Who’s who in children’s services?

Cite this article as:
Tara George. Who’s who in children’s services?, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31749

One problem we often encounter working with children and young people, especially those with complex health or social care needs, is trying to work out who the myriad of professionals referred to actually are. More importantly, who is actually involved and who should be involved? In the context of safeguarding the concept of the “Team Around the Family” or “TAF” is key in building connections and providing stability and safety for vulnerable youngsters.

A really important point to remember is that many children and young people don’t live in a traditional nuclear family unit consisting of a mother, father and siblings.  As part of an assessment, it is vital to ask about who is at home but not to make any assumptions about how household members are related (or not). Don’t assume every child lives with their parents or that they have a female and a male parent.

Interagency work is full of buzzwords which may well feel alien to doctors new to paediatrics or to the NHS. The aim of this article is to provide you with a sense of “who’s who?” with a glossary of some relevant and important terms. The author of this article is a GP working in the UK and the terms used here are relevant in the UK though there are almost certainly equivalent professionals internationally.

Universal services (sometimes called Tier 1 services) are those services that are provided to or are routinely available to, all children, young people and their families.

Targeted services (often called Tier 2) for children and families beginning to experience – or at risk of – difficulties, for example, school counselling, parenting programmes, support for teenage parents and so on. 

Specialist services are for children and families with multiple and complex needs. They are usually referred to in two tiers:


Tier 3 services such as intensive family support, specialist child and adolescent mental health services, and services for children with disabilities. 


Tier 4 specialist services for children and families with severe and complex needs, including child protection services, inpatient child and adolescent mental health services.

In England, the process of commissioning of services is a complex one and beyond the scope of this article. Some services which appear to be “health” are in fact commissioned by local councils rather than by the CCG. Whilst it is good practice for health, education and social care to work closely together, the links are often not as effective as we would like them to be.

The following professionals are likely to be ones which anyone working with children and young people need to know about. Some of the people in this list are well known to all. Others might be new to you. If I’ve missed any off, please let me know, especially if you are reading this as a fellow professional who I’ve forgotten.

Universal services

Community Health Universal Professionals

GP Practice– everyone living in the UK is entitled to be registered with an NHS GP practice.  A number of people who work within the surgery are part of Universal Services for every child.  The UK GMS contract is a complicated subject well beyond the scope of this article but if you are interested in finding out more, the website of your local LMC (local medical committee) would be an excellent place to start. Every GP surgery will have a safeguarding lead GP and almost every locality will have a named safeguarding GP.

GP– following medical school and foundation training, junior doctors can be appointed to a three year GP speciality training programme. To gain a CCT to allow practice independently as a GP doctors must pass the MRCGP examination as well as three years of workplace based assessments. Many GPs will have specific area of interest like child health, gynaecology, musculoskeletal care but all GPs are qualified to assess and treat children. GPs are the community first point of contact for illnesses, developmental concerns and can refer to secondary care if necessary. 

Practice Nurse– Practice Nurses undertake a diploma in primary care nursing following their undergraduate nursing degree. They see all children for their immunisations and are involved in managing children with long term conditions such as asthma. In most practices, nurses will be involved in contraceptive services provision for young people as well as adults. Nurses are regulated by the Nursing and Midwifery Council (NMC)

Midwife – Midwives are registered health professionals and the majority are educated to degree level.  They have a statutory duty to children and families up to 10 days postnatally. They take the newborn blood spot test (“heel prick” formerly called the Guthrie test) at day five. Midwives are regulated by the Nursing and Midwifery Council (NMC)

Health Visitor – Health visitors are registered nurses/midwives who have additional training in community public health nursing. Health Visitors take over from the midwife at day 10 though most will have arranged to meet the family during the last few weeks of pregnancy.  They are the first point of contact for families with questions around feeding and development. Health Visitors are regulated by the Nursing and Midwifery Council (NMC)

School Nurse – School nurses are qualified and registered nurses many of whom have chosen to gain additional experience, training and qualifications to become specialist community public health nurses (SCPHN – SN). School nurses work across education and health, providing a link between school, home and the community. They work with families and young people from five to nineteen and are usually linked to a school or group of schools. School nurses are usually the first point of contact for supporting teachers and children in school with minor health or developmental problems.  In most areas they run clinics for primary nocturnal enuresis. School Nurses are regulated by the Nursing and Midwifery Council (NMC)

Optometrist – Previously known as opticians, optometrists are trained to examine the eyes to detect defects in vision, signs of injury, ocular diseases or abnormality. They assess eye health, offer clinical advice, prescribe spectacles or contact lenses and refer patients for further treatment, when necessary. Optometrists study at university for at least three years and are registered with the General Optical Council.  Children should start seeing an optician regularly from around aged 4 – their parents need to register them with an optometrist for NHS care. Eye assessments and glasses are free of charge for children in the UK. Children have a one-off vision screening run by the school health service during their reception class year.

