The pre-school child
Introduction
More than 3 million children aged 0–16, the equivalent of 28 % of all children in England, attended Emergency Departments (EDs) in 2006/7 accounting for 25 % of all patients seen in EDs across the UK (Royal College of Paediatrics and Child Health and Royal College of Nursing 2010). As many as four out of five children attend with minor injuries, with one in five attendances resulting from parental concern about acute illness (Department of Health 2004). Findings from the Children’s National Service Framework 2004 (Department of Health 2004) indicate that 70 % of children attending rural EDs have accidental injuries and in inner city EDs 70 % of attendees are for acute medical illness. Recent figures suggest that children attending EDs often require an episode of care without an overnight stay, on average, an increase of 15%, highlighting the importance of community-based facilities competent in the assessment, treatment and observation of children (NHS Institute for Innovation and Improvement 2008). In the younger age group 1 child per 1000 of the population is in hospital with acute illness on any given day (Department of Health 2003a). Only a small percentage, less than 0.25 %, of all children attending the ED will require a paediatric intensive care bed.
Changing patterns of illness in children have shown a decrease in many of the acute presentations to the ED. This is felt to be due in part to the revision of immunization programmes, increased awareness of health promotion and the introduction of new technologies. Health promotion and early preventive measures have improved the management of some children’s conditions such as asthma. However, there is an increase in recognition of emotional/behavioural problems across childhood, including deliberate self-harm and harm to others (Department of Health 2003a).
Recent times have seen a shift in attitudes towards children and their needs and development, and considering the child as an individual in their own right rather than a ‘little adult’ is now more likely to be the norm. The concepts of children as people with rights are now also reflected in everyday policy and debate such as in the National Service Framework (Department of Health 2004), UNICEF (1990) and the UN Convention on the Rights of the Child (United Nations 1989). The Royal College of Paediatrics and Child Health and Royal College of Nursing (2010) have indicated the number of registered children’s nurses working within the ED setting is insufficient despite reports as far back as the 1950s stipulating that children in hospital must be cared for by staff trained in caring for children (Ministry of Health 1959); however, it is equally as important to recognize that emergency care skills are something conventional children’s nurse training does not offer (Royal College of Paediatrics and Child Health 2007a).
The visit to the ED is often a child’s first experience of hospital, thus making the whole incident doubly traumatic. Young children have insatiable curiosity about their surrounding environments, creating greater vulnerability by being generally unaware of the imposing dangers. Between 1 and 4 years a child’s physical and mental development is very rapid, with 50 % of the child’s mental capacity developed before the age of 5 years (Brain & Martin 1989). Coupled with substantial leaps in acquisition of language and multi-skills, such quick development can prove the danger for unsuspecting parents/carers. It can come as a surprise when the child is first able to scramble up the stairs and reach up to a work surface or has the strength to pull over a chair. Pre-school children usually arrive in accident and emergency as a result of accidental injury. The challenges of climbing furniture, stairs, the opening of all manner of containers, sampling even the most unpalatable of agents all increase the likelihood of a small child suffering falls, minor injury and poisoning (Mead & Sibert 1991).
Normal development
Pre-school children perceive the world differently from adults. The 2-year-old is egocentric and will perceive that he is the centre of his world, being unable to identify with anybody else’s point of view. The child may believe that it is he who is responsible for events that we know to be out of his control. Throughout this pre-operational phase of development, memory and imagination are developing rapidly. There is a tendency to mix fact with fantasy and a belief that the child’s thoughts can control events. There is an intuitive, magical quality to their thoughts (Hall & Elliman 2003).
The child under stress
The pre-school child is more vulnerable and traumatized when separated from his parents than at any other age. Bowlby (1953), in his famous study Child Care and the Growth of Love, shows how a child suffers maternal deprivation when separated from his significant carers, the male or female person who supplies love, care, protection and comfort.
Since then, many seminal reports have confirmed the importance of keeping parents and child together (Ministry of Health 1959, Department of Health 2004, Royal College of Paediatrics and Child Health and Royal College of Nursing 2010). This is particularly important in EDs where events leading to attendance will have caused some stress (Box 17.1). Injured/unwell children, despite their parents’ presence, may become clingy or dependent (regress) while in the hospital setting.
Effective nursing interventions at this early stage can do a lot towards developing a rapport with the child and family, and to alleviate stress and fear. Acknowledging the child’s suffering and putting it into context using toys or pictures can be helpful, as is prompt pain relief. Parental input from the outset is essential not only to reduce stress and induce normality in the child but also to reduce stress in the parents/carers themselves. Encouraging parents/carers to undress their child and to help them with the examination as well as to be there to give reassurance to their child reinforces the parents’ importance in the treatment and helps to allay their fears.
The environment in which a child is cared for has come under much scrutiny in recent years (Bentley 2004, National Audit Office 2004). Facilities for children are best provided in an environment away from adult patients. Children should have their separate waiting area geared towards their needs with appropriate toys, books, television, video and electronic games. Treatment areas should also be child-oriented not only in décor and furnishings but also in equipment so time is not wasted hunting for appropriate items such as child-size blood-pressure cuffs or pulse oxy-sensitivity probes.
Parental anxiety
Parents/carers frequently experience a lack of confidence in their judgement when their child is ill and often remain anxious and concerned, having to manage their sick child at home even after reassurance from a medical professional. In situations like this it has been shown that parents/carers do not know how to contact health services when their child has not improved (Neill 2000). It is easy in circumstances following an accident for the parents to feel inadequate or lose confidence in their own ability. This must be addressed in the ED constructively and without proportionate blame, to enable the parents to support their child. Reassurance, information and what the parents/carers can do to help their child should be clearly communicated. Poor handling of parents in the ED can have a long-term effect on both the child and the family’s recovery (Mead & Sibert 1991).
