Monday, 11 June 2018

Paediatrics is Not a Specialty - top tips for working with young people

Paediatrics is difficult to define as a specialty.  At one point the RCPCH talked about “doctors who look at specific health issues, diseases and disorders related to stages of growth and development.”  Now the RCPCH careers site has a very different note stating, "Whether a paediatrician, GP, children's nurse or pharmacist, our job is to help babies, children and young people thrive." I'm guessing that the RCPCH realised that it wasn't just doctors and it certainly wasn't just paediatricians who fitted the original description.

In fact paediatrics may not be a specialty at all.  It could be defined as the art of treating children differently from adults by knowing what diseases affect them, how they respond to illness and how to use that knowledge to help them during their illness or prevent them from becoming ill.

Anyone who works with children in a healthcare setting should study of the art of paediatrics.  We all need to develop our skills in assessing and treating ill children as well as becoming experts in all the other aspects of child health including safeguarding, growth and development.  Children and young people are different in so many ways and it takes a bit of effort to get good at working with them but it is completely worth it.

What is different about children and young people that requires a different approach and different skills?

Children respond differently to illness - Physiological changes can be dramatic in uncomplicated viral illness making the recognition of complicated infection difficult
Children may not localise, report or recognise symptoms - This is why constipation and UTI are often only diagnosed when they have been prolonged.
Children often present with something normal - This often happens because an adult is concerned and doesn't know that the symptom is normal.  One example is knock knees in children.
The overall likelihood of significant pathology is low - Much of paediatrics is about diagnosing normality or at least that the illness is uncomplicated and does not require medical intervention.  The other side of this coin is that the routine nature of a good outcome can lead to complacency and impairs our awareness of complications and significant pathology.
Children are vulnerable - As well as the safeguarding element of caring for children and young people, we have to consider how difficult it is for them to feel safe in a healthcare setting.  It is confusing and intimidating and it is too easy to forget to keep the child at the centre of the process.
There is a lot of uncertainty that goes with the assessment of children - paediatrics is often compared to veterinary medicine because we end up relying more on what we see.  It is fairly usual to find that we can't get specific symptoms and that our ability to examine is limited by the child's interaction.

Last week, I went onto TwitFace and asked the people who were online what their top tips are for working with children an young people.  What follows is based on some of the great responses I recieved.

Starting with the general advice:

There were also loads of tips for examining children:
I haven't been able to include everything and in some cases there were recurring themes which I have categorised together.  There were quite a few specific things that people have found to be useful in paediatric examination, some of which are listed here:
  • The guess what's in the tummy game.  I have a high success rate with guessing sausages.  However you go about it I would highly recommend this approach to abdominal examination.  It's probably quite scary for a child to have a stranger press their tummy, but if it's a game that seems to be a different matter.
  • For assessing gait, get the child to walk towards their parent rather than away from them.
  • For ENT examination:  Tell the child: "I have a magic fairy/dragon detector (ear thermometer) that goes beep when a fairy is in the room. If it beeps I have to check their ears and throat with my magic torch to make sure it isn’t hiding in there."  I have to try that one.
  • For respiratory exam, ask them to blow out the candles on an imaginary birthday cake.
One place even had a departmental rabbit.  I can imagine that would work to settle many an otherwise inconsolable child!

Paediatrics may not be a specialty but it is an art.  How you approach that art is up to you but whichever you go about it the end result should be the same:  The child will get the best care possible and you might be having some fun at the same time.

Edward Snelson
Possibly not a Paediatrician

Disclaimer - All the views expressed here are solely those of the author.  Any references to Royal Colleges are entirely fictional and should not be used as a reason to revoke the author's invitation to the annual RCPCH cheese night.

Acknowledgements: Thank you to all the people who shared their tips and tricks via social media or face to face.  More importantly, thank you to all the children who put up with us while we figure out how to do the whole paediatric examination thing.  Your patience and tolerance is appreciated.