Dentist – Dentists train for five years at University and then have two supervised years of practice. They are regulated by the General Dental Council. Children are entitled to free dental check-ups on the NHS and in most areas are offered an appointment twice a year from aged 2. Parents need actively to register their child with a dentist.

Education Universal Services

School – Statutory school age in the UK is the term after a child’s fifth birthday, though in England and Wales children become eligible for a full-time reception class place in the September following their fourth birthday.  Most families send their children to a pre-school or school nursery from aged 3 when they get 30 hours a week in term time of funded early years education. It is compulsory to be in education or training until aged 18, though “post 16 education” may be vocational/apprenticeship based rather than academic.

In the UK we have state schools which are open to all children free of charge although there are rules around distance and catchment areas. Private schools  (confusingly sometimes referred to as public schools) are fee paying schools which usually have entrance examinations and academic requirements to remain in the school. There are also special schools which provide tailored specific education for children and young people with significant special educational needs who would not be able to access education within a standard state school.  All state schools must have a designated safeguarding lead who is usually the head or deputy head. There must also be a lead for anti-bullying and a lead for looked after children who may be the same person as the safeguarding lead, or the SENDCO or another senior leader.

Teacher – Teachers in the UK are all graduate professionals. They may work in a primary (4-11 years) or a secondary school (11 years upwards).  Teachers are regulated by the General Teaching Council. Teachers spend many hours outside the classroom at evenings and weekends working on education and pastoral duties. 

Teaching Assistant (TA) – Teaching assistants work closely with teachers to support the delivery of education. They are qualified to at least an NVQ 3 but many are qualified teachers who chose to work in a lower paid but less demanding role. A TA may have a specific role working with children with special needs, or may be a general classroom TA.

SENDCO– All state schools must have a SENDCO (special educational needs and disability coordinator). They are almost always an experienced teacher who takes on this role in addition to their classroom duties. In Scotland the term SENDCO is not used, instead they have a principal teaching for additional support for learning.

More Intensive Services

Secondary Care Children’s Services

Child Health teams are often based together in hospital locations though many members may work out in the community too.

Paediatricians are specialist doctors who work exclusively with children and young people (usually up to the age of 18 though this may vary in different places). Paediatricians may be general paediatricians who had a wide-ranging interest and expertise or may have subspecialised into for example paediatric nephrology, cardiology, rheumatology etc. All paediatric departments will have a named doctor for safeguarding children and usually a named nurse for safeguarding too.  In larger hospitals there will be specialist doctors in Paediatric Emergency Medicine working in the emergency department, whereas in smaller District General Hospitals all doctors in the ED will be expected to assess and treat children acutely. Paediatric Surgeons look after children with surgical problems but again in a DGH it may well be that general surgeons operate on paediatric cases, with younger children transferred to specialist paediatric surgical units.

Paediatric Specialist Nurses are qualified nurses with additional qualifications and skills in specific disease areas. It is common to have specialist paediatric nurses looking after a caseload of children with long term conditions e.g. children’s epilepsy specialist nurses, children’s diabetes nurse, Cystic Fibrosis Specialist Nurse. Specialist Nurses may also have additional qualifications allowing them to prescribe. 

Community Paediatricians see children for a wide variety of reasons. It may be to assess general medical problems, specific developmental problems (such as ADHD or autism), learning difficulties (if a medical or neurodevelopmental cause is suspected), complex disabilities, or sensory impairments such as visual difficulties or hearing loss. Community Paediatricians do not generally deal with one-off, short-term or acute illnesses. They generally offer long-term support, co-ordination of services and management on a continuous basis. Much of the work of a community paediatrician is of a statutory nature, carried out under the Children Act, the Education Act and adoption regulations. The team has responsibility for preparing medical advice for education health care plans. The team also sees children who are being adopted or are in foster care

Community Paediatric Nurses generally work with children with long-term conditions; children with disabilities and complex conditions including those requiring continuing care and neonates; children with life-limiting and life-threatening illness, including those requiring palliative and end-of-life care.  Commonly they may be involved with tracheostomy care, complex wound management, home ventilation.  Some Paediatric Specialist Nurses are based within children’s community nursing teams rather than at a hospital base, this varies by area.

Play Specialists use play as a therapeutic tool to help children understand their illness and treatment. They lead play activities with children and young people who are in hospital or attending a hospital or clinic. Play Specialists are an invaluable part of the paediatric department when it comes to helping children cope with and understand painful or distressing procedures such as blood tests. They are qualified to NVQ Level 3.

