Primary care

The majority of acute illness in children is mild and transient (e.g. upper respiratory tract infection, gastroenteritis) or readily treatable (e.g. urinary tract infection). Although serious conditions are uncommon (Fig. 5.2), they must be identified promptly. The condition of sick children, especially infants, may deteriorate rapidly, and parents require rapid access to a general practitioner or other healthcare professionals working in primary care, who in turn require ready access to secondary care. Advice may also be obtained from a health professional by telephone, e.g. via NHS Direct, via the internet with NHS Direct Online or by NHS Direct cable TV services. Although an individual general practitioner will care for relatively few children with serious chronic illnesses (e.g. cystic fibrosis, diabetes mellitus) or disability (e.g. cerebral palsy), each affected child and family are likely to require considerable input from the whole of the primary care team.

Approximately 3 million children (1 in 4) attend an Accident and Emergency (A&E) department each year in England and Wales. The services which should be provided for children are shown in Box 5.1. The number of departments able to meet these expectations is increasing, often by creating a dedicated children’s A&E department.

Hospital admission

In England and Wales, 1.9 million, i.e. 1 in 6 children is admitted to hospital each year, representing 16% of all hospital admissions. About 60% of acute admissions are under the care of paediatricians, and the remainder are surgical patients (although a paediatrician is also involved in their care while they are in hospital, to oversee any medical requirements) (Fig. 5.3). Most paediatric admissions are of infants and young children under 5 years of age and are emergencies, whereas surgical admissions peak at 5 years of age, one-third of which are elective. The reasons for medical admission are shown in Table 5.1.

Table 5.1

Reason for emergency admission of children <15 years old to hospital

System	Specific disorders
Respiratory 25%	Respiratory infections 20%
	Asthma 3%
Injuries and poisoning 17%	Head injury 5%
	Poisoning 1%
Gastroenterological 13%	Gastroenteritis 5%
Infection 6%	Viral infection 5%
Urogenital 3%	Urinary tract infection 2%
Neurological 2%	Seizures 1%
Endocrine and metabolic 2%	Diabetes mellitus 1%
Skin 2%
Muskuloskeletal 2%
Other 28%

Data based on 58 061 admissions, 2009–2010. ISD, Scotland.

Although primary and community health services for children have improved markedly over the last decade, the hospital admission rate has continued to rise, although it may now be plateauing (Fig. 5.4). The reasons for this are unclear, but probably include:

• Lower threshold for admission: there appears to be an increased expectation of hospital admission by parents and medical staff worried that the child’s clinical condition may deteriorate

• Repeated hospital admission of children with complex conditions who would have died in the past but are now surviving, e.g. very low birthweight infants from neonatal intensive care units, children with cancer or organ failure.

Strenuous efforts are made to reduce the rate and length of hospitalisation (Fig. 5.4):

• Speciality of ambulatory paediatrics has been developed; it encompasses specialist paediatricians providing hospital care for immediate medical problems outside inpatient paediatric wards

• Dedicated children’s short stay beds within or alongside the A&E department are increasingly available to allow children to be treated or observed for a number of hours and discharged home directly, avoiding the need for admission to the ward

• Day-case surgery has been instituted for many operations which used to require overnight stay.

• Day units are used for complex investigations and procedures instead of inpatient wards

• Shared care may be provided between hospitals and primary care, with paediatricians and other healthcare professionals seeing children at home or in primary care settings

• Homecare teams aim to provide care in the child’s home and thereby reduce hospital attendance, admission and length of stay. Most teams comprise community paediatric nurses, but some include doctors, and either cover all aspects of paediatric care within a geographical area or are for a specific condition, e.g. cystic fibrosis or malignancy, usually centred around a tertiary referral centre. The problems managed at home by such teams include:

– Changing postoperative wound dressings or managing burns

– Day-to-day management and support for the family for chronic illnesses, e.g. diabetes mellitus, asthma and eczema

– Specialist care, e.g. home oxygen therapy, intravenous infusions via a central venous catheter (e.g. antibiotics or chemotherapy) or peritoneal dialysis

– Symptom and pain control and emotional support of terminally ill children (Fig. 5.5)

• Children’s hospices provide respite or terminal care for children with life-threatening conditions, including malignancy disease, neurodegenerative, metabolic and other disorders.

• Some teams provide a ‘hospital at home’ service for children who are acutely ill, in order to avoid hospitalisation.

Hospital admission of children

• Hospital admission of children should be avoided whenever possible.

• Most medical admissions are infants and young children; surgical admissions occur throughout childhood.

Pain

It is easy to ignore or underestimate pain in children. Pain should ideally be anticipated and prevented.

Acute pain

This may be caused by:

• Tissue damage, e.g. burns or trauma

• Specific disease process, e.g. sickle cell crisis

• Medical intervention, i.e. investigations or procedures

• Surgery.

Chronic pain

In children, chronic severe pain sometimes occurs as a result of disease such as malignant disease or juvenile idiopathic arthritis. Intermittent pain of mild or moderate severity, e.g. headache or recurrent abdominal pain, is more common.