The term ‘family-centered care’ is frequently used in children’s nursing and aims to evoke the inclusion of parental participation in child health and shared care decisions ensuring both the needs of the child and family are paramount (Hughes & Lyte 2009). Working within the ED setting, this concept is no different. The ED nurse’s attitude should be family oriented when dealing with children. Parents are often under a great deal of stress, feel guilty and are very anxious. These negative emotions can have a profound effect on the child. The parents need reassurance and a chance to relay their fears and guilt to the nurse (Bentley 2004).
Communicating with the child and family
Effective communication is central to nursing any patient of any age. A key factor in reducing stress and relieving anxiety is the way by which we communicate with the child and family. The value of effective communication is not only dependent on the nursing staff but also on the multi-disciplinary team. Good communication is the basis of forming a trusting relationship with the child and family and Maguire & Pitceathly (2002) suggest that this aids the practitioner in identifying the child or family members’ problem resulting in greater patient/family satisfaction.
Understanding illness
To a young child, illness is remote and viewed as an external process. There is a tendency to believe this has something to do with magic or is a punishment. Pre-school children do not fully understand internal body processes. In this pre-operative phase (Piaget 1990), children are only just developing their thought processes in relation to internal body organs. They have little concept of where internal organs lie, other than the heart, which lies in the middle of their chest and is used for loving and caring. When talking with pre-school children they often describe tummy ache and at the same time point to their head or equally they will say they have headache and point to their tummy. A child of this younger age is concerned with external injury and very often frightened of seeing blood, small cuts and marks. The external aspect of his environment such as light, equipment, uniforms and noise will affect the child much more than an explanation of what is going on in his/her body.
Play is a very important aspect of the child’s care and is at the very centre of a healthy child’s life (Webster 2002). Children can express fear and anxiety through play, so a playful environment will help reduce stress and anxiety. Watching a child play gives a fair assessment of social and multi-skills. Playing with children during examination and assessment will help the child understand treatment and procedures. Play specialists in EDs often have little or no time to plan play or distraction therapies because of the unpredictability of the setting and speed at which interventions are required (Knight & Gregory 2009) and therefore must have the skills to adapt to this situation quickly. Dolls and teddy bears come in very useful when trying to demonstrate what is about to be done to a child. Through play children are able to learn both the sensory and concrete information they need in preparation for some clinical procedures.
Asthma
There are approximately 5.2 million people in the UK with asthma, nearly 1 million of whom are children (National Institute for Health and Clinical Excellence 2007). During the past two decades, many scientific advances have improved the understanding of asthma and ability to manage and control it effectively. Since the late 1990s admission rates have declined (Shabu et al. 2007). However, recommendations for asthma care need to be adapted to local conditions, resources and services (Bateman et al. 2008). Asthma is acknowledged to be the most common long-term childhood condition and although mortality as a result of asthma is rare, the condition can have a significant impact on the child’s quality of life. Regardless of medical advances and technological improvement in asthma management confidential enquiries into asthma deaths have often indicated that the fatality could have been avoided if there had been better preventive measures, better recognition and help in avoiding delay during the final attack and in receiving earlier emergency care. Younger children with asthma are particularly vulnerable because they rely on others to react to the severity of their condition and to act on their behalf. Children in the 0–4-year age range have the most frequent health consultations with GP and out-of-hours services for asthma conditions.
Assessment
The overall clinical picture is developed from the combination of history, physical assessment and clinical investigations. If the child has obvious breathing difficulty, oxygen and nebulized bronchial dilators should be commenced immediately, prior to detailed history-taking from the parents/carers. Children under the age of five cannot adequately use a peak flow meter so peak expiratory flow is not recommended for this age group. Questions which should be asked in establishing a history of the event and the child’s general health are given in Box 17.2.
Physical assessment
Initial observation of the child will allow the nurse to observe respiratory rate, rhythm and effort (Aylott 2007). The respiratory rate and depth should be established first as this correlates to the severity of asthma. Normal breathing is effortless and quiet. The use of accessory muscles such as those in the neck and shoulders is described as laboured and requires substantial effort (Brooker & Nicol 2003). Intercostal and sternal recession is an indication of moderate to severe respiratory difficulty. As the child’s ability to speak is an indication of respiratory function, the nurse should know if the child can speak in full sentences using more than a few words or not at all. Parents are invaluable in assessing difficulties in the child’s normal pattern of speech, as ability to converse varies with this age group.
Respiratory assessment should be conducted and interpreted in association with other clinical assessment; therefore a rise pulse rate may be indicative of increasing hypoxia, but must be considered within context (Aylott 2007) such as if the child is upset, pyrexial or on beta agonists such as salbutamol, a tachycardia would be expected. Although wheezing is a classic symptom of bronchospasm, it is unreliable in detecting the severity of an episode. At assessment, any audible wheeze or wheeze on auscultation should be recorded and used as baseline. It is important to remember that if air is not being moved effectively in and out of the lungs, no wheeze will be present. Signs of respiratory distress, e.g., nasal flaring, grunting, wheezing, recession, use of accessory and intercostal muscles, chest shape and movement should be noted by looking and listening (Royal College of Nursing 2007).
Peak flow measurement is considered an important indication of the severity of an asthma episode; however, Scullion (2005) notes that young children can also be confused by the exhalation method required to use a peak flow meter. Exercise testing, by getting a child to run around for about six minutes, may therefore be more suitable for younger children. Peak flow measurement should therefore only be attempted in children who have previously and regularly used a peak flow meter.
Management
In cases of life-threatening asthma (Box 17.3) these children need immediate high-flow oxygen via a non-rebreathing mask, and a nebulized beta agonist such as salbutamol. Preparation should be to establish i.v. access for the administration of medications. Children in this age group both deteriorate and respond to treatment rapidly. The nurse must be vigilant for any changes and equipment should be at hand for intubation and ventilation.