Physiotherapists help people affected by injury, illness or disability through movement and exercise, manual therapy, education and advice. They can assess gait problems, help disabled children with mobility problems and help children with cystic fibrosis with chest physio. Physiotherapists are degree qualified professionals who may choose and area of specialisation such as chest physio, neurophysio etc.  Physiotherapists are registered with and regulated by the Health and Care Professions Council (HCPC)

Occupational Therapists (OT) provide intervention, support and/or advice to children and young people who are having difficulty joining in with the activities they need and want to do every day e.g. dressing, using cutlery, completing jigsaws, riding a bike, writing.  These difficulties may be due to poor gross and fine motor co-ordination, poor core stability, poor motor planning skills, visual perceptual difficulties or sensory difficulties.  OTs may offer advice and information to nurseries and schools to develop the staff’s knowledge of some of the difficulties the children/young people may have and how they can support them to join in these environments. OTs are degree qualified professionals. They are registered with and regulated by the Health and Care Professions Council (HCPC).

Speech and Language Therapists (SALT) support children and young people with speech, language, communication, oromotor and feeding problems. Speech and Language Therapists are degree qualified professionals. They are registered with and regulated by the Health and Care Professions Council (HCPC).

Paediatric Dieticians help babies, children and teenagers to eat and drink well.  They support children and their families where nutrition and special diets can be part of their treatment, including allergies, restrictive eating and cancer.  They have a key role in supporting families with children with allergies and those children who are fed via PEG, PEJ or other enteral means. Dieticians are degree qualified professionals. They are registered with and regulated by the Health and Care Professions Council (HCPC).

Orthotists provide devices for children and young people to be worn externally (orthoses) such as splints, insoles, spinal braces, lycra garments and specialised footwear to promote best posture and enable the best and most effective mobility. Orthotists are degree qualified professionals. They are registered with and regulated by the Health and Care Professions Council (HCPC).

Child and Adolescent Mental Health Services (CAMHS) comprise Psychiatrists (mental health doctors) and allied workers such as nurses, OTs, psychiatric social workers to look after children with mental health conditions. CAMHS services have historically been severely underfunded and there is little consistency across the UK in terms of what provision is made or what is commissioned from these overworked services. Inpatient CAMHS are provided at a Tier 4 superregional level and so young people needing specialised inpatient care may well end up many miles from their home. 

Social Care Services

Social Workers are degree qualified professionals who work with children and families and often specialise in a specific field of work – such as support for children and families or working with children with physical disability or mental health related needs. They work with social networks, families or communities, as well as individuals, and help develop supportive relationships.  The aim of social worker involvement is to empower families to achieve better outcomes at a “child in need” or “child protection” level. Social Workers in children and family services, may work with ‘looked-after children’, young offenders, children who have experienced or are at risk of abuse, children with health and mental health needs – and with their families. This may include helping families experiencing difficulties to resolve their problems. They may work specifically to assess and intervene where there are child protection concerns within a family or from elsewhere. Others may also manage the adoption and fostering processes, and support children with a disability. Most social care services will also employ OTs, support workers and other allied professionals within their teams and liaise closely with children’s services.

A brief note on Looked After Children (LAC)

This is a very important and much misunderstood area in terms of who’s who and how to address and refer to people who are a day to day part of a child’s life.  This is only a tiny snapshot, a much fuller article is mid production and when published will be referenced here.  


Looked After Child is a child who has been in the care of their local authority for more than 24 hours.  The term is synonymous with the term “in care” though this nomenclature has fallen out of current use.  
Foster Carers are paid by the local authority to look after children in care. Foster carers undergo rigorous training and being a foster carer is at least a full time job.  Foster placements may be for respite (especially for children with significant additional needs) now referred to as “short breaks”, short term or longer term.  Parental Responsibility for a LAC in foster care who have a care order is usually held by the local authority, possibly in conjunction with the birth parents.  A child in receipt of short breaks may be a LAC but their parents retain parental responsibility. A LAC will always have their own social worker and foster carers usually have their own social worker as well.


A Special Guardianship Order (SGO) is an order in England and Wales appointing one or more people over the age of 18 years to be a child’s permanent guardian. The order gives the special guardian parental responsibility for the child. The order is a private law order, which is made where a child cannot return to a parent but does not need to be kept in foster care or be adopted. The Scottish equivalent is a legal guardian.

