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) but should not be used in isolation. The use of pain rating scales may be difficult in the ED environment due to anxiety, distress, fear and the unfamiliarity with pain rating scales. Hall (2002) describes a paediatric pain assessment tool designed specifically for the ED comprising a mixture of subjective and objective assessments along with examples of injury. The child is asked to choose both a face and a number most appropriate to their degree of pain. The nurse then circles the most fitting behaviour seen in the child. Twycross (1998) suggests that children’s perceptions of pain are frequently established prior to a painful episode, thus making the task of pain assessment in ED more difficult.

For many children, immobilization and support of an injured area comprise the first step in pain control, but this should not be used as a substitute for analgesia. ED nurses must not underestimate actual pain, as opposed to the fear of pain and anxiety, as the cause of the child’s distress (Morcombe 1998).

For minor injuries, simple analgesia (paracetamol and ibuprofen and/or Panadol^® and codeine combinations) can be administered at an early stage, such as at assessment, thus easing the child’s passage through ED. Many departments enable the nurse to administer simple analgesia under Patient Group Directives. The start of the pain assessment and management process is at home with the parents administering simple analgesics. Unfortunately it has been found that where parents do not give children analgesia prior to attending the ED, they cite not having any suitable analgesics or the accident not occurring at home, and the majority felt that it was the hospital’s responsibility (Spedding et al. 1999). Aspirin is not to be used in children under 12 because of the risk of Reye’s syndrome (Scott & Thompson 2011).

Entonox, which is 50 % nitrous oxide, 50 % oxygen (and up to 70 % nitrous and 30 % oxygen in certain procedures) is a useful and rapid analgesia for children who are able to hold the mask or mouthpiece (pleasant-smelling masks are available). Its restrictions for use are the same as for adults. A safe dose is one that can be self-administered, and it should not be used for children with chest and moderate to severe head injury. It is useful for dressings, suturing and prior to cannulation (Bruce & Frank 2000).

Children with significant injuries such as displaced fractures, fractured femurs and burns affecting greater than 5 % surface area require opiates. These should be given intravenously due to faster action times, ability to titrate dose according to response and reduced risk of tissue storage associated with muscular injections following significant trauma (Advanced Life Support Group 2011). Intravenous cannulation is not easy in an injured/ill or distressed child and repeated attempts should be avoided: seek more experienced help and/or ask for the paediatric team’s assistance. Many departments use intranasal diamorphine, thus negating the need for cannulation for opiate administration.

Anaesthetic is useful for many procedures. Topical substances containing lignocaine are useful prior to non-urgent cannulation and venipuncture. Local anaesthetic for suturing and wound cleansing provides pain relief and thus increases the child’s cooperation. Unfortunately infiltration with local anaesthetic can be painful; warming the solution, buffering with sodium bicarbonate or applying topical adrenaline cocaine can reduce pain at infiltration. The use of topical adrenaline cocaine, especially on facial wounds, makes local anaesthetic unnecessary.

In some cases children requiring suturing or other procedure may be unable to cooperate despite all measures of reassurance, hospital play specialist, analgesia etc., or the wound is too large to allow adequate infiltration of local anaesthetic (maximum of 3 mg/kg of 1 % lignocaine): these children require general anaesthetic. Some departments advocate the use of sedation for such cases, but this may be problematic in terms of providing adequate staff and resuscitation facilities to ensure the safety of the child, as recommended by the Scottish Intercollegiate Guidelines Network (2002).

Regional nerve blocks are an effective source of pain relief. A femoral block, for example, provides good pain control while X-raying and splinting a fractured femur (Advanced Life Support Group 2011). Children with fractured femurs also require intravenous opiates as the initial pain management.

Where possible, all paediatric medications should be prescribed according to the child’s weight; where actual weights are not available a child’s weight may be calculated using the formula 2 × age + 4 (Advanced Life Support Group 2011).

It is essential for all EDs to keep a guide to paediatric medications such as the British National Formulary (Joint Formulary Committee 2012) in the children’s area and resuscitation room.

