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 he and mother were married at the child \200\231s birth; unmarried, but name registered on birth certi \201 cate (after December 2003); unmarried and entered into a PResp agreement with the mother; unmarried and obtained a court order for PResp; unmarried and obtained a R esidence Order. In addition unmarried fathers can acquire PResp by marrying the child \200 \231s mother. Parents cannot lose PResp unless the child is freed for adoption (or awarded to local authority as part of EPO or care order). \200 \200 \200 The doctor \200\223parent relationship Most professionals do not have any dif \201 culty w ith the idea that compe- tent adult patients should be involved in their treatment. In the case of children, their parents are the proxy decision-makers. In this regard, the followin g must be considered. \200 doctors have a duty to act in the best interests of their patients. In the All UK the Gener al Medical Council requires this standard from medical practitioners. Parents their child. Parents that they do not consider to be in the child \200\231s best interest. Given this re sponsibility, there will be times when a doctor may be forced to act against the parents in the interests of a child. have the right to make decisions about a procedure on behalf of do not have the right to insist on a doctor doing something 31_McClure_31.indd 1035 11/14/2012 3:40:32 PM CHAPTER 31 Pediatrics, ethics, and the law 1036 Assent and consent In the USA, the term \200\230assent \200\231 in a child is used to dist inguish valid \200\230consent \200\231 from a competent adult. The American Academy of Ped iatrics suggests that assent should include at least the following elements: \200 Helping the nature of his or her condition. the patient what to expect: with tests and trea tment. Telling Making a clinical assessment of the patient \200\231s understanding of the s ituation: the factors in \202 uencing how he or she is responding (including whether there is inappropriate pressure to accept testing or therapy). Soliciting an expression of the p atient \200\231s willingness to accept the proposed care: do not solicit a patient \200\231 s view without intending to weigh it seriously. Where the patient will have to receive medi cal care in spite of his/her objection, tell the patient that fact. Do not deceive them. the patient achieve a developmentally appropriate awareness: of \200 The American Academy of Pediatrics suggests that clinicians seek the assent of the school-a ge patient as well as informed permission of the parent for procedures such as: \200 \200 for diagnostic study in a 9-yr-old; Venepuncture Orthopedic surgery device for scoliosis in an 11-yr-old. With regard to consent, the clinician must present information in a man- ner suited to the child \200\231s developmental level. Parents should be able to assist, but in some cases th ey may be too close to the situation to assess the child \200\231s state accurately. Other professionals can provide important insight into a particular child \200\231s developmental level and comprehension of the information presented. In the process of consent, the child \200\231s situation in \202 uences each of these elements: \200 \200 \200 \200 Nature and the purpose of the therapy. Risk and consequences of therapy, and of not having therapy. Bene \201 ts and the probability that therapy will be successful. Feasible altern atives. Consent In the UK, consent must be suf \201 ciently informed and freely given by the desig nated person who is competent to do so. (See also b p.1037). \200 \200 \200 \200 \200 The adolescent if aged >16yrs. The adolescent if aged <16yrs and judged to be competent. Pa rents. Individual or local authority with parental responsibility. A court. Competence De \201 ning whether an adolescent demonstrates competence can be dif \201 cul t and may depend on the nature of the procedure, as well as the child. The adolescent must possess qualities associated with self-determination and self-identity, appropriate cogniti ve abilities, and the ability to rationalize and reason hypothetically. Understanding, inte lligence, and experience are also important qualities that may determine competence. 