Justice System Professionals

Probation Officers/Youth Case Workers support offenders on their release from prisons and young offenders institutions in England and Wales. They work closely with offenders, liaising with employers and educational services to try to ensure rehabilitation of young people who have committed criminal acts. In Scotland this role is carried out by social workers.

Youth Justice Workers work with young offenders who are in custody and on community sentences to ensure transition and rehabilitation when they are released from custody.

Family Case Workers work with children and young people whose parents are in custody.

Bubble Wrap PLUS – March

Cite this article as:
Anke Raaijmakers. Bubble Wrap PLUS – March, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32384

Can’t get enough of Bubble Wrap? The Bubble Wrap Plus is a monthly paediatric journal club reading list  from Anke Raaijmakers working with Professor Jaan Toelen & his team of the University Hospitals in Leuven. This comprehensive list is developed from 34 journals, including major and subspecialty paediatric journals. We suggest this list can help you discover relevant or interesting articles for your local journal club or simply help you to keep an finger on the pulse of paediatric research.

This month’s list features answers to intriguing questions such as: ‘How long does metronidazole treatment change the gut microbiology?’, ‘Do corticosteroids have a place in the treatment of acute pyelonephritis?’, ‘Is metformin safe for treating obesity in childhood?’, ‘Is it safe to delay antibiotic treatment in respiratory tract infections?’ and ‘Can dried blood spots be used for the detection of congenital CMV infection?’.

You will find the list is broken down into four sections:

1.Reviews and opinion articles

Decision to extubate extremely preterm infants: art, science or gamble?

Shalish W, et al. Arch Dis Child Fetal Neonatal Ed. 2021 Feb 24:fetalneonatal-2020-321282

Ethical Considerations in Pediatricians’ Use of Social Media.

Macauley R, et al. Pediatrics. 2021 Feb 22:e2020049685. 

Review of an episode of racial discrimination in a paediatric ward.

De Rose C, et al. J Paediatr Child Health. 2021 Feb;57(2):293-294. 

Diagnosis and management of neonatal hip dysplasia: a brief history.

Dunn PM, et al. Arch Dis Child. 2021 Feb 17:archdischild-2020-321138. 

Early clinical management of autosomal recessive polycystic kidney disease.

Liebau MC. Pediatr Nephrol. 2021 Feb 17. 

Neonatal acute kidney injury: a case-based approach.

Starr MC, et al. Pediatr Nephrol. 2021 Feb 17

Review: Identification and Management of Circadian Rhythm Sleep Disorders as a Transdiagnostic Feature in Child and Adolescent Psychiatry.

Arns M, et al. J Am Acad Child Adolesc Psychiatry. 2021 Feb 5:S0890-8567(21)00059-9. 

Islamic Beliefs About Milk Kinship and Donor Human Milk in the United States.

Subudhi S, et al. Pediatrics. 2021 Feb;147(2):e20200441

Opening doors: suggested practice for medical professionals for when a child might be close to telling about abuse.

Marchant R, et al. Arch Dis Child. 2021 Feb;106(2):108-110. 

2.Original clinical studies

Impact of Metronidazole Treatment and Dientamoeba Fragilis Colonization on gut Microbiota Diversity.

Gotfred-Rasmussen H, et al. J Pediatr Gastroenterol Nutr. 2021 Feb 24

Maternal Psychological Factors and Onset of Functional Gastrointestinal Disorders in Offspring: A Prospective Study.

Baldassarre ME, et al. J Pediatr Gastroenterol Nutr. 2021 Feb 24. 

Adjuvant corticosteroids for prevention of kidney scarring in children with acute pyelonephritis: a systematic review and meta-analysis.

Meena J, et al. Arch Dis Child. 2021 Feb 25:archdischild-2020-320591. 

Enteral Feeding and Necrotizing Enterocolitis: Does time of First Feeds and Rate of Advancement matter?

Masoli D, et al. J Pediatr Gastroenterol Nutr. 2021 Feb 10. 

A Prevention Program for Insomnia in At-risk Adolescents: A Randomized Controlled Study.

Chan NY, et al. Pediatrics. 2021 Feb 24:e2020006833. 

Hypotension in Preterm Infants (HIP) randomised trial.

Dempsey EM, et al. Arch Dis Child Fetal Neonatal Ed. 2021 Feb 24:fetalneonatal-2020-320241

Clinical implications of thrombocytosis in acute phase Kawasaki disease.

Park JH, et al. Eur J Pediatr. 2021 Feb 1. 

Perinatal risk factors for pediatric onset type 1 diabetes, autoimmune thyroiditis, juvenile idiopathic arthritis, and inflammatory bowel diseases.

Räisänen L, et al. Eur J Pediatr. 2021 Feb 23

Pica, Autism, and Other Disabilities.