Rapid oxygen therapy and nebulized bronchial dilators should be commenced and in cases of severe asthma (Box 17.4) an oxygen saturation of at least 95 % should be the aim (British Thoracic Society and Scottish Intercollegiate Guidelines Network 2011). It is important not to distress the child unnecessarily as this significantly increases the work of breathing. Intravenous access should be considered particularly if the child does not respond rapidly to nebulizer therapy.
Compliance with treatment is crucial to the successful management of this group of children. It is important to be calm and to keep the parents/carers informed of treatment plans to enable them to assist in the care of their child. Initial management involves inhaled bronchial dilators (short-acting and long-acting) and cortical steroids are the drugs of choice. The administration of beta agonists such as salbutamol (dose dependent on age) is the first-line treatment for acute asthma and they can be given by a variety of devices. For the mild to moderate asthma a spacer with mask can be ideal for the younger age group. However, with severe asthma it is advisable to use a nebulizer. It is important that the nurse explains what is being done first and uses toys and play where appropriate. Alternative devices such as a mouthpiece nebulizer can be more successful. If the child is very upset it is sometimes better to get a parent to hold the nebulizer by the child’s mouth than to increase the level of distress by attaching the mask to the child. If the child responds well to nebulizer treatment, they should be observed in the ED as per local policy post-nebulizer, to ensure that the response is not transient – ideally 2–4 h (British Thoracic Society and Scottish Intercollegiate Guidelines Network 2011). If the response is not maintained, the child should be admitted for treatment and continued assessment.
When planning the discharge of a young child from ED it is important that parents understand and are happy with ongoing treatment plans. Although a child may appear well after nebulizer therapy for an acute episode of asthma, the small airways obstruction can persist for several days. Parents must be able to administer supportive therapy at home. Many devices exist to assist young children in the inhalation of bronchial dilators. Spacers are commonly used for children under the age of five (British Thoracic Society and Scottish Intercollegiate Guidelines Network 2011). These create an enclosed space between an aerosol inhaler and the child’s mouth allowing him to work at his own pace without the need for hand-breathing coordination that an aerosol would demand.
The early use of steroids for acute asthma can reduce the need for hospital admission and prevent a relapse in symptoms after initial presentation. A short course of oral steroids can speed up the race for recovery from an acute episode of small airways obstruction. Prednisolone 1-2 mg/kg for three days or longer if necessary (Royal Pharmaceutical Society 2010) is recommended for children who have not responded to regular home treatment over a period of 24 hours or more prior to ED attendance. Children regularly on inhaled steroids may also benefit from this boost.
As well as advice on drug therapy, it is important that parents and carers are able to detect their child’s worsening condition and know when and where to seek help (Box 17.5). Parents/carers should be advised to return to the emergency department if:
• the respiratory rate increases
• the ability to speak deteriorates
• the positive response to inhaled bronchodilators reduces
• the child becomes agitated and is not behaving as normal for a child.
Follow-up should be arranged for all children discharged from ED; this can usually be done via children’s community nurse teams and/or the child’s own GP.
Acute laryngotracheobronchitis (viral croup)
Croup is a broad term used to describe an infection, usually viral in nature, of the upper airway and vocal chords. Croup is a common childhood illness, with the majority of children presenting with symptoms including acute onset of barking cough, low-grade fever and stridor. The stridor is made worse by crying, agitation and coughing. The most important thing to remember is to keep the child as happy as possible with as little or no intervention as possible (Bjornson & Johnson 2007). Croup is more common in boys than in girls, usually occurs between 6 and 36 months of age, and peaks during the second year of life (Zoorob et al. 2011). Croup most commonly occurs in damper weather of late autumn, winter and early spring. Typically the symptoms are worse between 18.00 and 06.00 and peak around the second or third night.
Pathophysiology
• inflammation of the subglottic area
• increased mucus production, which can affect the entire respiratory tract.
The increase in mucus together with the pharyngeal irritation results in the hoarse cough. Obstruction to airflow through the upper airway causes stridor and difficulty in breathing, and can progress to hypoxia. Hypoxia with mild obstruction indicates involvement of the lower airway, where obstruction causes ventilation perfusion mismatching. Later, hypercapnia occurs as hypoventilation progresses with obstruction (Dykes 2005). Less common symptoms of croup are highlighted in Box 17.6.
Assessment
Physical assessment
Assessment of the child in ED should focus on determining the degree of threat to the respiratory function. The work of breathing should be assessed in terms of the child’s colour, level of consciousness, respiratory rate, use of accessory muscles, nasal flaring and intercostal recessions. The degree of stridor is significant; the nurse should know whether the stridor is inspiratory, which usually indicates a supraglottic cause, or expiratory, which usually comes from the trachea. In severe cases inspiratory and expiratory stridor may be present. The loudness of the stridor is not an indication of its severity, but often influences the degree of anxiety. It is important to establish whether stridor is present at rest or only when the child becomes agitated or exerts him- or herself.
Having assessed the severity of the croup, the first line treatment is dexamethasone 0.15 mg/kg orally (Sparrow & Geelhooed 2006) if this is ineffective or if the child is assessed as having moderate to severe croup then the administration of an adrenaline (epinephrine) nebulizer 5 mL 1 in 1000 is the next step. This is best administered by a parent holding the nebulizer in front of the child, as face masks and mouthpieces can be frightening and considerably increase the child’s distress. Adrenaline acts both as a bronchodilator and suppresses histamine, thereby reducing mucous secretions and relieving airway obstructions. The effects of adrenaline nebulizers are relatively short-acting but often quick-acting. Should the child’s condition be deteriorating then a repeat adrenaline nebulizer 5 mL 1 in 1000 should be administered while preparations for intubation are underway with the support and presence of an anaesthetist. However, if the child is showing signs of improvement then further assessment should be taken 30 minutes post-nebulizer. Clinical investigations, such as blood tests and chest and neck X-rays, do little to alter the management plan but do much to increase the child’s distress and anxiety. For this reason investigations of this nature should not form part of the initial management (Box 17.7).
