Catherine Sumsky

Chapter Contents

Introduction

This chapter considers reasons for Emergency Department (ED) attendance by children between the ages of 5 and 13 years. While this age range is somewhat arbitrary, especially in the context of the decreasing age of puberty, for the purposes of this chapter it will be used as a chronological benchmark between pre-school children and adolescence. Some of the more common injuries and conditions occurring in this age group will be considered, with particular reference to a child’s development and the need for a suitable environment and a family-centred approach.

Children’s school years are proposed as the best years of their lives, but unfortunately they are also a very dangerous time. Children’s maturity and their interests and needs differ from adults. Therefore, simply reproducing injury-prevention strategies that are relevant to adults does not adequately protect children. As children develop, their curiosity and wish to experiment are not always matched by their capacity to understand or respond to danger (World Health Organization 2008). Each year one in five children attends an ED and one in 10–15 children will be admitted to hospital (Department of Health 2005). Once children reach the age of 5 years, unintentional injuries are the biggest threat to their survival. Death in childhood is most prevalent during the first year of life, while the fewest deaths occur between the ages of 5 and 14. Of these deaths trauma and neoplasms are the biggest killers (National Institute for Health and Clinical Excellence 2005, American College of Surgeons 2008). The number of deaths from trauma in this age group has decreased dramatically since 1991; this may be due to an increase in safety awareness or an increase in paediatric resuscitation courses.

Children’s deaths following injury are most commonly road traffic accidents (RTAs) followed by drowning, suffocation, fire and falls (Mead & Sibert 1991). About 10 000 children are permanently disabled annually as a result of accidents (Morton & Phillips 1996). Road traffic fatality injury rates (global) per 100 000 children aged 5–14 years, varied between sexes. Boys’ injury rates were 22 per 100 000 whilst girls’ were 13.8 per 100 000 (WHO 2008). However, the figures do not show the real impact an accident can have on both the child and the extended family. The cost can be enormous in both physical and emotional terms which can have a long-lasting impact on all facets of children’s lives: relationships, learning and play. Among those children who live in poverty, the burden of injury is highest, as these children are less likely to benefit from the protective measures others may receive (World Health Organization 2008).

Child development

Children are involved in different types of accident according to their stage of development. At 5 years of age children run confidently, although they frequently fall. As they progress from infant to junior to secondary school, balance and coordination improve, as does their dexterity. Children in this age group become more aware of their bodies and subsequently may be self-conscious during examinations. As children develop, their curiosity and wish to experiment are not always matched by their capacity to understand or to respond to danger. According to World Health Organization (2008) data, boys tend to have both more frequent and more severe injuries than girls; this is evident from the first year of life.

Piaget’s theory of the development of causal reasoning (Piaget 1983) demonstrates a systematic progression in children’s understanding of illness: this is linked to Piaget’s four stages of cognitive development:

The pre-operational stage is dominated by the perception and direct experiences, while illness concepts are related to phenomenism and contagion. Phenomenism occurs in the younger children in this stage, the cause of illness is believed to be external, such as the sun. Contagion occurs in the older children in this stage: illness is seen to be in objects or people. Colds are caught by someone coming near and transferred by magic. Pre-operational children may see illness or unpleasant procedures as punishment for their naughty behaviour. They are unable to comprehend unpleasant procedures being part of the cure.

In the concrete-operational stage children can apply thinking and reasoning to real objects and events. Contamination children can distinguish from cause and effect, such as bad food will give a tummy ache. However, all illnesses are seen as being caused by contact with the causative agent: if someone has a rash and it is touched then the rash is transmitted. Internalization occurs in the older children in this age group, where illness is seen as internal with an external cause; for example, kissing someone with a cold will cause the germs to go into your mouth and make you ill. Mechanisms of illness remain poorly understood but there is a realization that the body responds to causative agents such as allergens. Children in this age range understand that illnesses are preventable by immunizations and healthcare (Swanwick 1990).

When caring for children, consideration for their conception of illness can ease the path of the child through assessment and treatment to admission or discharge. Be aware of using metaphors when explaining to children as they might confuse or increase fear: for example, white cells ‘fighting’ infection may give rise to terrifying thoughts of soldiers with guns, missiles and tanks in their bloodstream. Despite this acquired understanding, many children regress in behaviour when they become ill, probably as a coping mechanism for the stress associated with hospitalization (Swanwick 1990).

Childhood is a social construction and is characterized by boundaries that shift with time and place and this has implications for vulnerability to injury. Tasks that may be considered the norm in one country for the child and family can vary enormously in another country where the child may be protected by economic and domestic responsibility (World Health Organization 2008). Childhood and developmental stages need to be seen as being closely linked with age, sex, family, culture and social background.

Children aged between 5 and 7 years have gained some independence, both socially and intellectually, but their behaviour is unpredictable. They become preoccupied when playing, their perceptions of speed and distance are often wrong and therefore they continue to need supervision, particularly on roads etc.

Much of an early school-goers’ time is spent under adult supervision at school or in the home. Increasingly, as they get older, children spend their time away from home in parks and playgrounds unsupervised. Being unsupervised can lead to children using unsuitable areas to play in, such as derelict buildings, water or building sites. They can also indulge in dangerous activities, such as playing with fire, increasing the likelihood of injury. The majority of older children drown in open water and dams, followed by public and private swimming pools; 84 % were unsupervised and lacked swimming abilities (Candy et al. 2001).