Fields VL, et al. Pediatrics. 2021 Feb;147(2):e20200462

Efficacy and Safety of Metformin for Obesity: A Systematic Review.

Masarwa R, et al. Pediatrics. 2021 Feb 19:e20201610. 

Maternal Chronic Conditions and Risk of Cerebral Palsy in Offspring: A National Cohort Study.

Strøm MS, et al. Pediatrics. 2021 Feb 18:e20201137. 

Molecular Diagnostic Yield of Exome Sequencing in Patients With Cerebral Palsy.

Moreno-De-Luca A, et al. JAMA. 2021 Feb 2;325(5):467-475

Augmented Reality-Assisted Video Laryngoscopy and Simulated Neonatal Intubations: A Pilot Study.

Dias PL, et al. Pediatrics. 2021 Feb 18:e2020005009. 

Multisystem inflammatory syndrome in children related to COVID-19: a systematic review.

Hoste L, et al. Eur J Pediatr. 2021 Feb 18:1-16. 

Association between childhood asthma and history of assisted reproduction techniques: a systematic review and meta-analysis.

Tsabouri S, et al. Eur J Pediatr. 2021 Feb 17. 

The intraperitoneal bacteriology and antimicrobial resistance in acute appendicitis among children: a retrospective cohort study between the years 2007-2017.

Dabaja-Younis H, et al. Eur J Pediatr. 2021 Feb 16. 

Adopting otitis media practice guidelines increases adherence within a large primary care network.

Bradley M, et al. J Paediatr Child Health. 2021 Feb 16. 

Bacterial Meningitis in the Absence of Pleocytosis in Children: A Systematic Review.

Zimmermann P, et al. Pediatr Infect Dis J. 2021 Feb 9. 

Association of in utero antibiotic exposure on childhood ear infection trajectories: Results from a national birth cohort study.

Hu YJ, et al. J Paediatr Child Health. 2021 Feb 15

Lack of changes in preterm delivery and stillbirths during COVID-19 lockdown in a European region.

Arnaez J, et al. Eur J Pediatr. 2021 Feb 12:1-6. 

Associations Between Neonatal MRI and Short- and Long-Term Neurodevelopmental Outcomes in a Longitudinal Cohort of Very Preterm Children.

Jansen L, et al. J Pediatr. 2021 Feb 9:S0022-3476(21)00114-1. 

Outcomes following admission to paediatric intensive care: A systematic review.

Procter C, et al. J Paediatr Child Health. 2021 Feb 12. 

Delayed Antibiotic Prescription for Children With Respiratory Infections: A Randomized Trial.

Mas-Dalmau G, et al. Pediatrics. 2021 Feb 11:e20201323. 

Antibiotics for Acute Respiratory Tract Infections: Now, Later, or Never?

Gerber JS, et al. Pediatrics. 2021 Feb 11:e2020046839. 

Diagnosis of celiac disease is being missed in over 80% of children particularly in those from socioeconomically deprived backgrounds.

Whitburn J, et al. Eur J Pediatr. 2021 Feb 10. 

Antibiotic exposure during pregnancy and childhood asthma: a national birth cohort study investigating timing of exposure and mode of delivery.

Uldbjerg CS, et al. Arch Dis Child. 2021 Feb 9:archdischild-2020-319659. 

Association Between Proton Pump Inhibitor Use and Risk of Asthma in Children.

Wang YH, et al. JAMA Pediatr. 2021 Feb 8:e205710. 

Effects of a nudge-based antimicrobial stewardship program in a pediatric primary emergency medical center.

Shishido A, et al. Eur J Pediatr. 2021 Feb 8. 

Comparison of rectal and axillary temperature measurements in preterm newborns.

McCarthy LK, et al. Arch Dis Child Fetal Neonatal Ed. 2021 Feb 8:fetalneonatal-2020-320627. 

Consequences of coronavirus disease-2019 (COVID-19) lockdown on infection-related hospitalizations among the pediatric population in Denmark.

Polcwiartek LB, et al. Eur J Pediatr. 2021 Feb 8:1-9

Mental Wellbeing and General Health in Adolescents with Asthma: The PIAMA Birth Cohort Study.

van der Laan SEI, et al. J Pediatr. 2021 Feb 3:S0022-3476(21)00108-6. 

Neonatal Golden Hour: A survey of Australian and New Zealand Neonatal Network units’ early stabilisation practices for very preterm infants.

Hodgson KA, et al. J Paediatr Child Health. 2021 Feb 5

Perianal streptococcal disease in childhood: systematic literature review.

