Paediatrics Manual The Children's Hospital at Westmead Handbook 2e - sample


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Designed to be a quick reference manual, this second book in the Quick Flick series presents comprehensive yet concise information in an easy-to-read format. It adopts a multidisciplinary approach, covering serious child-specific conditions and common clinical situations, and clearly explains good management techniques and treatment of sick children.

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Paediatrics Manual The Children's Hospital at Westmead Handbook 2e - sample

  1. 1. Practical paediatrics This chapter includes: requirements of good paediatric practiceᮣ making the diagnosisᮣ the child in hospitalᮣ principles of good care.ᮣ Requirements of good paediatric practice • A sound basic approach • A working knowledge of child growth and development • An appropriate history and physical examination • Knowing where to find additional information • Being ready to ask for advice if you don’t know • Recognising the family and social context • Whenever possible, a sense of humour More mistakes are made by not asking (that is, a poor history) and by not looking (that is, inadequate examination) than by not knowing. Making the diagnosis • Enquire about the presenting problem(s). • Take whatever background history is relevant to the type of consultation. For a child requiring hospital admission, this will always include full past, family and social history. In any consultation ask about the child’s immunisation status. • Commence your examination with observation from 1–2 metres: does the child appear unwell, pale, afraid, short of breath, drowsy or abnormal in any other way? This part of the examination is often the most revealing. • Continue the examination by going to the site of the presenting complaint or to the system you think is most likely to be involved. • Write down a differential diagnosis. • Perform only simple investigations first. • In an emergency situation, ask what has happened while assessing the urgent priorities—A (airway), B (breathing), C (circulation)—then direct the examination to the apparent problem. (See Chapter 3.) • Explain to the parents and the child what you are doing at each stage. 1
  2. 2. 2 PAEDIATRICS MANUAL2 • If unable to make a firm diagnosis, remember that you are more likely to be seeing an atypical or unusual presentation of a common illness, as opposed to a truly ‘rare’ condition. • Where the diagnosis is unclear, tell the parents this and your plan of action. • Don’t hesitate to consult if necessary. The child in hospital Effects of illness and being in hospital • Children’s thoughts and feelings about illness, injury, pain, operations and hospital can be difficult to discern. • Some apparently ‘good’ children may in reality be depressed, withdrawn or in pain; many will ‘overreact’ to even comparatively harmless procedures. • ‘Needles’ are universally feared and/or disliked by children. • Regression to a less mature behaviour pattern is common, especially if the child is immobilised, is very unwell or requires prolonged treatment. • Separation from family is a most stressful aspect of hospital care. Very young children will often not understand why their mother has left or that she will return. • Children often misinterpret illness or treatment as punishment. Some paediatric pitfalls • Comments by hospital staff implying ineptitude of other doctors are common. In paediatrics such comments are often also made about parents and schoolteachers. Decry this unfair and useless practice. If mistakes have indeed been made, learn from them yourself. • Be wary of discounting parental anxiety. A mother’s intuitive feeling that her young child is seriously unwell should be interpreted as a ‘red flag’, even if the child does not look especially unwell to you. • Be wary of quiet children: they may be the most emotionally disturbed ones. • Be wary of assuming what you say in the presence of any child will not be understood. This pitfall is especially relevant with a dysmorphic, physically impaired or apparently unconscious child. Principles of good care Active efforts are needed to minimise the separation, pain, unfamiliarity, loneliness and boredom that often accompany illness where hospital admission is required. Remember the importance of the family in the child’s illness and the child’s illness in the family.
  3. 3. Q UICKFLIC K 1 PRACTICAL PAEDIATRICS 3 Good medical care • Minimise the number of procedures (injections, blood collection, catheterisations and so on) and perfect the skills in carrying out these procedures, to cause the least fear, suspense, pain, surprise or indignity. • Carefully organise the investigation and treatment to minimise the length of admission. • Use adequate analgesia for painful procedures, where necessary using narcotic analgesics ‘titrated against’ the child’s pain. • Make hospital admissions as short as possible. Appreciating the special vulnerability of some children Children who are likely to be especially vulnerable include: • Very young children • Those from broken or disturbed homes • Those who have had previous illness or accidents • Those suffering severe pain • Those who react badly to change • Those having eye, mouth, throat, genital or bowel operations • Those who have suffered physical, sexual or emotional abuse. Avoiding separation from parents—especially the mother This is a crucial countermeasure and it has the following benefits: • It reduces distress in the child and parents. • It promotes the relationship between mother and child. • It promotes the parents’ understanding of the child’s illness and future needs. • It helps medical and nursing staff to understand the child’s unique characteristics and needs. • It speeds convalescence. Communicating Parents must be kept appropriately informed about their child’s progress and made to feel that their contribution is valued and taken into consideration. Try to talk directly with them each day. The GP must be kept informed of progress and the treatment plan at discharge. Play and education To a small child, ‘play is work, thought, art and relaxation’. Providing opportunities for play serves many needs; possibly the most important is helping the child cope with the hospital experience. Older children should, whenever possible, continue schoolwork when in hospital.