31_McClure_31.indd 1036 11/14/2012 3:40:32 PM ASSENT AND CONSENT 1037 Criteria for establishing competence The patient must: \200 Demonstrate an understanding of the nature, purpose, and necessity of the proposed therapy. Demonstrate and understanding of the bene \201 ts, risks, and potential consequences of n ot having the treatment. Understand that this information applies to him/her. Retain and us e that information to make decision. Ensure their decision is made without being pressurize d. \200 \200 Assessing competence is the legal responsibility of the patient \200\231s doctor or other d esignated health care professional. A patient \200\231s refusal to co-operate with competen ce assessment should not be regarded as demonstrating incompetence. In England, Wales, and Northern Ireland adolescents aged 16 \200\22318yrs can consent to treatment, but cannot ref use treatment that is otherwise intended to prevent their serious harm or death. Adolescent s aged less than 16yrs may legally consent to treatment if they ful \201 ll the criteria f or competence. In Scotland, all children and adolescents may con- sent to treatment irrespe ctive of age, so long as they are deemed com- petent to do so. 31_McClure_31.indd 1037 11/14/2012 3:40:32 PM CHAPTER 31 Pediatrics, ethics, and the law 1038 Con \201 dentiality and disclosure When should you tell the whole truth? What if you make a mistake? What do you say to the team? What will you say to the family? Will you disclose your error? Will you say you are sorry? How will you handle this in terms of your personal feelings? How will you feel about yourself? These are questions we all have to think about \200\224whatever our level of seniority and whatever \201 eld of practice. The General Me dical Council provides guiding principles and responsibilities of the doctor in these situa tions. It should be remembered that deception or \202 awed disclosure may take many forms , e.g. presenting \200\230just the facts \200\231, or saying \200\230there \200\231s alwa ys hope \200\231, or thinking that \200\230you can \200\231t tell a patient everything \200\231, or omission, or evasion. Con \201 dentiality in regard to patients In adolescent practice, the issue of con \201 d entiality arises when the young person presents for certain types of advice or treatment (e .g. contracep- tion, abortion, STIs, substance misuse, mental health issues, and family pro blems). \200 The duty of con \201 dentiality owed to a person under 16 is the same as that owed to any other person. It is not absolute and may be breached where there is risk to the health, saf ety, or welfare of the young person or others. Disclosure should only take place after cons ulting the young person. The personal beliefs of a practitioner should not prejudice the ca re offered to a young person. \200 Objections to disclosure of information should be respected, although in certain situations disclosure may be required by law for the purposes of protecting the adolescent or others from signi \201 cant harm. Breach of con \201 dentiality and disclosure of information It may be proven legal to brea ch con \201 dentiality in the following situa- tions: \200 any situation in which there is a risk of harm to Incompetent individual: the adolescent or to others. Competent individual: history of curre nt or past sexual abuse; history of current or recent suicidal thoughts or self-harm behavi or; homicidal intentions; where serious harm to the individual is likely to occur. \200 \200 \200 \200 The patient should always be informed that the information will be dis- closed and the reas on why. Attempts should be made to encourage the patient to agree to disclosure. Legal guid ance from professional bodies or from medico-legal services may need to be sought. 31_McClure_31.indd 1038 11/14/2012 3:40:32 PM CONFIDENTIALITY AND DISCLOSURE 1039 Con \201 dentiality and disclosure of medical information to other agencies Improving chil dren \200\231s well-being is dependent on agencies being able to share relevant information about them. The general rule is to seek con- sent to share information unless you believe it is contrary to the child \200\231s welfare. It is the parents (or whoever has parental r esponsibility) who can give consent. In UK law, the parental right to determine whether a child <16yrs has medical treatment ter minates if and when the child achieves suf \201 cient understanding and intelligence to un derstand fully what is proposed. In practice, a young person <16yrs of age can consent to t reatment, but if they refuse it, parents may override their decision. This is termed Fraser or Gillick competence (b p.1007). Whether an adolescent is Fraser com- petent depends on t he complexity of their medical needs as well as their emotional maturity and