Gualtieri R, et al. Eur J Pediatr. 2021 Feb 2

Early detection of significant congenital heart disease: The contribution of fetal cardiac ultrasound and newborn pulse oximetry screening.

Menahem S, et al. J Paediatr Child Health. 2021 Feb 2. 

Paediatric appendicitis during the COVID-19 pandemic.

Sheath C, et al. J Paediatr Child Health. 2021 Feb 1

Live attenuated vaccines under immunosuppressive agents or biological agents: survey and clinical data from Japan.

Kamei K, et al. Eur J Pediatr. 2021 Feb 1. 

Sensitivity of Dried Blood Spot Testing for Detection of Congenital Cytomegalovirus Infection.

Dollard SC, et al. JAMA Pediatr. 2021 Feb 1:e205441. 

Newborn Dried Blood Spot Testing for Congenital Cytomegalovirus Screening: The Little Engine That Could.

Demmler-Harrison GJ. JAMA Pediatr. 2021 Feb 1:e205445. 

Early Motor Function of Children With Autism Spectrum Disorder: A Systematic Review.

Lim YH, et al. Pediatrics. 2021 Feb;147(2):e2020011270. 

Use of E-cigarettes and Other Tobacco Products and Progression to Daily Cigarette Smoking.

Pierce JP, et al. Pediatrics. 2021 Feb;147(2):e2020025122. 

Monitoring the recovery time of children after tonsillectomy using commercial activity trackers.

Lambrechtse P, et al. Eur J Pediatr. 2021 Feb;180(2):527-533. 

High flow in children with respiratory failure: A randomised controlled pilot trial – A paediatric acute respiratory intervention study.

Franklin D, et al. J Paediatr Child Health. 2021 Feb;57(2):273-281. 

Pediatric COVID-19 and Appendicitis: A Gut Reaction to SARS-CoV-2?

Malhotra A, et al. Pediatr Infect Dis J. 2021 Feb 1;40(2):e49-e55

Use of probiotics in the treatment of functional abdominal pain in children-systematic review and meta-analysis.

Trivić I, et al. Eur J Pediatr. 2021 Feb;180(2):339-351. 

Evaluation of an educational video providing key messages for doctors to counsel families following a first afebrile seizure.

Ng EWM, et al. J Paediatr Child Health. 2021 Feb;57(2):198-203. 

Sleep, Growth, and Puberty After 2 Years of Prolonged-Release Melatonin in Children With Autism Spectrum Disorder.

Malow BA, et al. J Am Acad Child Adolesc Psychiatry. 2021 Feb;60(2):252-261.e3. 

Associations of Maternal Cardiovascular Health in Pregnancy With Offspring Cardiovascular Health in Early Adolescence.

Perak AM, et al. JAMA. 2021 Feb 16;325(7):658-668. 

Maternal Cardiovascular Health: A Critical Period for Offspring Lifetime Cardiovascular Health?

Daniels SR. JAMA. 2021 Feb 16;325(7):630-631

Open Schools, Covid-19, and Child and Teacher Morbidity in Sweden.

Ludvigsson JF, et al. N Engl J Med. 2021 Feb 18;384(7):669-671

Predictive Models of Neurodevelopmental Outcomes After Neonatal Hypoxic-Ischemic Encephalopathy.

Peeples ES, et al. Pediatrics. 2021 Feb;147(2):e2020022962. 

3.Guidelines and best evidence

4.Case reports

Not only appendicitis: rare appendix disorders manifesting as surgical emergencies in children.

Samuk I, et al. Eur J Pediatr. 2021 Feb;180(2):407-413. 

Severe movement disorder and psychosis from haloperidol withdrawal in a 7-year-old girl with autism.

Syamkumar S, et al. J Paediatr Child Health. 2021 Feb;57(2):286-288. 

Neonatal systemic lupus erythematosus syndrome presenting as 4 months of ‘persistent ringworm’.

Patel F, et al. Arch Dis Child. 2021 Feb;106(2):153. 

Purpuric, delayed child: Beyond septicaemia and into inborn errors of metabolism.

Hertzog A, et al. J Paediatr Child Health. 2021 Feb 15. 

Use of Cognitive Shortcuts in Decision-making for Children With Severe Neurologic Impairment.

Bogetz JF, et al. Pediatrics. 2021 Feb 11:e20200930. 

Hand sanitiser-associated ocular chemical injury in children.

Rodríguez-Ares MT, et al. J Paediatr Child Health. 2021 Feb 10. 

If we have missed out on something useful or you think other articles are absolutely worth sharing, please add them in the comments!

