Record keeping Clear, detailed note keeping is required. \200 Written notes: full and contemporaneous notes should be kept including comments made by par ents and the child. All notes must be signed and dated with the name of the doctor printed underneath an entry. Diagrams: Photographs: requested from medical photography with parenta l consent. \200 particularly body maps to illustrate location of injuries. may be helpful, but should be da ted and signed or 28_McClure_28.indd 1007 11/14/2012 3:38:55 PM CHAPTER 28 Child protection 1008 Assessment by social care Social care and the police will undertake an assessment. They wil l collect the relevant information from all professionals involved. Referrals may result in : \200 \200 \200 No further action being taken. Provision of support and help for the child and their family . A fuller assessment of the needs and circumstances of the child. Strategy meeting This is a meeting between professionals from all the relevant agencies (so cial services, police, education, health) to decide on the next action or steps. Child protection conference This will be convened if there are concerns about signi \201 c ant harm. The timing will vary and may be after discharge from hospital as long as the chil d is in a place of safety. A plan is needed to ensure the child \200\231s wel- fare and saf ety is addressed. When a child is considered at risk, then following the conference: \200 \200 He/she will be the subject of a child protection plan. A more comprehensive assessment (cor e assessment) will be arranged and undertaken. A key worker will be appointed. A review con ference will be arranged within 3mths. \200 Children not considered at risk have: \200 \200 A support plan organized. Follow-up between the family and other professionals arranged. Report writing for child protection conferences See also b p.1006. Those members of the med ical team directly involved in the initial assessment and/or subsequent management of the c hild should write a medical report. Parents have the right to see reports before a case con ference. There are a number of important key points in writing these reports: \200 \200 \200 \200 \200 They should distinguish fact from observation and allegation. Relevant information should b e used from current and past records. Medical terms should be explained for the bene \201 t of laypersons. Include observations and relevant statements from child and carer. State c learly whether the injury is unexplained or does not \201 t with history. State medical o pinion only. Con \201 dentiality and disclosure of medical information Guidance regarding con \201 den tiality and information disclosure is pro- vided by the UK General Medical Council (GMC). T here are various reports from 2004 onwards that can be found on the GMC website (see www.gm c-uk.org/). In addition, there is a useful consultation document 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.