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The community station: OSCE paediatrics

Summary:

  • You are more or less in the shoes of a GP or another community practitioner
  • A very complex case centered around one child (but there may be other children in the periphery!) with challenging biological, social, psychological and educational needs that are not being addressed
  • Some ethical and legal dilemmas (read: SAFEGUARDING) that need to be addressed as well
  • The idea is not to fix everything at once, but to identify and anticipate problems and know what resources are available in the community

Important points:

  • Don’t panic! You are not a social worker!
    • You just need to be able to spot warning signs and anticipate problems, and show some understanding of what is out there for struggling families.
    • The pathways to access help are notoriously complex, overlap, and there are dozens of people involved at every stage – it can get quite confusing if you start looking too much into details

Example: Case 1

Jamie is a 4-year-old boy who was born at 26 weeks of gestation and was admitted to NICU for 12 weeks. He was on home oxygen until last year, but now is getting recurrent chest infections and his health visitor has expressed concerns about his weight dropping centiles, and because he is withdrawn and not developing as expected. He lives with his mum Sarah, who is expecting another baby, and his older (7yo) and younger (2yo) sisters, Shannon and Millie. His mum is currently unemployed; she had quit smoking but took it up again when the home oxygen was discontinued – at first on the balcony of their flat but now inside. She has just started a relationship with a new partner, but he does not live with them at the moment.

You see Jamie accompanied by his mother who reports another chest infection: Jamie seems very quiet and you cannot elicit any speech from him – he does not make eye contact and hyperventilates and groans when you try to examine him. You notice he has bruises behind his left ear. When asked about the whereabouts and health of her other daughters, the mother is vague and says they are home alone but they get on fine by themselves. Jamie is indeed very much below his target gentile in height and weight. The mother has no specific plan regarding Jamie’s schooling meant to start in September, saying she has other things to think about at the minute.

Tip 1: Make full use of your reading time

  • Reading time is tight!
  • Skim through the case, underlining salient points, perhaps writing in the margin B for biological, S for social, P for psychological, E for educational, E/L for ethico-legal, and BIG WARNING SIGNS for safeguarding.
  • There are questions at the end to prompt you – read these as well and quickly draft answers using the rest of your reading time and the spare paper they give you!

Applying this to case 1:

Safeguarding: Worked example for case 1

  • Warning signs
    • Single parent in adverse social circumstances with new partner
    • Children left home alone, mother does not seem concerned
    • Child appears fearful around adults
    • Signs of neglect
    • Bruising in classic spot for abuse
  • Risk factors:
    • Child: prematurity, low birth weight, chronic disability
    • Parent: mental health diagnosis, substance abuse, parents experiencing abuse, history of child abuse, unsupported parents, large family size
  • Suspecting abuse? What should you do?
    • Take a full history (past medical history, social history, other children at home, domestic violence, parental mental health)
    • Full examination (plot height and growth on charts, full exposure with chaperone and inspection for injuries – record on topographical chart and photograph with parental consent)
    • Check Child Protection Register
    • DOCUMENT
    • SEEK SENIOR INPUT
  • Immediate actions
    • DOES THE CHILD NEED IMMEDIATE PROTECTION?
      • Call the police or 999
      • If less acute, refer to paediatrics for admission
    • Could this be sexual abuse?
      • Refer to local sexual abuse assessment unit if <72h episode (post-pubertal) or <1w episode (prepubertal)
    • IS THIS FGM?
      • If confirmed FGM in <18yo, statutory duty to contact police
      • Consider need for iCASH or GUM clinic
  • What about the parents?
    • Remember, you need to tell parents you are making a referral to social services, unless you believe doing so would put the child at greater risk of harm

Key point: How does safeguarding referral work?

  • Speak to your senior and to the named practitioner for safeguarding (could be a senior GP, a paediatrician or a specialist nurse)
    • Will advise on referral to social services
  • You must fill out a statutory intervention form (SIF form) detailing your concerns
  • Social services have 24h to come up with a plan, collecting information under the Common Assessment Framework (CAF)
  • Multidisciplinary Child Protection Conference (with police, healthcare, social services, NSPCC) to decide on outcome for child
  • Main legislation: Children Act 1989
  • Outcomes for a child + siblings following Child Protection Conference:
    • Child protection register
    • Child in need plan
    • Application to court for removal of the child

Biological issues: Case 1

  • Background: ex-premature child with significant respiratory complications, recently weaned off home oxygen
  • Acute issue: recurrent chest infections
  • Chronic issue: growth faltering (likely due to suboptimally controlled chronic lung problem, recurrent chest infections, and suspicion of neglect), not reaching developmental milestones
  • Environmental aggravating factors: parent smokes in household

What can you do?