Criteria for admission
All children with moderate to severe croup should be admitted for observation. This can be determined by poor or transient response to treatment, persistent stridor at rest, oxygen saturation level below 92 % and any degree of hypoxia. Admission should also be considered for any child who is clinically dehydrated, social circumstances should also be considered when making a decision to admit or discharge the child. If the family live a long distance from healthcare facilities or do not have transport admission should be considered.
Discharge advice
• stay with the child and observe the breathing pattern, as a worsening obstruction will not always wake the child from sleeping
• if the croup returns look after the child in a warm humidified environment, e.g., a steamy bathroom (made so with a hot shower running for five to ten minutes)
• if there is no improvement or the child worsens return to ED. There is no evidence to support this, however practice and experience tell us this is so.
Epiglottitis
Epiglottitis is a bacterial infection caused by Haemophilus influenzae type b (Hib) and is a relatively uncommon but life-threatening condition. Unlike laryngotracheobronchitis, it has no winter peak of incidence, nor is it more common in the evening or at night (Table 17.1). It can occur at any time of the day, throughout the year. People of all age groups are at risk of contracting epiglottitis, but it is most common in the age group 2–7 years old. Among children the incidence of epiglottitis has been reduced due to vaccination against Hibl; however this reduction in the incidence is not apparent in adults (Mathoera et al. 2008).
Table 17.1
Differentiation of croup from epiglottitis
| Symptom | Croup | Epiglottitis |
| Age | 6 months–3 years | 2–5 years |
| Season | Winter | All year |
| Worst time of day | Evening/night | Any time |
| Aetiology | Parainfluenza virus | Haemophilus influenzae |
| Onset | Over days | Over hours |
| Proceeding illness | Yes | No |
| Fever | <38.50°C | >38.50°C |
| Sore throat | Sometimes | Yes |
| Drooling | No | Yes |
| Cough | Harsh barking | No |
| Stridor | Inspiratory and expiratory | Soft expiratory |
| Voice | Hoarse | None |
| Wheeze | Often present | None |
| Position | Varied, active | Upright with neck extended |
Assessment
Acute epiglottitis is a rapidly progressive airway emergency that progresses to complete airway obstruction within hours in the absence of prompt diagnosis and treatment (Atik & Krilis 2012). Obtaining an accurate history from parents/carers is imperative, as physical examination of the child is restricted when epiglottitis is suspected. Finesilver (2003) states physical examination only reinforces the diagnosis derived from the history, as diagnosis is often made well before examination on this basis.
Physical assessment
It is essential the child is kept calm and that repeated attempts to examine the throat are not made. Such examination can lead to a complete obstruction of the airway by pushing the epiglottis onto the larynx (Reynolds 2004). For these reasons, assessment is a hands-off visual activity. Children with epiglottitis usually prefer to sit up leaning forward, often with their neck extended forwards and their elbows on their knees, the so-called tripod position. This allows the maximum use of their compromised airway. Most children will have a soft inspiratory stridor without an associated cough. Most children are reluctant to speak but those who do usually have a muffled voice. Drooling is a strong indication of epiglottitis because swallowing is painful, due in part to a sore throat (Tanner et al. 2002). The child usually has significant pyrexia in excess of 38.5°C. Stridor is frequently present.
Management
If epiglottitis is suspected the most important action is to summon specialist help. The child’s epiglottis needs to be examined under anaesthesia in theatre and an artificial airway established in a controlled environment. While waiting for this the ED nurse should keep the child and parent/carers calm, ensuring that the child is in the most comfortable position for him and is given oxygen if possible. If the child is upset by oxygen therapy then it should not be pursued.
Accidental injury
Accidental injuries are a major health problem throughout the UK. They are the commonest cause of death in children over one year of age. Children aged 0–4 are most likely to have an accident in the home (Royal Society for Prevention of Accidents 2008). Over 1 million children under the age of 15 experience accidents in and around the home every year, some are taken to the ED but many more are treated by general practitioners and by parents and carers (Audit Commission 2007). Falls account for the majority of non-fatal accidents, while the highest number and proportion of deaths (46 %) are due to house fires (Office for National Statistics 2002).
The causes of accidents involving pre-school children are varied. Young children are vulnerable because they rely on their parents to provide a safe environment for them and to keep a careful watch on them while they explore and play. The role of the ED nurses is not just associated with treatment; they are also in a position to help educate the public and prevent further accidents from occurring. Despite all these opportunities, comparison of the home accident statistics for 1999 and 2002 indicates that even with the increased awareness and health promotion and a commitment to prevent home accidents the overall incidence of home accidents continues largely unabated (Royal Society for Prevention of Accidents 2006).
Aetiology
The factors that increase a child’s risks of accidental injury are similar to agents that may increase the incidence of non-accidental injury. Bennet & Muir (2010) describe how children from lower social classes have a death rate from injury five times higher than that of children living in a higher social class. Environmental stress in the family such as illness, shortage of money and paternal tension leads to an increase in the incidence of childhood accidents.
Trampoline injuries
Trampoline sales have rocketed over the last few years and along with it so have children attending the ED with associated injuries. It is a misguided conception that parents believe injury will only occur through falling from the trampoline, and therefore apply safety netting. However Wootton & Harris (2008) found as many as 68 % of the injuries incurred are sustained without leaving the confines of the trampoline. Due to the smaller size of the pre-school child, accidents often happen because two or more smaller children are using the trampoline at a time, which may result in collision and unnecessary falls. Trampoline accidents happen when children try different stunts such as somersaults, bouncing at the sides of the trampoline, jumping off the trampoline sustaining limb injuries or crouching underneath the trampoline and equipment. Limb injuries are most common, with neck and head injuries being the most serious (Royal Society for Prevention of Accidents 2005).