Musculoskeletal injuries

As they get older children usually become increasingly competitive, participating in regimented repetitive training, and this creates a potential for serious physical (over-use or acute) and psychological injury. Psychological problems are difficult to measure, whereas acute physical injury can be assessed. Foster & Kay (2003) suggest that the diagnosis of a musculoskeletal problem is essentially clinical and describe comprehensive assessment skills.

There are three main types of musculoskeletal injury associated with children’s sport:

Osteochondritis refers to a group of conditions affecting the growth plate. The disorder results from the stresses produced at the bone/ligament junction or articular surfaces during physical activity. The most commonly affected areas include:

Rest is usually sufficient to cure these injuries, but orthopaedic follow-up should be given (O’Brennan et al. 2001).

Extensive training without a proper build-up period can lead to stress fractures. Runners and gymnasts are the most likely to incur these injuries. Sports injuries can be prevented with careful supervision, a gradual increase in training activity, and correction of poor technique or inappropriate use of equipment.

Fractures

The developmental process of the skeletal system is such that children are prone to incomplete fractures, described as greenstick or torus fractures, with dislocations rare (Davies et al. 2003). These are usually a disruption of the bone cortex on one side as opposed to a complete break. Emergency nurses must be prudent when assessing limb injuries in children as often those with greenstick fractures display no visible signs of bruising, swelling or deformity, leading to these fractures remaining undetected. Most greenstick fractures will heal independently; however, it is common practice to immobilize the fracture with plaster for pain relief.

Mechanism of injury is important, as is exact location of pain and extent of movement and pain association. It is often difficult to make this assessment if the child is very distressed, and simple immobilization and simple analgesia may be useful until after X-ray. Some children sustain fractures that are displaced, and these fractures require reduction to allow healing without deformity to the affected limb. It is preferable to carry out the reduction procedure under general anaesthetic.

Although children most commonly sustain greenstick fractures, they are not exempt from other types of fracture. Fractures through a growth plate (epiphysis) are described as Salter–Harris fractures and graded I–V. They require referral to orthopaedic specialists and may need surgical intervention (Davies et al. 2003).

If a child is discharged with a lower limb cast, her developmental dexterity must be considered. Many 5-to-7-year-olds may be unable to mobilize with crutches partly because of balance and partly because of the weight of the cast. In some cases, a Zimmer frame may be a better aid. Crutches use in the older child may also be difficult due to balance, and schooling also needs to be considered as many schools with a large pupil population or stairs may feel that the child on crutches is at risk of further injury. Parents and children should be made aware of the risks and side-effects of an immobilized limb and be aware of local facilities for review and advice (also Chapter 6).

Limping child

Acute non-traumatic limp is a common reason for children to present to the ED. There is a wide differential diagnosis for these patients, and there are certain serious conditions that cannot be missed (McCanny et al. 2012). Diagnoses include fractures, soft tissue injury, osteomyelitis, septic arthritis, irritable hip, juvenile arthritis, Baker’s cyst, Perthes’ disease and slipped upper femoral epiphysis.

Some children may be systematically unwell presenting with associated symptoms of headaches and vomiting; history of seizures, acute or chronic pain and a febrile illness (Baren et al. 2008). Investigations must exclude infective causes. Investigations may include venipuncture (apply topical anaesthetic cream at triage), X-ray, ultrasound scan and observation. Management of the child in the ED consists of analgesia, support and antipyretics.

Hip disease should be considered in any child with thigh, groin, or knee pain (Baren et al. 2008). Perthes’ disease is a condition found in the age range 5–9 years, more commonly in boys, where avascular necrosis of the femoral epiphysis (femoral head) occurs. Physical examination may show a limp secondary to either pain or a leg-length discrepancy. The aetiology is unknown; diagnosis is made by X-ray. Treatment varies from centre to centre and may include immobilization with traction or splints in conjunction with analgesia.