Paediatric pieces for Prehospital practitioners

Cite this article as:
Jason van der Velde. Paediatric pieces for Prehospital practitioners, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32110

I’m one of those that see little humans as little humans and big humans as big humans and don’t buy into the whole angst that children are different. Some humans require small bits of kits and some require rather large bits of kit….

Now before I get hissed at by a sizable proportion of readers, may I place my views into context? This may go some way into keeping you engaged, and, perhaps, convincing you that an alternative approach to equipment management might indeed be applicable to your practice. I’m a rural Prehospital Emergency Medicine and Critical Care Retrieval Physician. I grew up in the ambulance and rescue services in South Africa and have been engaged in looking after humans of all shapes and sizes since 1992. I currently work in stunningly beautiful West Cork, which despite being on the edge of Europe, can feel like being in the Australian Outback when you’re 3 hours away from a hospital with a post-arrest neonate or an 8-year-old with polytrauma. The Trauma Centre I’m attached to in Cork City is exceptionally busy, with a mixed adult and paediatric caseload. Approximately a third of my personal workload is paediatrics; oh and I have 5 children under the age of 14.

COVID has brutally shone a spotlight on the CRM issues we face every day in acute care specialities;  particularly with regards to equipment and consumables management. Overnight we decluttered many of our cubicles, creating isolation spaces. Rooms that are devoid of anything that might possibly become “contaminated”. Rooms are just “rooms” and no longer “clinical environments”.  We’ve had to adapt and conscientiously think about what consumables we bring to the bedside. Whatever we don’t use will need to be thrown out and whatever we don’t bring in will result in a potentially adverse delay, whilst a runner goes to fetch it from a distant storeroom. Folks, the latter is nothing new to the high visibility brigade… Welcome to Prehospital Care in the hospital! 

I’ve recently gone through a major upheaval, totally rethinking my equipment lists and layout whilst bringing a new 258 brake horsepower 4×4 into service. I manage circa 500 patients every year in the field. Kit logistics is everything, given the distant storeroom is a hospital up to 3 hours away and Gardai (the Irish word for police) don’t like to be used as runners. I must confess that I’m pretty old fashioned with what I use, and I don’t like change. It’s probably because I’m used to carrying what I need on my back and started my career in a system that at the time had very little. 

I’ve been motivated by the wealth of novel kit management ideas that have evolved from COVID preparation freely shared by colleagues on Social Media. In my own department, we’ve adopted various “Packs” to bring into  “COVID Rooms” to both reduce waste and to re-create our “clinical environment”, albeit one patient at a time.  

Pre-packaged kits ready to grab and go

I was asked to write a prehospital post on “adapting kit for children” and to highlight how I “improvise for children”. Sorry to disappoint, I certainly don’t “adapt kit” for children and I certainly don’t “improvise” either. What I do is innovate, putting hours and hours of iterative design and experience into safe equipment governance regardless of the size, shape or dilemma a human might find themselves in. 

How often have you reached for the simple in-hospital ward transfer bag, only to realise you probably should have been making use of that gym membership, let alone the health and safety implications of a ridiculously heavy bag stuffed to the gunnels? When you carry everything on your back as part of your daily routine, you get very used to minimising not only packaging but bulk. We’ve effectively been doing this in prehospital care for years without really thinking about it. Modulising equipment by clinical task reinforces a minimalistic approach and dramatically reduces both waste and weight. My new iteration of equipment bags takes this into account whilst also the addition of tackling the COVID infection control dilemma. 

Equipment ergonomics is nothing new to paediatric practice. For example, having everything to hand in a logical order is the hallmark of successful phlebotomy in a squirming toddler. The MOST important thing to start with is to ask yourself what you need a kit bag to achieve? I have evolved the primary platform on a comfortable army Bergen, which is equipped to ONLY provide life and limb threatening care to a human from preterm to centenarian a few hours hike through a mountain trail. To achieve this takes an immense amount of preplanning. For me, this latest iteration has built on a prehospital career of over 25 years, with 12 years of Irish practice to adapt, and there’s still so much more to do. The hallmark of quality prehospital care is not cutting corners and not improvising. I have the exact same standard of equipment, monitoring and drugs that you would expect available in a trauma unit. Innovation comes through layout and the principle of packaging everything into procedure based modules.

Experience has proven that it’s counterproductive to have a little bag full of syringes and needles. You’ll either have too many or not enough. Think about each and every life-saving procedure, for example, a chest drain then break it down into individual component parts. Do you have everything you need? With just one flap open on my bag, I have everything I need to pre-oxygenate an infant. There’s an Ayres T-piece, HME, angle piece, and one of each size 1 to 3 facemask, plus a single 10ml syringe for letting air into or out of the facemask seal. I consider airway adjuncts to be a separate module. 