  • Deal with acute problem: antibiotic prescription, follow-up appointment, adequate safety-netting
  • MDT approach: OT, PT, dietician, GP, paediatric respiratory physician, specialist nurse, general paediatrician, health visitors, community paediatrics, CAMHS (behavioural problems)
  • Anticipating problems: refer to immunisation clinic within GP surgery, liaise with health visitor team, address smoking cessation with mother and signpost her to HCA- or pharmacist-led smoking cessation clinics
  • Children’s Community Nursing Team to avoid admission and facilitate early discharge

Go one step further! Look at the whole family situation….

  • Mother is pregnant!
    • Is she attending her antenatal appointments? Is her care midwife- or consultant-led?
    • Advice on lifestyle modifications (smoking, alcohol, drug) – does she need signposting to Inclusion (Cambridge drugs and alcohol services), or referral to a nurse specialist?
    • Is she taking folic acid?
  • Has she received adequate vaccination (flu, pertussis)?

Key point: Other services to be aware of

  • Sensory impairment team
    • Regular audiology and ophthalmology review eg for Down’s
    • Sensory difficulties in ASD
  • Physio/OT
    • Orthotic aids and braces for CP, wheelchairs through OT
  • SALT/gastro
    • Communication and swallowing/feeding problems
  • Sexual health
    • iCASH
    • Point-of-care HIV and other STI testing available through the Internet for high-risk groups
    • Contraceptive needs (“Ask Brooke” helpline for teenagers)

Social issues: Case 1

  • Unemployed single mother of three, soon four
  • Child with a disability and increased needs
  • Child showing signs of growth faltering – is nutrition sufficient and adequate?
  • Children left home alone – no social network support, nowhere else for them to be in the middle of the day if mother has to leave the house?
  • Is the mother’s parenting adequate?

Key point: Pathways for social issues

  • First port of call: Citizen Advice Bureau
    • Is the family receiving all the benefits they are eligible for?
    • Eg Disability Living Allowance, Carer’s Allowance
  • Disabled Children’s Social Care Services
    • Every child with a disability is automatically assigned a named social worker
    • Provides families with financial support for child to access community services, signpost to children’s centres, leisure centres, schools
  • Council
    • Is the housing appropriate? Mouldy or inaccessible housing, etc
  • Food poverty:
    • Healthy Start Vouchers – Voucher programme for healthy foods (milk, fruit) in over 30,000 UK shops
    • Cambridge City Foodbank – Food voucher system
    • Free school meals
  • Parenting
    • Sure Start Children’s Centres – provide parenting education and maternity grants for parents on benefits
    • Antenatal parenting classes (available through the NHS)
    • Free childcare vouchers
    • Romsey Mill Children’s Centre or other community centres for childminding and socialising for children and parents
  • Respite care (charities like SCOPE might help with access)
  • Links to jobcentre plus for mother

Psychological issues: Case 1

  • Psychological burden of disability for Jamie, psychodevelompental delay
  • Psychological burden on siblings who may feel neglected
  • Mother pregnant again, might bring up potentially traumatic memories of NICU admission (not uncommon for parents to experience PTSD-like symptoms)

Key point: Services and pathways for psychological issues

  • Jamie – referral to MDT team through community paediatrics (follow up by psychologist, CAMHS)
  • Siblings – school might employ a therapist, can also access children’s therapist through community youth centres or NSPCC
    • ChildLine and Barnado’s are other charities looking after children’s mental health
  • Mother – screen for depression and anxiety, refer through local pathway for assessment for counselling, speaking therapy, mindfulness or CBT
    • Charities like Mind have useful resources and local support group meetings

Educational issues: Case 1

  • No plan for Jamie’s schooling, mother appears disengaged
    • Seeing his developmental delay, he will need additional input and mainstream schooling may not be appropriate (but it might be!)
  • What about his siblings’ schooling?

Key point: Services and pathways for educational issues

  • Education and Health Care Plan
    • Legal document that describes a child’s special education, health and social care needs, and how to meet these needs
    • EHC needs assessment by council
    • SEN Coordinator (SENCo) ensures needs are met
  • Support in school
    • Mainstream vs specialist school
    • Counsellor
    • School nurse
    • Specialist teacher/teaching assistant
    • Educational psychologist
    • Behavioral support

Other resources to be aware of about improving child health

What measures are in place to improve child health?

  • First, think about what factors impact child health?
    • Infections
    • Prematurity
    • Congenital and genetic diseases
    • Obesity
    • Unintentional and deliberate injuries
  • What measures can you think of that might improve these?

The DOH health child programme involves….