Accidental poisoning
Under the age of five years, children explore their environment around them and frequently place objects in their mouths as part of this process, resulting in a large number of calls to poisons services, but a relatively low rate of serious poisoning (Bateman 2012a). Over 28 000 children receive treatment for poisoning, or suspected poisoning accidents every year (Royal Society for Prevention of Accidents 2008). More boys than girls take poisons accidentally, and it has a higher incidence in families with existing stresses such as illness, pregnancy or recent birth, absence of one parent, a house move or anxiety/depression in a parent. Some children die from poisoning each year, but the number of deaths has fallen over recent years, probably because of better treatment and because of the child-resistant container regulations. There are also fewer tricyclic antidepressants prescribed (Lyons et al. 2008).
The most commonly digested poisons are childhood medicines such as paracetamol elixir or cough mixture, oral contraceptives and vitamin supplements. Household products such as detergents, bleach, disinfectant, perfume and cosmetics are also commonly ingested (Boxes 17.8, 17.9 and 17.10). The Royal Society for Prevention of Accidents (2006) has suggested that the provision of a secure cupboard within the home should be provided as part of the built-in provision of any new homes that are built. The best location for the cupboard would be within the kitchen at a height of 1.5 metres above floor level so that smaller children cannot gain access.
Assessment
• what has been taken – the container is a useful aid to active ingredients
• how much has been ingested – the container will give useful clues to the amount left, as will the appearance of the child if spillage is possible
• parents and carers should be asked about spillages at home
• description of child’s behaviour or symptoms since ingestion: vomiting is of particular significance as it reduces the likelihood of absorption
• any pre-existing illness should be noted as should any medication the child is currently taking: unless clear evidence to the contrary exists the ED nurse should assume and treat the child as if he has ingested the maximum amount of poison available.
The majority of children who have ingested the common poisons noted above will show no immediate physical signs. As a baseline the following should be established:
Management
Specific management of a poison can be aided by gaining specialist advice from a regional poisons unit or via Toxbase (www.toxbase.org). Common principles of care exist: for most poisonous substances information and clinical management can be easily downloaded from specialist advice centres.
In the majority of cases of accidental poisoning, the potential toxicity is low and therefore enforced emesis is considered unnecessary. In these cases activated charcoal is used as a binding agent to absorb toxins. A single dose of activated charcoal in most cases should be given within one hour of ingestion. The dose by weight is calculated at 1 g/kg or a dose by age 25–50 g (Royal College of Paediatrics and Child Health 2003). Because of the risk of aspiration, charcoal should never be given in the absence of a gag reflex or where there is impaired consciousness unless the airway is first protected by an endotracheal tube.
The decision whether to admit a child under 5 years of age can be made solely on the circumstantial history and the presence or absence of symptoms. If the child is thought to have ingested a toxic agent, such as aspirin, paracetamol, a tricyclic antidepressant, an opioid or an iron-containing compound, hospital observation is invariably required, at least for a few hours, to allow appropriate analytical measurements or more intensive monitoring (Vale & Bradberry 2012). Parents should be constructively offered advice and support, as many will have found the child’s accidental poisoning very distressing.
With narcotic drugs, clinical symptoms are similar with all types of opiate drug and the nurse should suspect ingestion of narcotics if the child has pinpoint pupils. Sometimes an accurate history can be difficult to obtain, particularly if the drug is an illegal substance. Narcotic drugs often cause respiratory depression for several hours after ingestion and have a sudden onset. If the child shows signs of respiratory depression or is unconscious intravenous naloxone should be given. Children should always be admitted following narcotic poisoning.
Iron ingestion
Although used as a dietary supplement, an excess of iron is extremely toxic, causing severe gastric haemorrhage. Any symptoms the child may have should be treated on admission; i.v. access should be established at an early stage and fluid resuscitation commenced if necessary. Intramuscular desferrioxamine (15 mg/kg/h) should be given, and may be necessary over a 24-hour period depending on the severity of symptoms. Administration should be stopped when improvement occurs. The iron desferrioxamine complex (ferrioxamine) is excreted in the urine, which becomes orange-red, and may be eliminated by dialysis if renal failure develops (Bateman 2012b).
Paracetamol/acetophinomen overdose
This is one of the most common drugs that children accidentally ingest however, unlike in adults, it is very rare that death or hepatotoxicity results from such ingestion (Penna & Buchanan, 1991). In children <5 y acute paracetamol/acetophinomen toxicity is usually due to accidental ingestion, in the older child this may be the result of attempted suicide (Hickson et al. 1989). It is a simple, effective analgesic, with few side effects when taken as per the recommended dose. Paracetamol/acetophinomen poisoning is however potentially fatal (Bronstein et al. 2010).
History
The history is crucial, and the ED nurse must ascertain dose taken, time taken and any past medical history that may make the patient more susceptible than average to the toxic effects of paracetamol (Fenner et al. 2011).
Management
Investigations are the timed serum paracetamol concentration, liver and kidney functions and prothrombin time. Paracetamol concentration in blood should be obtained between 4 and 16 hours of ingestion to enable patient risk to be determined. The standard treatment of choice for patients who have taken a potentially toxic dose of paracetamol is the antidote acetylcysteine. The optimal dosage of acetylcysteine and the appropriate dose adjustment for body weight remain unclear and are difficult to study in patients (Ferner et al. 2011), where necessary advice should be taken from senior staff and the clinical toxicology database of the National Poisons Information Service of the relevant jurisdiction.
Safeguarding children
The nature of the work of safeguarding children is complex, multifaceted and uncertain (Smith 2010). Whether working directly with children and young people or with adults whose lives impact on children, a health professional can make all the difference.