Older children can describe the nature and severity of the pain they are experiencing. In younger children, assessing pain is more difficult. Observation and parental impression are commonly used and a number of self-assessment tools have been designed for children over 3 years old (Fig. 5.6).

Management

The approaches to pain management are listed in Box 5.2. This should allow pain to be prevented or kept to a minimum. Age-appropriate explanation should be given when possible and the approach be reassuring; however, it is imperative not to lie to children, otherwise they will lose trust in what they are told in the future. Distraction techniques such as blowing bubbles, telling stories, holding family toys or playing computer games, as well as the involvement of trained play specialists, can be highly successful in ameliorating pain in children. Some children develop particular preferences for a particular venepuncture site or distraction technique, and this should be accommodated as far as possible.

Box 5.2   Approaches to pain management

Explanation and information

• Psychological, by the parent, doctor, nurse or play specialist

• Behavioural

• Distraction

• Hypnosis

Medical

• Local: anaesthetic cream, local anaesthetic infiltration, nerve blocks, warmth or cold, physiotherapy, transcutaneous electrical nerve stimulation (TENS)

• Analgesics:

– Mild – paracetamol, NSAIDs

– Moderate – codeine, NSAIDs

– Strong – morphine

• Sedatives and anaesthetic agents:

– Intranasal midazolam, nitrous oxide, general anaesthetic

• Anti-epileptic and antidepressant drugs for neuropathic pain

Consider the route for analgesics – oral if possible, otherwise intravenous, subcutaneous or rectal.

(NSAIDs, non-steroidal anti-inflammatory drugs).

For minor medical procedures, e.g. venepuncture or inserting an intravenous cannula, pain can be alleviated by explanation and the use of a topical anaesthetic. Additional and appropriate use of inhalation agents such as nitrous oxide (laughing gas) or the adjunctive use of mild sedation alongside pain relief, e.g. intranasal midazolam, can be helpful for more painful procedures such as suturing a wound. For more invasive procedures, e.g. bronchoscopy, a general anaesthetic should be given.

Postoperative pain can be markedly reduced by local infiltration of the wound, nerve blocks and postoperative analgesics. For severe pain, there was reluctance in the past to use morphine in children for fear of depressing breathing. This should not occur when morphine is given in appropriate dosage under nursing supervision to children with a normal respiratory drive. Intravenous morphine can be given using a patient-controlled delivery system in older children or a nurse-controlled system in young children.

 Pain should be anticipated and prevented rather than treated.

Discharge from hospital

Children should be discharged from hospital as soon as clinically and socially appropriate. Although there is increasing pressure to reduce the length of hospital stay to a minimum, this must not allow discharge planning to be neglected. Before discharge from hospital, parents and children should be informed of:

• The reason for admission and any implications for the future

• Details of medication and other treatment

• Any clinical features which should prompt them to seek medical advice, and how this should be obtained

• The existence of any voluntary self-help groups if appropriate

• Problems or questions likely to be asked by other family members or in the community. These should be anticipated by the doctor and discussed. What do the nursery or school, baby-sitters or friends need to know? What about sports, etc?

In addition:

• Suitability of home circumstances needs to be assessed, particularly when the home requires adaptation for special needs

• Social support may need to be arranged, especially in relation to child protection

• Medical information should be added to the child’s personal child health record

• Consider which professionals should be informed about the admission and what information it is relevant for them to receive. This must be done before or at the time of discharge. The aim is to provide a seamless service of care, treatment and support, with the family and all the professionals fully informed (Fig. 5.7). This can be facilitated for children with a chronic illness or disability by having a key worker to coordinate their care.

Ethics

Situations arise in paediatric practice in which the course of action that should be followed is unclear. Knowledge of the ethical theories and principles which underpin medical practice is helpful in understanding the issues involved. It is important to justify decisions to investigate or treat in accordance with these principles, and in language that is clear to all concerned.

Evidence-based paediatrics

Clinicians have always sought to make decisions in the best interests of their patients. However, such decisions have often been made intuitively, given as clinical opinion, which is difficult to generalise, scrutinise or challenge. Evidence-based practice provides a systematic approach to enable clinicians to efficiently use the best available evidence, usually from research, to help them solve their clinical problems. The difference between this approach and old-style clinical practice is that clinicians need to know how to turn their clinical problems into questions that can be answered by the research literature, to search the literature efficiently, and to analyse the evidence, using epidemiological and biostatistical rules (Figs 5.8, 5.9). Sometimes, the best available evidence will be a high-quality systematic review of randomised controlled trials, which are directly applicable to a particular patient. For other questions, lack of more valid studies may mean that one has to base one’s decision on previous experience with a small number of similar patients. The important factor is that, for any decision, clinicians know the strength of the evidence, and therefore the degree of uncertainty. As this approach requires clinicians to be explicit about the evidence they use, others involved in the decisions (patients, parents, managers and other clinicians) can debate and judge the evidence for themselves.