Slipped capital femoral epiphysis (SCFE) is defined as displacement of the femoral epiphysis on the femoral metaphysis (femoral neck). SCFE is often associated with overweight children but can occur in non-obese children. It generally occurs in adolescents during prepubescent growth (10–14 years) and is more common in boys.

SCFE can be classified into two categories, stable and unstable (Baren et al. 2008). Clinically, the child is able to weight-bear with or without crutches with a stable SCFE, but is unable to walk at all with an unstable SCFE despite crutches. Confirmation is by X-ray, and often corrective surgery is required (Baren et al. 2008). The onset can be acute or insidious, with 30 % developing the same condition in the opposite limb (Waterson et al. 1997, O’Brennan et al. 2001, Barnes 2003, Davies et al. 2003).

Abdominal pain

Abdominal pain is one of the most common reasons children in this age group often attend EDs (Marin & Alpern 2011). Assessment and accurate diagnosis can sometimes be made difficult, as discussed previously, by the level of cognitive development, pain, effects of hospitalization and level of cooperation by the child.

Children with abdominal pain present with a host of signs and symptoms, including vomiting, altered bowel habits, diarrhoea, constipation, anorexia, not drinking, nausea, frequency of micturition, pain on micturition and pains that may be colicky, continuous or stabbing in nature.

Urinary tract infection, gastroenteritis, constipation, appendicitis, menarche, period pain, renal stone, obstruction, perforation, inflammatory bowel disease, pneumonia, otitis media, diabetes, trauma and psychosomatic pain are all reasons for ED attendance with abdominal pain (Waterson et al. 2000). The history and development of pain provide many clues for diagnosis. Acute pain of sudden onset may indicate obstruction or perforation. A more insidious onset is indicative of appendicitis, and colicky pain is usually associated with intestinal disorders such as gastroenteritis or inflammatory bowel disease.

Assessment of the child with acute abdominal pain, as with all ill/injured children, begins with a rapid assessment of airway, breathing, circulation and disability and any compromise treated immediately as per resuscitation guidelines.

Further assessment and management includes recording of baseline and subsequent observations, urinalysis, pain assessment and appropriate administration of analgesics, and may include venipuncture, cannulation, intravenous fluids and specialist opinion if surgical intervention is considered necessary (Box 18.2).

Consent

Consent/refusal of treatment is a much-debated topic within the field of adult EDs. Consent in paediatrics can also give rise to much discussion and confusion.

Since the Children Act (Department of Health 1989) a child under the age of 16 years of age has been able to consent to treatment if they are deemed Gillick competent or if not Gillick competent a parent can give consent on their behalf (Dimond 2001). Thus some of the children referred to in this chapter may be able to consent to treatment.

In order for a parent or child to give consent they must be given all relevant information and time and opportunity to ask questions, i.e., to offer informed consent. A child who fully comprehends what they are consenting to and the consequences of that consent can be said to be Gillick competent (also known as ‘Fraser guidelines’) (Waterston et al. 1997, Dimond 2001).

In some much-published cases children have refused treatment such as blood transfusions on religious grounds, but Courts of Appeal have overturned the child’s refusal and treatment has continued. In an ED where a child refuses consent to treatment an impossible situation arises whereby the nurse must attempt to obtain consent, with parental participation, giving further explanations regarding the necessity of treatment and consequences of refusing treatment. If the child continues to refuse then the best possible alternative treatment is used with comprehensive documentation in the child’s notes.

In a life-threatening situation consent is not necessary if the child is unaccompanied; the welfare of the child is paramount. If parents refuse treatment, e.g., blood transfusion, in a life-threatening situation on the grounds of religious beliefs, professionals who consider the treatment essential acquire consent as for an unaccompanied life-threatening situation.

Many children attend EDs unaccompanied or accompanied by an adult who is not a parent or guardian. Consent can be obtained from those who are:

De facto carers include teachers, baby-sitters, step-parents or anyone currently caring for a child; The Children Act (Department of Health 1989) gives such a person the right to make decisions on behalf of the child. Dimond (1996) suggests that ED staff could obtain consent from ‘de facto’ carers for immediately necessary treatment such as stitches or injections (see also Chapter 39).

