The sick child

FOR some GP trainees, paediatrics will form part of their training scheme and many will have experience of it fromtheir foundation training. But for others, their only experience of treating children will have been learned in medical school.

Whatever your level of experience, it is important to remember that the principles of caring for children in general practice are straightforward and based on the basic principles of good medical practice.

History and examination

Taking a good history is the very cornerstone of every consultation and it’s no different when the consultation involves a child. Children and young people are individuals with rights and it is important to involve them in a consultation and to listen to what they have to say.

Clearly where a child is too young to communicate effectively you must rely on their parents. Always listen to parents and take on board their concerns – it can be all too easy to dismiss them as being over-anxious. Many of the complaints that we see at MDDUS concerning children are raised by parents who believe their concerns have not been taken seriously or that they have not been listened to.

Communication is vital in terms of obtaining consent for examination. Where a child is capable of giving consent or agreeing to an examination then you should involve the child in that decision, explaining what will happen in a way that they can understand. Where the child does not have capacity to consent, you should involve the parent. In one case from MDDUS’ files, the mother of a young boy complained because a doctor examined her child’s testicles. She felt it was completely unnecessary and had not consented to the examination, but in fact it was a perfectly reasonable examination for the doctor to do in the circumstances. He apologised for not explaining to the mother why he wanted to examine the child’s testicles and for not obtaining her explicit permission to do so. The mother accepted his apology and the complaint was resolved.

Investigation and treatment

MDDUS advisers are sometimes asked if a doctor can treat a child who attends the surgery without a parent or other adult. Doctors can see children and young people on their own and treatment can be provided with their consent if they are capable of understanding the nature, purpose and possible consequences of investigations or treatment.

The capacity to understand will vary and depend on the maturity of the child, the treatment proposed and the complexity of decision to be made. Doctors have the same duty of confidentiality to children as they do to adult patients. Information can be shared with their parents if the child agrees, where the child lacks capacity, where it is in the child’s best interest to share the information or where there is an overriding public interest.

Documentation

The GMC advises doctors to keep clear, accurate, contemporaneous and legible medical records that report the relevant findings. It is advisable to consider documenting relevant negative findings as well as positive ones. For example, in the case of a febrile child – where a child has been examined to determine if there is a non-blanching petechial rash present – it would be equally important to record its absence as well as its presence.

MDDUS has dealt with several claims where there is an alleged delay in diagnosis of meningitis. This is notoriously difficult to diagnose in the early stages, where the early symptoms and signs may be quite non-specific. The recording of the absence of such a rash demonstrates that the doctor has considered this diagnosis and examined the child, checking for appropriate signs of the illness. This helps greatly in the event of a complaint or claim raised at a later date that a diagnosis of meningitis was missed.

Prescribing

When prescribing for children you should be familiar with and refer to guidance published in the British National Formulary. And if in doubt…ask!

In all aspects of their work doctors must recognise and work within the limits of their competence. If you require advice about treating children, seek assistance from your trainer or a senior colleague. Full guidance concerning the treatment of 0-18 year olds is available from the GMC.

Dr Anthea Martin is a medico-legal adviser at MDDUS