The earliest organized professional response to child abuse in the UK was the British Society against Cruelty to Children in 1883, which led to the National Society for the Prevention of Child Cruelty (NSPCC) being established in 1890 (Royal College of Paediatrics and Child Health 2007b). The legislative framework for child protection is enshrined in the Children’s Act (Department of Health 1989) and the Children (Scotland) Act (Scottish Office 1995). Over the years, the recognition and handling of child abuse has come a long way. Lessons already learnt have frequently been as a result of tragedies leading to public enquiries, such as that of the death of Marie Colwell in 1974, Jasmine Beckford in 1985, Kimberly Carlile in 1987 and more recently the violent deaths of Victoria Climbié in 2000 and that of Baby P in 2007. In the UK, the death of Victoria Climbié in 2000 brought child protection to the forefront of people’s mind, public and professionals alike. The subsequent report by Lord Laming with 108 recommendations, 27 of which related to healthcare aimed to reshape and reorganize individual practice in child protection (Royal College of Paediatrics and Child Health 2007b).
Lord Laming identified five key messages from the Victoria Climbié inquiry. These were:
It may be that a child is seen just once and yet the record of the event could help to save a life. Victoria had no fewer than five ‘unique’ hospital reference numbers. Often it is only when many apparently unrelated factors are pieced together that practitioners can identify a case of child abuse. Good record-keeping is always factual, clear, accurate, accessible and comprehensive (Royal College of Nursing 2007). Write down all observations and discussions as they happen, include details of communications with other healthcare agencies notified. Seek guidance from Trust policy and senior colleagues, liaising with a designated named child protection nurse, always dating and timing any actions. Confidentiality must not be confused with secrecy. Information should always be shared on a ‘need to know’ basis when it is in the best interest of the child. The intercollegiate committee services for children in EDs, recommends that all staff, whether clinical or non-clinical, must receive training in safeguarding children appropriate to their posts (Royal College of Paediatrics and Child Health 2007b).
Following on from Lord Laming’s original report, The Victoria Climbié Enquiry (Department of Health 2003c), and as a result of the recent Baby P investigations, Ministers announced to the UK Parliament in late 2008 that Lord Laming had once again been asked to prepare an independent report on the progress being made nationally to deliver and implement effective child protection and also identify any possible barriers and how these could be overcome. In March 2009, Lord Laming produced ‘The Protection of Children in England: A Progress Report’ in which he highlighted the progress that had been made over the previous 5 years in implementing the legislation and guidance outlined in documents such as Every Child Matters (Department for Education and Skills 2004) and the interagency working that had occurred as a result of guidance in the document Working Together to Safeguard Children (Department for Children, Schools and Families 2010), both of which provided a sound framework for promoting and ensuring the welfare of the child. However, he also made very clear the new challenges ahead in protecting children from significant harm and neglect with one of the main challenges being to ensure leaders of local services effectively translate policy, legislation and guidance into day-to-day practice on the frontline of every service (Lord Laming 2009).
Prevalence
The true incidence of child abuse is difficult to ascertain. In 2004, there were 26 000 children on the child protection register, 41 % were considered to be at risk due to neglect, 19 % due to physical abuse, 18 % due to emotional abuse and 9 % due to sexual abuse (Royal College of Paediatrics and Child Health 2007b). As a result of recommendations by Lord Laming in 2003, child protection registers were phased out in England in 2006 and instead children are made subjects of child protection plans under guidance from Working Together to safeguard Children (Department for Children, Schools and Families 2010).
Because of differing perceptions of child abuse, and hence changing definitions, as well as difficulties in ascertainment, it is impossible to build up a full picture of its incidence of abuse (Royal College of Paediatrics and Child Health 2007b). The first national survey of all types of abuse and neglect was conducted in the UK for the NSPCC (Cawson et al. 2000). In the study, 2869 young adults between the ages of 18 and 24 years were interviewed. There were no definitions of abuse and neglect but respondents were asked if they had experienced specific behaviours.
The prevalence figures obtained were as follows:
• serious physical abuse (violence used regularly over the years, or which had caused physical injury or frequently led to physical effects): 7 %
• serious absence of physical care (behaviours that carried a high risk of injury or long-term harmful effects): 6 %
• serious absence of parental supervision (staying home alone without supervision overnight under 10 years of age or staying out overnight without parents knowing their whereabouts under 14 years of age): 5 %
• serious emotional maltreatment (control and domination (psychological and/or physical), humiliation, withdrawal, antipathy, terrorizing and proxy attacks): 6 %
• sexually abused (contact and non-contact – against their wishes or under the age of 13 years): 16 %
• sexually abused (contact – against their wishes or under the age of 13 years): 11 %.
First-born children are more likely to be affected and it is not uncommon to find one child is abused while other siblings are free from abuse. Young children of pre-school age are more at risk because they cannot seek help. Most children are abused by a parent; but in this context a not uncommon scenario is a co-habitant living in the house who is not the child’s biological parent. Statistically, the younger the parents, the more likely it is that they will abuse their children. Child abuse is also seen across all layers of society. The acknowledgement that child abuse exists and is quite common is an important start for ED staff; however, in order to enable detection the nurse needs to keep an open and enquiring mind. It is also worth noting that children who are subjected to maltreatment are unlikely to have one type of abuse (Browne 2002) (Box 17.12).
The definition taken from Working Together to Safeguard Children (Department for Children, Schools and Families 2010) of child abuse is as follows: ‘Abuse and neglect are forms of maltreatment of a child. Somebody may abuse or neglect a child by inflicting harm, or by failing to act to prevent harm. Children may be abused in a family or in an institutional or community setting; by those known to them or, more rarely, by a stranger. They may be abused by an adult or adults or another child or children.’ These forms of abuse are described as below. Common physical and non-physical indicators of child abuse are given in Box 17.13.