Health promotion

Many opportunities exist for health promotion in the ED. The waiting area can be used in a variety of ways to target both parents and children with specific aspects of health promotion and accident prevention. Displays about topical issues such as the prevention of sunburn, safety equipment and meningitis symptoms can provide parents and children with practical commonsense advice. Individual advice supported with written information can help to prevent recurrent accidents, as well as trouble-shooting the specific incident.

Distress is common in children and parents following an accident, even when the physical injury is minor; this is due to the sudden and unexpected nature of the incident, and emotional support may be necessary.

Anecdotal evidence suggests an increase in the number of schoolchildren attending ED following incidents of bullying, even during primary school. Bullying involves persistent, deliberate, unprovoked, physical or psychological harm by a more powerful child or young person or group, against a weaker child or group and a proportion of all ages are faced with bullying daily (Gini 2008, Karatas & Ozturk 2011).

Children who attend the ED frequently with apparently trivial complaints may be being bullied, or the child may disclose bullying at assessment. The nurse must be sensitive/supportive in these cases. Providing information about other agencies such as Kidscape and Childline for ongoing support and management is vital. Bullied children are often reluctant to involve schoolteachers if bullying is occurring in school, but most schools have adopted an anti-bullying policy; gentle persuasion may convince the child that ‘telling’ will stop the bully and prevent others being bullied. Referral to the school nurse may provide a link within the school environment.

Obese children and young people may be the victims of bullying and as a consequence attend the ED. There is a lack of agreement of the diagnostic criteria for the classification of obesity but studies demonstrate an increased prevalence (Fruhbeck 2000, Ruxton 2004). Childhood obesity may lead to long-term health problems, including hypertension, sleep apnoea, asthma, early puberty, diabetes, back pain and slipped upper femoral epiphysis (Ruxton 2004). Treatment of childhood obesity involves promoting a healthy diet, increased physical activity and a behavioural component (Fruhbeck 2000, Ruxton 2004). In the ED it involves the treatment of the presenting complaint and promotion of a healthy lifestyle.

Parents attending the ED may be victims of domestic abuse. Domestic violence impacts on the child directly and indirectly and is now a recognized form of child abuse.

Effects of domestic violence on a child include:

As with bullying, the ED nurse must be sensitive to the needs of the child and abused parent; the ED is for many the first agency the family turns to for help. Physical injuries are cared for and the impact on the child is dealt with as per local child protection policy. The ED nurse should then provide guidance to other agencies such as women’s aid groups, the NSPCC, domestic violence units, health visitors and school nurse services.

All children attending the ED are potentially victims of child abuse (Chudleigh 2005, Sanders & Cobley 2005), domestic violence or bullying. The ED nurse must be conversant with trigger factors to these types of incident and be able to provide support and information and refer to the appropriate agency. Although issues of child protection arise across the whole of childhood and beyond, this issue is considered in detail in Chapter 17.

Conclusion

Children attend EDs following accidents as a result of the environment in which they live; many attend using the department as a primary healthcare. Such patients are often labelled as inappropriate attenders; however, this is frequently both unjust and judgemental. There are often situations that force families to attend for primary care – out of GP hours, referred previously by GP, faith in the ED, time of day, etc. ED nurses are obliged to meet the needs of all attending children, giving them the best possible service.

The needs of children between the ages of 5 and 13 years vary considerably. The ED nurse must have an awareness of the developmental stages of children in order to provide appropriate, safe care. The ED environment is important for meeting the needs of children and their families, as is the attitude of staff to children and their families, especially if they are subsequently admitted from ED. Children’s positive or negative memories of their hospitalization experiences may influence their future attitudes toward healthcare, utilization of healthcare services, and even their career decisions (Ryan-Wenger & Gardner 2012). Optimum care results from a family-centred approach, with aftercare advice directed at the child and parent in order to achieve concordance.

References