As children approach adolescence they are more likely to attempt to flaunt their independence, resent rules and authority, and take risks. Peer pressure influences children’s behaviour in activities that they know to be dangerous but take part in to avoid losing face in front of their friends. Children will often lie about the mechanisms of injury to prevent detection of a dangerous/banned activity or location.

Illness and hospitalization are stressful experiences for child patients and their families. Illness itself can produce stress and when hospitalization is added to illness, that stress is increased. Studies have shown that hospital experiences can seriously influence a child’s development. Negative hospital experiences can interfere with a child’s rehabilitation and recuperation and can inhibit normal growth and development (Ryan-Wenger & Gardner 2012).

Hospital attendance is stressful at any age; Visintainer & Wolfer (1975) identify five categories that worry a child regarding hospitalization:

Both the child’s and the parent’s previous experiences of hospital/illness/injury as well as the parent/child relationship can have a profound effect on the child’s attitude, behavior and recovery.

As well as differences in cognition between the ages in this group, there are also anatomical and physiological considerations that will impact on the child’s recovery (Barnes 2003, Advanced Life Support Group 2011).

Environment and family-centred care

The Children and Young People’s National Service Framework (NSF) (Department for Education and Skills/Department of Health 2005) and Children’s Charter (Department of Health 1995) state that EDs caring for children should provide an environment that, as a minimum, has:

Many others, such as the Royal College of Paediatrics and Child Health and Royal College of Nursing (2010), the Royal College of Paediatrics and Child Health (2007, 2009) and the American Academy of Pediatrics (2009), have made similar recommendations regarding the provision of care of children in EDs. While the aim of the ED is to provide 24-hour care by paediatric nurses, this is difficult to achieve and must not detract from the skills and experience that general nurses have in caring for children. Paediatric nurses within EDs augment the expertise of general nurses; the children’s nurse acts as a resource, innovator of practice and educator in all things paediatric.

When a child presents to hospital they rarely present alone. A sick or injured child is usually accompanied to the ED by at least one adult, and sometimes by numerous family members and friends, including other children. Family-centred care should be the aim throughout the child’s stay, and both the child and her family should be involved in decisions about care wherever possible (Brown et al. 2008). Lee (2001) suggests that Casey’s model of partnership could be implemented in the ED environment. Casey’s model developed from the philosophy stated as: ‘The care of children, well or sick, is best carried out by their families with varying degrees of help from suitably qualified members of the healthcare team whenever necessary’.

The child may require help to meet his needs in order to function, grow and develop. These needs are met by:

Using Casey’s partnership model in the ED, the nurse determines whether a parent wishes to be involved in their child’s care. Some parents may feel unable to be involved, for instance being unable to be present during suturing. Others would expect to be involved, for example, comforting the child during suturing. Parental involvement is not necessarily a time-saving process, as time is required to enable parental participation. Partnership care may result in quicker discharges from the ED, for instance for a child with constipation and a reduced re-attendance rate, which is of benefit to the child, family and nurse (Lee 2001).

Children usually benefit from a parent or carer being present during examination/investigation, but pressure should not be placed upon parents/carers if they feel unable to be with their child during specific treatments. It is important for ED nurses to reassure parents that their continuing presence is welcome should hospital admission become necessary.

Should a child need critical intervention, such as resuscitation, many parents would wish to stay with their child. The needs of parents must be considered, with the provision of a nurse to support the parents during this time, keeping them informed, giving explanations of treatments/procedures. Both nurses and medical staff may feel stressed by parental presence in an already tense situation, but in aiming for family-centred care, the parents’ and the child’s wishes should be respected wherever possible. Even if the parents decide not to be at their child’s bedside, knowing that they have the option fosters trust and positive communication (Baren et al. 2008).

The majority of children attending the ED do so following injury rather than illness although most will have relatively minor injuries (Hendry et al. 2005). To the child and parents a minor injury may appear catastrophic. A child-friendly environment, including books, toys and hospital play specialist, will distract and provide a sense of normality for the child, thus helping to reduce the emotional impact of injury. The attitude of the multi-professional team, from receptionists to radiologists, towards children and their families plays a large part in reducing the impact of the injury/illness and the ED visit (Nadzam & Westergaard 2008).

Activities and conversation should be related to things included in the child’s normal world, such as the current children’s films, childhood heroes, pop stars and footballers. Parents and others, especially other children, can be particularly helpful with this. The younger children in this age group appreciate bravery awards and stickers following their treatment.

When planned properly, family presence helps meet the family’s needs without disrupting medical care. With time, commitment and support this type of change is possible.

Pain assessment and management

Most children attending the ED will require pain relief in some form. Pain assessment can prove difficult, even in older children, and a long-standing problem in paediatric pain management has been the difficulty of objectively assessing pain. An assessment tool such as QUESTT is designed specifically for the assessment of children’s pain (Box 18.1).

The impact of anxiety on a child’s pain level should not be underestimated and appropriate measures to reduce anxiety are an important part of pain control (Jeffs et al. 2011). It is imperative that assessment and management of pain are appropriate to the child’s understanding and not beyond comprehension. The use of toys and play demonstration is proven to be helpful in reducing anxiety and increasing cooperation in the younger child. The use of play therapy promotes normalization by providing a non-threatening environment and familiar activities in an otherwise unfamiliar and often frightening environment. Through structured play activities children and their carers can be educated about procedures in a manner appropriate to the child’s developmental stage. This reinforces the need for the nurse to have an awareness of normal childhood development, so communication is effective and pain assessment accurate.

Pain scales, such as numerical continuums, facial expressions and visual analogues, can be a useful aid to pain assessment (Royal College of Nursing 2009, Bailey et al. 2012