Physical
Most commonly, physical abuse is inflicted on the child under the guise of punishment or when an adult loses control. It usually involves violence, often of a short duration but repetitive. Physical abuse includes poisoning and suffocation. A study of non-accidental drowning’s found that there were no cases of accidental bath drowning over the age of 18 months, and in all cases over this age the child drowned due to abuse or epilepsy (Kemp et al. 1994). Similarly, Barber & Sibert (2000) suggest that it is very rare for children over the age of 3 years to present with non-accidental bruising or fractures, in contrast to accidental causes. Besharou (1990) notes that deliberately inflicted burns can be distinguished by their severity and area. For instance, burns resulting from deliberate immersion in hot water have distinct lines around them and no splash marks (Joaghim 2003). In the absence of a clinical or plausible accidental explanation, these types of injuries are highly suggestive of abuse.
Neglect
Neglect is the persistent and severe failure to provide love, care, food, shelter or the physical circumstances to allow for normal development (Box 17.14). It also includes willfully exposing a child to any kind of danger. Neglect can lead to failure to thrive, manifest by a fall away from initial centile lines in weight, height and head circumference, which is why repeated growth measurements are crucially important in primary care. Signs of malnutrition include wasted muscles and poor condition of skin and hair. It is important not to miss an organic cause of failure to thrive; if this is suspected, further investigations will be required.
Emotional abuse
Emotional abuse is the persistent emotional ill-treatment of a child such as to cause severe and persistent adverse effects on the child’s emotional development. It may involve conveying to children that they are worthless or unloved, inadequate, or valued only in so far as they meet the needs of another person; having age or developmentally inappropriate expectations imposed on children; causing children frequently to feel frightened; or the exploitation or corruption of children (Department of Health 2003b). All abuses involve some emotional ill-treatment. Iwaniec (1997) argued that parents and carers who persistently criticize, shame, threaten, humiliate, induce fear and anxiety and who are never satisfied with the child’s behaviour and performance, and do so deliberately, are emotionally abusive and cruel. Children suffering from emotional abuse may be withdrawn and emotionally flat. One reaction is for the child to seek attention constantly or to be over-familiar. Lack of self-esteem and developmental delay are again likely to be present.
The parents
The vast majority of child abuse involves at least one of the child’s parents. Approximately one-third of parents who were abused as children are at risk of abusing their own children. As abused children, they may have been subjected to marked negative reinforcement and an inability to get their needs met, have little practice in problem-solving, and no basis for trusting others. As a consequence they may lack empathy with their children as little was directed towards them and a self-perpetuating cycle then begins (Tercier 1992). The parents may present as hostile or exhibit a lack of concern or guilt or may show a lack of interest or disturbed interaction with the child and seem more interested in their own problem than the child’s, for example, how they are going to get home. That noted, it is important to acknowledge the crisis and distress that investigation and intervention cause to the child and family and that there may be conflicting interests between the needs of the child and those of the parents; however, it is also important to stress that under the Children Act (Department of Health 1989) the child’s welfare is paramount.
Management of suspected child abuse
Every ED should have an agreed procedure for the management of suspected child abuse and nurses need to be acquainted with this procedure. All such cases of suspected abuse should be reported to senior medical staff and consultant paediatricians for further investigation and intervention where necessary. Suspicions of child abuse start at initial assessment; an astute nurse will pick up discrepancies in the history of the incident, incompatibilities between the alleged mechanism of injury and the actual injury, and the usual interactions between the child and his carer (Saines 1992). All life-threatening conditions must be given immediate attention; however, while the nursing care and treatment of the child’s physical needs remain paramount, the emotional needs of the child must also be addressed. When clinicians are suspicious of child abuse they have a duty to inform the parents of the need to inform and notify a child protection agency. Local guidelines for child protection should be followed and the child and family should be supported and cared for in a private but safe area during their stay in ED (Department of Health 2003b).
The health worker’s attitude can have a great impact on the child. It is imperative that the health carer appears non-judgemental and is not disgusted by findings or revelations. These should be handled with diplomacy to prevent a difficult situation from becoming inflamed; however, it should be acknowledged that abused cases of any kind could foster feelings amongst staff of hostility and anger towards the alleged perpetrators. Nevertheless, for nursing to be effective, staff must control these feelings. Team leaders and members should monitor each other’s emotional and physical well-being and provide support for those who appear to be affected by an incident (Cudmore 1998).
Evidence
No child should be discharged into the custody of parents or carers if staff feel that there is a risk to the child’s health and welfare. Where parents are unwilling to cooperate the protection of the Children Act (Department of Health 1989) may need to be applied to bring an Emergency Protection Order. In most instances, however, where non-judgemental approaches are used and open communication prevails parental agreement will be forthcoming.
Sanders & Cobly (2005) note that there is a culture of under-reporting of suspected non-accidental injury in children in EDs, which is largely to do with the fact that a significant proportion of medical and nursing staff receive no formal training in identifying potential indicators of child abuse and because they have no rapid access to a paediatric opinion. Additionally, bureaucratic and inter-professional barriers to accessing confidential information about children from social services registers also lead to long delays in the ability of clinicians to obtain a rapid assessment of each suspected case of abuse.
The reforms arising out of Lord Laming’s inquiry into the death of Victoria Climbié, who died of abuse at the hands of her aunt and her aunt’s partner, present an ideal opportunity to encourage clinicians to be alert to the possibility of non-accidental injury and address the current culture of under-reporting (Department of Health 2003c). The recommendations from this report and the subsequent review are reshaping the way child protection cases are managed and have influenced the children’s national service frameworks (Department of Health 2003c, Welsh Assembly Government 2004).
Sexual abuse
This occurs when dependent, developmentally immature children are forced to participate in sexual activity. Although sexual abuse may occur at any age, peaks tend to occur between the 2–6 years and 12–16 years (Tercier 1992). Perhaps the most difficult area of abuse to detect in ED is sexual abuse, primarily because sexually abused children often display no physical signs and it is therefore necessary to be alert to the behavioural and emotional factors that may indicate abuse.
