Paediatrics: Medical assessment

Medical assessment

The purpose of the medical assessment is to:

•   Assess whether the child has been injured and/or whether there are any other medical or developmental concerns.

•   Provide appropriate investigations and treatment for the child.

•   Provide an opinion about possible cause.

When assessing a child who may have been the victim of child abuse it is important to inform and involve your senior colleagues at an early stage.

The assessment should be carried out (along with an experienced/ senior colleague, if possible) in an environment that provides a sufficient degree of comfort for the child and their parents/carers, as well as suf-ficient access and lighting for examination. It is good practice to have a nurse or other health professional present at the time of history taking and examination.

History

·  A thorough history is required.

•   The presenting problem should be documented chronologically, outlining the sequence of events and circumstances leading up to presentation and referral.

•   The family history, past medical history (e.g. clotting defects, bone disorders, psychiatric), and social history should be detailed.

Examination

This should include a general examination of all the systems.

•   Weight, head circumference, and height should be plotted on a growth chart.

•   Neurodevelopmental assessment is appropriate in infants/toddlers.

•   External injuries should be recorded in detail, including their location, size/dimensions, and appearance.

•   Photographs should be taken.

Examination of children with suspected sexual abuse should only be undertaken by designated/trained professionals (e.g. the named child pro-tection lead or police-surgeon).

Child protection plan

•   Where there are concerns about a child enquires should be made to social care. There is a confidential list of names of children subject to a child protection plan within a local authority area who are believed to be at continuing risk of significant harm. This is maintained by the local authority within the social care department, every local authority is required to hold one.

A child protection plan is drawn up by professional staff working together with the parents, carers, and the child (where old enough). Children with a child protection plan have a social worker who is responsible for co-ordinating work with the child and the family.

The family must have a clear understanding of the planned outcomes and that they are willing to work to these within a specified time frame.

• A child will be the subject of a child protection plan until it is believed that the child is safe from any future harm. Regular meetings are held with the parents/carers and child to review the work being done and progress made.

• If a child moves out of one area, if they are the subject of a child protection plan, the information must be passed on to the new local authority area.

Consent

This is an important consideration that needs to be taken into account before proceeding with the medical assessment of any child. If the child is deemed to have sufficient understanding to make an informed decision, consent should be obtained from them. This principle is commonly re-ferred to as ‘Gillick competency’, although now we think in terms of Fraser competency. Children of sufficient understanding cannot be medically examined without their consent even when an emergency protection order has been made.

Gillick competency

This is named after the ruling of the House of Lords (Gillick v. West Norfolk and Wisbech Area Health Authority [1985]). It stated that the parental right to determine whether or not a child below the age of 16yrs will or will not have medical treatment terminates if and when the child achieves sufficient understanding and intelligence to enable him to under-stand fully what is proposed. This term has now been replaced by Fraser competency.

Record keeping

Clear, detailed note keeping is required.

• Written notes: full and contemporaneous notes should be kept including comments made by parents and the child. All notes must be signed and dated with the name of the doctor printed underneath an entry.

• Diagrams: particularly body maps to illustrate location of injuries.

Photographs: may be helpful, but should be dated and signed or requested from medical photography with parental consent.