intellect. Disclosing personal information and medical information about a child to other professional s (teachers, social worker, police, other health profes- sionals) is not a problem if conse nt is given but should be proportionate. \200 Judgment needs to be exercised and very personal medical information should only be shared if relevant and necessary to promote the child \200\231s well-being. Medical and other sens itive information about parents needs their permission to divulge. Only share relevant fact s when needed. If consent is not given then it can be justi \201 ed if: there are very goo d reasons to do so (see it is in the public interest. Whatever decision is made this must b e in keeping with the Data Protection Act, the Human Rights Act, and the common law duty of con \201 dence and also guidance from the General Medical Council (UK). \200 \200 \200 b Chapter 28); or 31_McClure_31.indd 1039 11/14/2012 3:40:32 PM CHAPTER 31 Pediatrics, ethics, and the law 1040 Withholding or withdrawing treatment in children There are medical situations where the tre atments used to try to keep a child alive will neither restore them to health, nor provide them any other meaningful bene \201 t. In these circumstances treatments such as mechanica l ventilation, heart pumps, etc., may no longer be in the child \200\231s best inter- ests. Ethical framework \200 Duty care team is to comfort and to cherish our patient, the child, and to prevent them exp eriencing pain and suffering. We undertake this in partnership with the child \200\231s par ents or carers. Legal within the framework of the law. Any practice or treatment given with the intention of causing death is unlawful. Respect \200\230their best interests \200\231 as a p consideration. of care and the partnership of care: our duty as part of the health duty: all health care professionals are bound to ful \201 ll their duty for children \200\231s rights: our treatments for children should have Double effect It is recognized in English and Scottish law that, e.g. increasing doses of a nalgesia, necessary for the control of pain or distress, may shorten life. We use opiates f or the bene \201 t of the child during life and we do not use them to cause or hasten deat h, but this may be a consequence \200\224the dou- ble effect. The principle has four freque ntly cited conditions: \200 \200 The action must be either morally good or neutral. The bad effect must not be the means by which the doctor achieves the good. The intention of the doctor must be the good effect. Th e good effect must be equivalent or greater than the bad. \200 Euthanasia Withholding or withdrawal of treatments, such as ventilation often does not lead to death. It should be clear that active measures to shorten life are not appropriate or l egal and that palliative care is to be continued. Process of decision-making Making a decision about withholding or withdrawing life-sustaini ng treat- ment requires time. It is advisable that the whole team is involved, and enough i nformation and evidence about the child \200\231s condition is availa- ble. The decision to withhold or withdraw life-sustaining therapy should always go hand in hand with planning p alliative care needs. \200 Process: safeguarded in the best way possible. Responsibility: for decision-making. The sen ior member of the team is the consultant in charge of the child \200\231s care and should l ead the decision-making while decisions are being made the child \200\231s life should be the clinical team carries the corporate moral responsibility 31_McClure_31.indd 1040 11/14/2012 3:40:32 PM WITHHOLDING OR WITHDRAWING TREATMENT IN CHILDREN 1041 process: s/he bears the \201 nal responsibility for the chosen course of action. Family i s made with the consent of the parents. Good communication is essential, as is building a r elationship based on trust. Second opinions: it is good practice to consider this option. O ther consultants working within the team may have advice. However, additional input from ex perts in another hospital may be required. This is particularly useful in unusual circumsta nces where there is uncertainty about prognosis and the child \200\231s likely future impai rments. Legal the decision-making process in most cases can be brought to a resolution. The re are instances where hospital legal advisers and court involvement are required, especial ly where there is disagreement between parents or parents and the medical team involved abo ut the right way to proceed. and parents: the \201 