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The changing face of paediatrics and child health

One hundred years ago, infection was the major cause of morbidity and mortality in childhood. Improvements in the environment, sanitation and housing began the trend for advancement in population health, and this was accelerated by the introduction of immunizations and antibiotics. Changes have occurred in society too, many of which are beneficial to children and their health and well-being. Children are better and more widely protected than was the case a century ago. Educational standards, social support, medical care and knowledge about child development have all improved, and child abuse has become unacceptable.

However, inequalities in both wealth and health are increasing, and the ‘gap’ between the richest and poorest has a profound impact on children's lives. Referrals for emotional and behavioural problems are rising dramatically, and childhood obesity is seen as the major public health problem of our time. A relatively new aspect of paediatrics is the understanding that many determinants of adult health have their origins antenatally, in infancy and in the early years of childhood.

Health care has also changed in paediatrics. Over the last 40 years, we have seen more children admitted to hospital, but the experience of hospitalization has changed. Once visiting hours for parents were limited to 30 minutes per day, but now the normal expectation is that parents will stay with their child. Where possible every effort is made to keep children out of hospital, and many aspects of specialized complex care have become available in the community. Even for the acutely ill child, short-stay observation wards now allow serious causes of illness to be excluded and children to be discharged to recover at home. A significant proportion of admissions are for social reasons, for example, if there are concerns that the family is unable to cope or they live too far away to safely send the child home.

The determinants of health

The way health is considered has also changed over the decades. In the early part of the 20th century, health was considered to be the absence of disease. However, in 1948, the World Health Organization changed the way we look at health when it declared that ‘health is a state of complete physical, mental, and social well-being, and not merely the absence of disease and infirmity’. In paediatrics, this has been accompanied by a more holistic approach to children, with greater emphasis on well-being especially for those coping with chronic conditions and disabilities.

Two major factors have changed priorities in the care of children and their services. The first is the understanding that socioeconomic status has a powerful influence over many aspects of children's health. Poverty is now known to be a significant predictor of a number of major measures of health, including:

• Birth weight
• Perinatal morbidity
• Sudden infant death syndrome (SIDS)
• Admission to hospital
• Obesity.

The other factor that has changed the way we view disease arises from the ‘Barker hypothesis’. Barker and his colleagues brought to light how events in pregnancy and infancy can have a long-term effect on health. Exploring infant growth records from the last century, they showed that babies born small for gestational age were at significantly increased risk for hypertension, cardiovascular disease, diabetes and obesity in adult life, particularly if they showed rapid catch-up growth in the first year of life. Their findings demonstrated how critical the early years are in programming later health outcomes.

Rather reassuringly, economists have shown that although the preschool years are a vulnerable period, they are also a critical period amenable to intervention. The evidence clearly shows that when society invests in the early childhood years and provide support, community programmes, guidance for parents and education, there are profound benefits on many later outcomes such as physical health, academic achievement, mental health, antisocial behaviour and substance abuse.

Types of paediatric problems

With the changing face of childhood disease, health professionals need to be competent at managing a broad variety of conditions. These conditions include the following broad categories:

• Acute illnesses such as bronchiolitis, respiratory infections and anaphylaxis
• Chronic illnesses such as asthma, epilepsy, diabetes and cancer
• Disabilities—both physical and intellectual
• Injury: accidental and non-accidental
• Disorders of eating and nutrition, including weight faltering, obesity and anorexia
• Mental health disorders such as attention deficit disorder, challenging behaviour, depression and anxiety.

Some of the particular challenges we need to face are emotional and behavioural problems, childhood obesity, child abuse and neglect, accidents and injuries, sexually transmitted disease and teenage pregnancy, increase in disabilities and chronic illness, substance misuse, suicide and self-harm and poor vaccine uptake.

By directly treating childhood conditions, by ensuring effective screening and prevention programmes and by advocating for better public health interventions, paediatricians and all those working in child health have a fantastic opportunity to influence the long-term outcome of their patients. Paediatrics is a challenging specialty but a very rewarding one.

Communication skills in paediatrics

Paediatricians need to be happy with informality, enjoy humour and appreciate the unpredictability that children bring to consultations! Young children do not have a full understanding of the role of health professionals. Children will naturally be anxious and uncertain in an unfamiliar environment. They may not understand all of the language in the consultation, but they quickly detect a sense of personal warmth, friendliness and relaxed mood in adults around them. It helps to have pictures, toys and videos to help children understand that the room is a good place for children.

In paediatrics, the focus of the consultation changes with the age and understanding of the child. In a young baby, the discussion is entirely with the carers (usually parents) who act as advocates for the child's needs. As children mature, they need to be included in the discussion. It is important to understand children's concerns and their right to be involved in decisions. Paediatricians need also to consider the concerns of the family and communicate sensitively with all family members.

Approaching the consultation

• Try to be friendly, confident and non-threatening. It may be best to examine an exposed part of the body first before undressing the child, or do a pretend examination on their teddy bear.
• Try to get down to the child's level—kneel on the floor or sit on the bed. Look at the child as you examine them. Use a style and language that is appropriate to their age—‘I’m going to feel your tummy' is good for a small child but not for an adolescent.
• Explain what you are going to do, but be careful of saying ‘can I listen to your chest’ as they may refuse!
• Babies are best examined on a couch with the parent nearby; toddlers may need to be examined on the parent's lap.
• In order to perform a proper examination, the child needs to be undressed, but this is often best done by the parent and only the region that is being examined needs to be undressed at any one time.
• Older children and adolescents should always be examined with a chaperone—usually a parent but, if the child prefers, a nurse. Allow as much privacy as possible when the child is undressing and dressing.
• Sometimes, you may need to be opportunistic and perform whatever examination you can when you can. Always leave unpleasant things until the end—for example, looking in the throat and ears can often cause distress.
• Hygiene is important both for the patient and the paediatrician to prevent the spread of infection to other patients. Always wash your hands before and after each examination.
• Always sterilize or dispose of equipment that has been in contact with a patient, such as tongue depressors or auroscope tips.

History taking

The history often indicates the diagnosis before examination or investigations. The history can be taken from a parent, a carer or from the child. Record who gave the history and in what context. Use an independent interpreter if there are language difficulties.

Beginning the examination—observation

Much information can be gained by careful observation of the child. This starts while you are first talking to the parents.

• Signs of acute severe illness (need urgent intervention):
  • shock
  • severe respiratory distress
  • altered consciousness level
• Signs of pain or anxiety
• Growth and nutrition
• Features of syndromic disorders
• Developmental progress:
  • gross motor and fine motor movement
  • social interaction
  • speech and understanding
• Interaction with carers
• Hygiene and clothing
• Mood and behaviour.

The examination of individual systems is discussed in detail in the following chapters.