  • Improving parent health and education
    • Good prenatal care
    • Breastfeeding support – Baby Friendly Initiative
    • Parental mental health, 6 week cheek
    • Sure Start centres (childcare support)
  • Immunisations
  • Screening
    • NIPE, 6 week check, blood spot, hearing
  • Health Visitor
  • Nutrition
  • Activity
    • Active Kids, Change4Life
  • Education
    • Bookstart
    • Sexual health education
  • Child safety
    • Think! Road safety

Other services/ resources

  • Help for Disabled Children
    • Disabled Children’s Social Care Service: Assesses needs of kids <18yrs. Supports kid’s access to community, training for skills, and signposts to services e.g. clubs, schools etc. Families can get up to £2K/annum for activities.
    • Financial support: Carer’s allowance and personal independence payments (new name for disabled living allowance)
    • Special Needs Community Information Point: Information and advice service
  • Financial Help
    • Cambridge Foodbank: works on a food voucher system that entitles you to 3days of emergency food. Distributed by council, children’s centre.
    • Benefits:
      • Child benefit
      • Disability living allowance/ personal independence payments
      • Carer’s allowance
      • Employment and support allowance
    • Parents Needing Help with Childcare
      • Romsey Mill Children’s Centre: groups and activities for families under 5s. Have childminding, play/learning activities, classes for parents, antenatal and postnatal
      • Free childcare vouchers: for 3 and 4 year olds mainly
      • Assessment by social services at home
      • Foster care “placement agreement” set out by council
  • Smoking: “Kick Ash” for under 16s in Cambridge
  • Substance & Alcohol Misuse
    • CASUS: Cambridge child and adolescent substance use service. <18yrs, self-refer or refer by GP or anyone that works with children
    • Talk to Frank (national) : Website and call/text/email/online chat for advice that is confidential and info aimed at young people
  • Sexual Health and Contraception
    • iCASH – Integrated contraception and sexual health services: “Lime Tree” GUM clinic in Cambridge, STD testing, contraception and advice. Self-referral, appt or walk-in
    • “Ask Brook” helpline on sexual health and relationships aimed at under 25s
    • Emergency contraception:
      • Pharmacies: free if registered with a Cambridge GP otherwise £25
      • GP or Lime Tree: can also check for STDs

Resources to be aware of about teen pregnancy

  • Advice
    • Young Woman’s Guide to pregnancy: leaflet with info on services
    • “Worth talking about” helpline & section of NHS website for teens who think they’re pregnant
    • Ask Brook helpline on sexual health and relationships
  • Health
    • Specialist midwife for teen mums
    • Family nurse partnership (national): home visits by a specialist nurse from early pregnancy to 2yrs. Health education, job prospects, antenatal care, breastfeeding. Meet more often than health visitor
  • Housing and Education
    • Cambridge housing service: parents <21ys
    • Council sorts money/ childcare so those <16yrs can remain in education
    • Care to learn Charity: Helps with childcare costs for 16-20yrs who want to go to college etc

Practice case 2

Connor is an 8 year old boy with Down’s syndrome. He is brought in by his mother, Julia, who says that he has ‘one of his ear infections’ again; she says he mentioned the pain for the first time 7 days ago and she had been giving him pain relief until now. They attend today because she has some time off from her job at the supermarket. She has 5 year old twins at home, who she says will be watching TV until she gets back. The family recently moved to the area after the father passed away in a traffic accident 2 years ago. The twins have started preschool recently, while Connor is homeschooled by his mother – when asked about this, Julia mentions that they go through things when she finds time but that he is ‘very difficult’ to teach.

Today on examination, Connor seems unkempt: his nails are dirty, and his clothes are stained and smell of smoke. He is irritable and difficult to examine, but on otoscopy both his tympanic membranes appear red and inflamed, with exudate behind them. There are no other abnormalities on examination, but looking at his growth chart reveals that he has fallen over 2 weight centiles over the past year.

Practice case 3

George is a 5-year-old little boy who lives with his sister, mother and grandparents in a council house.  George has suffered repeated chest infections since birth and has remained below his predicted growth curve, falling further behind each year.  On arrival in the UK, one of these infections led to his admission to hospital and investigations revealed that he suffers from CF.

His mother is 12w pregnant.  She moved to the UK with her husband and his parents 3y ago.  Her husband is currently working abroad.  Her father-in-law has Alzheimer’s and her mother-in-law has severe OA.  They live with her and she is their main carer.  She has another child, 2yo, who is currently well and confirmed not to be suffering from CF.  Her first child died in his first year from a chest infection.

George started school last September, but his teachers are concerned that he is falling behind, as he misses so much time off school.  They have noticed that his mother seems to be very low, and they are worried that she is not coping, as George often looks disheveled and often turns up without a coat or socks.  The school nurse has asked the health visitor to visit the family.

Nadia is worried about George’s health, especially as he has missed his “pre-school booster” due to being ill at the time.  She has asked her GP for these, as well as a flu jab.  She also worries about how likely it is that her unborn child may have CF too.

What problems arise from this case?

What structures are available in the community to address these issues?

What programs are in place nationally to promote child health?

29/03/2019

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