nal decision about withdrawal of treatment input: with time, effective communication, and support, Professional framework See also b pp.198 \200\223199. The Ethics Advisory Committee of the Royal College of Pediatrics and Child Health (RCPCH) identi \201 ed \201 ve situations w here it may be ethical and legal to consider withholding or withdrawal of life-sustaining t reatment. These are summarized in the Box 31.3. Where there is disagreement, or where there is uncertainty over the degree of future impair ment, the RCPCH advises that the child \200\231s life should always be safeguarded until th ese issues are resolved. Box 31.3 Ethics Advisory Committee of the RCPCH recommendations See \200\230Witholding or withdrawing treatment in children \200\231, May 2004, M www. bapm.org/publications/document /guidelines/Withholding&withdrawing_ treatment.pdf \200 Brain speci \201 c criteria are met, is futile and the withdrawal of ICU treatment is appr opriate Permanent vegetative state: this state, which has speci \201 c diagnostic criteria , follows brain insults such as trauma and hypoxia. It may be appropriate to withdraw or wi thhold life-sustaining treatment No chance: the child has such severe disease that life-sus taining treatment simply delays death without signi \201 cant alleviation of suffering. Tr eatment to sustain life is inappropriate No degree of physical or mental impairment will be so great that it is unreasonable to expect them to bear it Unbearable: and irreversible il lness, further treatment is more than can be borne. They wish to have a particular treatmen t withdrawn or to refuse further treatment irrespective of the medical opinion that it may be of some bene \201 t death: mechanical ventilation in such circumstances, where purpose: the child may be able to survive with treatment, but the the child or family feel that, in the face of progressive 31_McClure_31.indd 1041 11/14/2012 3:40:33 PM CHAPTER 31 Pediatrics, ethics, and the law 1042 Good ethical and legal practice in suspected child abuse A full account of the reporting of child abuse is given in b Chapter 28 (b pp.998 \200\2231010). The crucial issue for doctor s is the safety of the child and this overrides considerations such as con \201 dentiality . Reporting: information with other clinicians and social services and police. Parents and ca rers have parental responsibility for their children. Share your concerns and course of act ion with them as far as is safe for the child. as soon as abuse is suspected it is important to share this Criminal proceedings \200 \200 \200 Crown prosecution service decides whether to bring a criminal case. Burden of proof needed is \200\230beyond all reasonable doubt \200\231. No hearsay evidence is permissible. Magis trates Court or Crown Court. Civil proceedings \200 \200 Burden of proof needed is \200\230on balance of probability \200\231. Magistrates Court, C ounty Court, or High Court. Divorce and other civil matters included as well as child abuse . Court orders (Children Act 1989) Police Protection Order \200 \200 Application: Duration: Child removed to suitable accommodation or prevention of removal fro m a current location of safety (e.g. hospital ward). by the police in case of emergency. maximum 72hr. Emergency Protection Order Duration: occasion only. Application: 8 days, but can be extended for a period of 7 days on one by anyone but usually by social services. Child Assessment Order Implemented when parents are uncooperative. In practice little used and not if there are gr ounds for an emergency protection order. Duration: Application: \200 7 days. by an authorized person, usually the local authority. Interim Care Order Duration: Application: Gives parental responsibility to the local author ity (i.e. social services). \200 \200 maximum 8wks. by the local authority usually (or NSPCC). Supervision orders Duration: Application: \200 12mths in the \201 rst instance. by social services or NSPCC. Note: The courts have powers to authorize or prohibit medical examination of a child at the time the order is made or during the course of the order. 