Various degrees and forms of sexual abuse include molestation, touching or fondling of the child’s genitalia, masturbation of the perpetrator by the child, combination of oral-genital contact, attempted or actual anal or vaginal intercourse, exhibitionism, voyeurism and exploitation of children in the preparation of pornographic materials. Sexual abuse differs from other forms of child abuse in that it is not used as a form of punishment. However, while violence is seldom a factor, coercion and threats are common (Tercier 1992). Hobbs & Wynne (2001) suggest that physical abuse and sexual abuse are thought to be closely related; however, the two can occur independently of each other. This relationship is based on power: the threat of physical abuse gives the perpetrator the power to ensure the compliance of the child and allows them to guarantee that the child keeps the sexual abuse a secret (Chudleigh 2005).
Sexual abuse may present to ED staff in a number of different ways:
• physical complaints: for example, abdominal pain, urinary tract infection, per rectum and per vaginal bleeds
• parental accusations; this should always be taken seriously where one parent or carer accuses another
• request by the child for help; children do not fabricate stories of sexual activity
• physical abuse; children who have been physically abused may present with evidence of sexual abuse; careful examination may reveal trauma or infection
• emotional or psychological problems; these may present as bed-wetting, night terrors and developmental regression
• sexually transmitted diseases; any sexually transmitted disease in a child should be considered evidence of sexual abuse until proven otherwise.
Management
The management of children who are suspected of being sexually abused is similar to that for child abuse. Establishing rapport and trust is critical, using language that is appropriate for the child’s age and development stage: it is important to stress that children have short attention spans and therefore a prolonged interview will not be tolerated. Children must be constantly reassured that it is alright to share their secrets with the nurse and for this reason it is best to interview the child away from the family members, even those not initially believed to be involved in the abuse or neglectfulness (Sheridan 1995). Once there is significant indication that sexual abuse may have occurred, arrangements should be made for a physical examination to be completed. Forensic examination should be completed first to ensure that evidence is not destroyed therefore a joint examination in conjunction with an experienced paediatrician may be appropriate to save the child from repeated examination.
A number of key facts need to be established in gaining a history of sexual abuse. These are presented in Box 17.15.
Fabricated illness
Fabricated illness in babies and children by a parent/carer is often referred to by any number of different terms, most commonly Munchausen’s syndrome by proxy (MBP), factitious illness by proxy or illness induction syndrome (Department of Health 2004). Professor Roy Meadows (1977, 1997) who first described Munchausen by proxy (Box 17.16), however, in 2001, following continuing contention regarding the existence, application and definition of the term MBP and many complaints by parents/carers claiming to be falsely accused of child abuse, the Department of Health developed guidance for child protection professionals attempting to give credibility and validity to MBP and introduced the new term ‘fabricated illness’ (Department of Health, Home Office, Department of Education and Skills, Welsh Assembly Government 2004). Munchausen by proxy is now the term reserved for the disorder whereby there are two elements, one indicating a behaviour in the parent/carer for a particular self-serving psychological need and secondly a diagnosis in the child who has been harmed by the parent/carer (Schreier 2002). Fabrication and induction of illness is a broad term to describe a group of behaviours by parents, or those ‘in loco parentis’, that cause harm to children. The behaviours have a wide range, from those causing immediate, direct physical harm (inductions), to verbal fabrications of symptoms that are more indirectly and chronically dangerous in both physical and emotional ways. There are many in-between variants. The illnesses fabricated include any medical, surgical or psychiatric conditions, and may extend to fabrication of special educational needs and disabilities (Royal College of Paediatrics and Child Health 2007b).
Fabrication of illness or illness induction should be considered whenever a baby or child presents with unusual signs and symptoms that are not easily explained physiologically. The fabrication of illness is usually manifested in one of three ways:
• induction of illness or injury by a variety of means
• falsification of signs and symptoms that may include fabrication of past medical history
• falsification of specimens of bodily fluids, falsification of hospital record charts, letters and documents.
The variety of diseases mimicked or produced is alarmingly diverse and limited only by the parent’s imagination and insanity. The child, who is usually under 5 years old, is most commonly presented with problems related to one body system such as blood in urine or recurrent seizures. The illness story is related consistently by the carer, who in 90 % of cases is the child’s natural mother. Events relating to the illness episode only start in her presence. While ideal parenting behaviours may be demonstrated, the mother is often inappropriately calm in relation to the gravity of the child’s illness.
Fabricated illness can be difficult to detect and may go unrecognized for long periods (Eminson 2000). Parents who fabricate or induce illness in >80 % of cases, are mothers. McClure et al. (1996) found that 6 % of children died as a direct result of extreme fabricated illness, with 12 % requiring paediatric intensive care. Up to 35 % of children from reported incidents suffer major physical problems as a result of the abuse, with as many as 50 % of children experiencing long-term morbidity. Child welfare concerns arise when the patterns of presentation in the child are not consistent and incongruent and the conjunction of unobserved parental access and deterioration in the child’s health occurs. At all times, nurses must have a high index of suspicion and while it is possible that there are any number of explanations for any of these circumstances, each will require careful consideration (Box 17.17). When concerns are such that a positive explanation for the child’s presentation is that of fabricated illness then referral to a senior paediatrician and social services should be made.
Despite the understandable feelings of anger and frustration of clinical staff in these situations, the need for non-judgemental care remains paramount, as is the continuing need for vigilance to safeguard children. Support and debriefing should be made available for staff, including all the multidisciplinary team who have been involved in the care of abused children and who have been affected by fabricated or induced illness (Dolan 1998).
Conclusion
A trip to the ED is usually the young child’s first experience of hospital. Every effort should be made to make the experience as little upsetting as possible. Avoid separation from parents/carers, explain simply what is wrong, and if and how it can be amended, in a language that is easily understandable to the child. On this first visit to the hospital, it is the emergency nurse’s responsibility to ensure the experience is as positive as can be.
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