31_McClure_31.indd 1042 11/14/2012 3:40:33 PM SERIOUS CASE REVIEWS 1043 Serious case reviews Following \200\230Working Together to Safeguard Children 2006 \200\231 serious case review s are commissioned in cases where a child dies or sustains seri- ous injuries, and abuse or neglect is known or suspected to be a factor. They were previously referred to as \200 \230Part 8 reviews \200\231 as de \201 ned in section 8 of \200\230Working Together to Sa feguard Children \200\231 (Department of Health, 1999).1 The purpose of serious case reviews is to: \200 Establish lessons to be learned about the way in which local professionals and organization s work together to safeguard and promote the welfare of children. Identify what those lesso ns are, how they will be acted on, and what is expected to change as a result. Improve inte r-agency working and better safeguard and promote the welfare of children. Reference Department of Health (1999). Working Together to Safeguard Children: a guide to i nter-agency work- ing to safeguard and promote the welfare of children. London: HMSO. 31_McClure_31.indd 1043 11/14/2012 3:40:33 PM CHAPTER 31 Pediatrics, ethics, and the law 1044 Legal aspects of international adoption The Adoption and Children Act 2002 and the Family P rocedure (Adoption) Rules 2005 have comprehensively reformed the law on adoption. A new pro cess called \200\230placement \200\231 has replaced the process of \200\230freeing for ad op- tion \200\231. The following notes cover some basic information for UK citizens wishing to bring an adopted child from another country. \200 In general anyone over 21 can legal ly adopt a child. \200 The UK does not have a statutory upper age limit, but each local a uthority has the power to determine if a prospective adoptive parent is above its acceptabl e age limit. Married couples must adopt \200\230jointly \200\231, unless one partner canno t be found, is incapable of making an application, or if a separation is likely to be perma nent. Unmarried couples may not adopt \200\230jointly \200\231, although one partner in th at couple may adopt. UK requirements for adoption It is a criminal offense if a parent adopts a child overseas w ith the intention of bringing the child to the UK without having been approved. \200 A person must be approved for adoption by their local social services department before a c hild can be identi \201 ed. A detailed \200\230home study \200\231 will be conducted by l ocal social services or an \200\230approved adoption society \200\231. A list of approved societies can be obtained from the British Association for Adoption and Fostering (M www.ba af.org.uk). A medical clearance and full police background check are also required. Once th e approval for adoption has been granted, the prospective parent(s) should then contact the following departments for advice: the UK Border Agency \200\224Inter-country adoption and immigration rules (M www.bia.homeof \201 ce.gov.uk/sitecontent/documents/residency/ interc ountryadoption.pdf The prospective parent(s) must also apply to the nearest British Embassy or Consulate to obtain clearance for the child to enter the UK. The Home Of \201 ce Immig ration service has an information package (RON117) that explains the procedures. The UK has now rati \201 ed the Hague Convention on Protection of Children and Co-operatio n in respect of Intercountry Adoption 1993. This means that, in many cases, provided an ado ption order is obtained in the child \200\231s country of origin, it will not be necessary for the applicant to obtain an order in the UK as well. However, where the child \200\231s country of origin has not rati \201 ed the Hague Convention, the procedures are more strin gent. Applications for adoption in the UK are still necessary and may be trans- ferred to t he High Court. 31_McClure_31.indd 1044 11/14/2012 3:40:33 PM LEGAL ASPECTS OF INTERNATIONAL ADOPTION 1045 Medical care There is now a growing literature on the medical problems encountered by some internationally adopted children, albeit in predominantly US jour- nals. It should be remembered that many internationally adopted children have come from instituti ons in countries with many endemic diseases. In the USA, international adopted children hav e been reported to have the following conditions identi \201 ed on arrival: \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 Hepatitis B. Intestinal parasites. Tuberculosis. Congenital syphilis. Anemia Lead poisoning . De \201 cient immunization. Emotional and behavioral problems. Unsuspected medical probl ems. Developmental delay. Microcephaly. In some instances, parents now consult an expert in adoption-medicine to review the informa tion given by the adoption agency. The American Academy of Pediatrics has recommendations o n pre-adoption review and screening on arrival. The pre-adoption review will include the fo llowing: \200 The specialist should be able to advise on the medical summary, the risk of fetal alcohol syndrome, and explain the meaning of Russian diagnoses, such as \200\230per inatal encephalopathy \200\231, \200\230hypertensive \200\223 hydrocephalic syndrome \200 \231, and \200\230pyramidal insuf \201 ciency \200\231. Assessment of growth and developm ent charts, and any photographs and videos. Once the child has arrived, it is advisable to document the adequacy of immunity gained fro m any immunizations. In addition to considering and testing for the diseases noted above, t he child will require testing for the following infections on arrival and 4 \200\2236mths l ater. \200 \200 \200 Hepatitis B. Hepatitis C. HIV (note that very few internationally adopted children arrive w ith this infection). Last, the adoptive parents should consider long-term developmental follow-up. 31_McClure_31.indd 1045 11/14/2012 3:40:33 PM This page intentionally left blank 1047 Index A ABC of high dependency 46 abdomen, acute 685 abdominal examination 33 shock 57 diabetic adrenal insuf \201 ciency 530 \200\2232 adrenal stimulation test 431 adrenarche, premature 482, ketoacidosis 98 \200\223101, 413 metabolic acidosis 103, 485 104 \200\2235 -adrenergic antagonist neonates 145 acitretin 810 acne vulgaris 822 acquired aplastic abdominal mass 351, 653 abdominal migraine 311 abdominal pain, poisoning 86 adrenocorticotrophin stimulation test 431 adrenoleukodystrophy 536 adriamycin 248 adult health services, transit ion to 803 \200\230adult \200\231 seborrhoeic eczema 841 anemia 626 \200\2237 recurrent 310 \200\22311, 593 abdominal paracentesis 217 abdominal wall acquired immune de \201 ciency syndrome 726 acrodermatitis, papular 814 actinic prurigo 834 actinomycin 672, 678, 681 activated charcoa l 84 activated partial defects 866 \200\2237 Ablespacer 268 abortion, spontaneous 110 absence from school 991 ab sence seizures/ advanced life support 40 \200\2231 adverse drug thromboplastin time 634 epilepsies 505, 512, 513 reactions 1014 \200\22315 Aerochamber 268 a \201 brinogenaemia, congenital 639 activated protein C resistance 644 acute disseminated daydreaming confused with 502 \200\2233 absolute risk reduction 15 absorption, drug 1016 abstinence syndrome, neonatal 186 abuse se e child abuse acanthocytes 608 accessory auricles 146 Accuhaler 268 acetaminophen see par acetamol acetazolamide 517 acetylcysteine 86, 274 achalasia 327 achondroplasia 469, 950 agoraphobia 584 Aicardi syndrome 501 airway encephalomyelitis 520 \200\2231 adalimimab 775 Adam \200\231s disease 761 adapalene 822 adenoidectomy 279 adenosine 57, 250 Adolescent Pediatric Pain assessment 36 high dependency 46 management 210 newborn life support 108 albendazole 341 Albers \200\223Sch nberg disease 764 Tool 1018 adolescents 793 \200\223803 chronic illness 802 \200\2233 communication with 575, albumin 646 alcohol misuse 800 allergic conjunctivitis 914 allergic contact 794 con \201 dentiality 1038 consent 1037 molecular genetic analysis 934 dermatitis 811 allergic rhinitis 280 allergies, food 316 \200\22317, 318 allopurinol 684, 8 18 alopecia 830 alopecia areata 830 alopecial totalis 830 alopecia universalis 830 Alport \200\231s syndrome 373, 899 alprostadil 58 altered level of adoption, international 1044 \200\2235 Adoption and Children Act aciclovir altered level of (2002) 1044 Adoption Team for consciousness 79 Bell \200\231s palsy 519 chickenpox 710, 827 encephalitis 79 encephalopathy, acute 553 Placement, Permanence and Child Protection Division 1044 adrenal carcinoma 675 adrenal cris es 432 adrenal excess 434 \200\2235 adrenaline (epinephrine) -adrenergic antagonist erythema multiforme 816 fever 701 ginigivostomatitis 904 herpes simplex 185, 826 herpes zoster 185, 710 neonate s 185 oncology 683 sepsis 71 shingles 827 consciousness 72 \200\2239 clinical assessment 74 \200\2235 Glasgow coma scale 76 \200\2237 management 78 \200\2239 poisoning 86 anaphylaxis 64 angioedema 813 bronchiolitis 289 croup 285 food allergy/ aluminum hydroxide 330 amblyopia 911 American Academy of Pediatrics 1036, 1045 American Psychiatric Association 569 intolerance 317 palliative care 691 acid \200\223base problems 104 \200\2235 32_McClure_Index.indd 1047 11/14/2012 7:09:09 PM INDEX 1048 routine 118 atomoxetine 601 atopic eczema/ ametropia 911 amikacin 682 amiloride 451 amino acid metabolism, disorders of 965 aminoglyco side 79, 362 amiodarone 57, 86, 142, antepartum hemorrhage 121 dermatitis 808 \200\2239 atrial septal defect 233 atrioventricular septal anterior horn cell disorders 540 anterior knee pain 754 anterior uveitis 915 anthracycline 678 anticholinergic poisoning 86 anti-diuretic hormone de \201 ciency 92 defect complete 236 partial 233 250 atropine amitriptyline 311, 518, 691 amniocentesis 118 amniotic bands 951 amniotic \202 uid volume 370 amoxicillin balanitis/ poisoning 86, 87, 88 retinopathy of antihistamine poisoning 86 anti-Parkinsonian drug prematurity 188 sinus bradycardia and heart block 56 attachment disorder 589 attention de \201 cit hyperactivity disorder 600 \200\2231 poisoning 86 antiphospholipid syndrome, balanoposthitis 880 maternal 124 antithrombin (III) de \201 ciency 644 contraindications 283 gastritis 330 Lyme disease 712 neonates 180 otitis media 900 peptic u lcer disease 330 pneumonia 292 auscultation of the lungs 31 autism spectrum 1-antitrypsin de \201 ciency 346 anus examination 33 disorders 602 \200\2233 autoimmune haemolytic neonates 145 amphotericin 71, 683, 684 ampicillin anemia 624 anxiety disorders 584 \200\2238 aortic stenosis 237 Apert \200\231s syndrome 950 aplastic a nemia 626 \200\2237 apneustic breathing 75 apnoea 154 appendicitis, acute 845, 864 Aristotl e 1030 arrhythmias see dysrhythmias/ arrhythmias; speci \201 c dysrhythmias/arrhythmias autoimmune myasthenia altered level of gravis 544 consciousness 79 autoimmune thyroiditis 428 automatic auditory bacterial gastroenteritis 339 brainstem response testing, neonates 141 autonomic dysfunction 957 autosomal dominant inher itance, renal disease 372 autosomal recessive inheritance, renal disease 372 fever 701 neonates 129, 152, 180 red blanching rashes 818 sepsis 71 amrinone 57, 86 amsacrine 679 anemia 610 \200\22327 kidney disease, chronic 368 arterial blood gas 261 artesunate 723 arthritis 768 \200\22379 avascular necrosis 753 azathioprine neonates 192 anesthetists 884 analgesia 1018 septic 697, 738 \200\2239 liver failure, chronic 345 myasthenia gravis 544 rheumatoid articular osteochondroses 760 analgesic ladder 691 post-operative care 890 palliative care 691 anaphylaxis 53, 64, 317 An cylostoma duodenale 341 androgen insensitivity syndrome 490 anencephaly 170 Angelman syndro me 943 genetic testing 933, 935 Ascaris lumbricoides 341 asparaginase 656, 679, 685 Asperger \200\231s disorder 602 aspirat ion syndromes 295 aspirin 245, 618, 641, 717 assent 1036 \200\2237 Association for Children with Life threatening or Terminal Conditions 690 factor-negative polyarthritis 776 rheumatoid factor-positive polyarthritis 775 systemic lupus erythematosus 781 Takayasu \200\231s arteritis 791 Wegener \200\231s granulomatosis 790 angioedema 813 aniline dye poisoning 88 anion gap 104 Ann Arbor system, azithromycin 274, 292, 333 Association of Pediatric Anesthetists 884 asthma 262 \200\2239 astigmatism 911 asymmetric neck re \202 ex 558 asystole 42 ataxia 524 ataxia telangiectasia 724 ataxic cerebral palsy 550 ataxic respiration 75 atenolol 86, 397 athlete \200\231s foot 828 B Bacille Calmette \200\223Gu rin (BCG) vaccine 728 staging of Hodgkin \200\231s lymphoma 661 neonates 141 anorectal back pain 742 bacteraemia 714 \200\22315 bacterial gastroenteritis 339 bacterial infected b lood malformations 872 \200\2233 anorexia nervosa 594 \200\2235 antalgic gait 733 antenatal care products 648 prematurity 114 32_McClure_Index.indd 1048 11/14/2012 7:09:09 PM INDEX 1049 meningitis 721 meningococcal bacterial meningitis 721 bacterial skin infections 827 bad news, breaking 690 balanitis/bal anoposthitis 880 balanitis xerotica obliterans 839 see also hypertension; hypotension blood transfusion 646 \200\2237 septicaemia and shock 714 oncology 685 post-operative care 888 reactions 648 \200\2239 neonates 115, 129, 152, 179, 182 bereavement support 690 Bernard \200\223Soulier Bandolier 18 Bardet \200\223Biedl blood vessel disorders 824 \200\2235 syndrome 640 best interests 1032 betamethasone 114, 150 bezoars 857 bicarbonate loss, abnor mal 958 syndrome 372, 949 retinal dystrophies 921 Barker hypothesis, IUGR Bochdalek hernia 852, 853 body mass index (BMI) charts 402 \200\2233 formula 400 infants 111 Barlow \200\231s test 748 Bartter \200\231s syndrome 373, body temperature, neonates 140 body weight see weight boils 718, 827 bone age 461 bone marrow 386 Bieri Faces Pain Scale 1018 bilirubin basic life support 38 basophilia 608 basophilic stippling 608 Bassen \200\223Kornweig syndr ome 920 bathing, neonates 140 Batten disease 921 batteries, ingested 856 Beau \200\231s lin e 833 Beckwith \200\223Wiedemann syndrome 949 encephalopathy 130 \200\2231, 195 failure syndromes 626 \200\2237 transplant 680