In prehospital care, you do not have the luxury of knowing the size of the next patient. In the picture of my opened airway module, you will note I’ve everything required to manage a human airway. Spot the vacuum sealed hand suction if you can! You may notice a lack of toys. Airway cameras fail in the cold and wet. I’ve not yet met one that’s West Cork proof. 

Working repeatedly in  “COVID positive” homes really wakes you up to the realities of how poor our infection control practices were. In the new system, each module is vacuum-sealed in a clean room, before going into the main bag. If a module is opened, everything, regardless of if it’s used or not, is either discarded or re-sterilized as appropriate. The outside packaging of an unused module is easily decontaminated with a simple wipe or UV light. The bag itself is washable. 

Kit unused in a bag that’s been touched repeatedly by contaminated gloves should never have been a thing in the first place. Think about it! When you’re sucked into the moment of treating a sick child, the last thing you appreciate is infection control. Solutions need to be human proof. We can’t simply just do what we’ve always done. I call it the RNLI test. If your kit and all its contents reliably can survive a winter trip to an Irish offshore island, lying exposed in the hull of an open rescue boat, you’ve achieved infection control packaging! This means EVERYTHING, down to the stethoscope and SpO2 monitor requires vacuum sealing. 

Another advantage of having everything vacuum sealed is that when you prepare your kit, you’re not rushed, and everything can be meticulously checked with a colleague, using a challenge-response checklist. When you open your kit in chaos, you can be confident that everything you need is there, laid out exactly the same way on a nice clean piece of plastic – and not a dirty floor. Disposing excess packaging reduces clutter around the patient. Whilst there is a cost associated with setting up such a system, there are savings too. You don’t end up throwing as much away. By using a checklist , you also have the ability to record the expiry date of a piece of kit on the outside of the module.  You can either opt for having a store room with all the various modules vacuum sealed on a shelf to simply replace, or like me, you have a number of fully stocked bags always ready to go. I chose the latter, with three identical bergens allowing me the “luxury” of being able to offer one bag per polytrauma patient at a rural Road Traffic Collision.

Monitoring has always been a bulky problem. The solution has come about out of a novel community defibrillation project we initiated in West Cork. We wanted to equip every single off-duty member of the ambulance service with a patient monitor and defibrillator in the back of their private vehicle. With these professionals on a text alert system, we are able to go a long way to achieving a 10min response time in rural life or limb-threatening calls. Even the cheapest patient monitor, that conforms to the standards, costs €20k. By modularising everything into a sturdy waterproof case, ie purchasing SpO2, 12 lead ECG, defibrillator, BP cuff individually, we produced the same monitoring and defibrillation standard, in a far more rugged pack for a quarter of the price. 

Moving forward, my single kit bag now includes all the monitoring and drugs required for an RSI or cardiac arrest, including waveform capnography and ECG! These are not new technologies, but smaller, cheaper items such as EMMA Capnography and Bluetooth-to-iOS ECG devices. I no longer have the heavy monitor or hands so full of equipment that I can’t safely climb a flight of stairs, let alone reach a child trapped in a mindboggling place! It helps create that clinical environment in a non-clinical area. If further “next step” critical care retrieval paraphernalia is required, such as a ventilator, blood warmer or syringe driver,  this can be brought out from the car. 

But why on earth would all this be relevant to a paediatrician or paediatric nurse in an average hospital who may or may not ever have to retrieve or transport a sick child anywhere further than radiology? 

Around the corner, around the world” is a philosophy that defines risk in retrieval medicine. It’s not distance, but the very act of transferring a patient from one place to another that carries the risk. Most people are worried about a cardiac arrest en route. What will you do today if that cardiac arrest was caused by an infusion line, chest drain or endotracheal tube dislodging in transit in that unfamiliar, non-clinical space? The riskiest time is just transferring a patient across the bed to the trolley, radiology table or theatre table. After that, my least favourite place to be is an elevator or crowded corridor. Ask yourself the most basic and simple safety question… Is the equipment bag that accompanies me fit for purpose to provide critical care support to this little patient in an elevator? 

A journey to remember

Cite this article as:
Viv Forde and Owen Keane. A journey to remember, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32101

Imagine yourself on a stretcher rolling away from your home, out of your driveway. BUMP onto a ramp, then pushed from the ramp into the back of an ambulance. Hear the sound of the stretcher being locked in place, and all you can see is the white ceiling and bright lights. BANG! The door slams after you. You look around and see machines you do not recognise with no understanding as to what they do. They look scary, some of them BEEP, and you are sick and in pain. For any adult, this is daunting.

Now imagine that you are a 5-year-old child. What would be going through your mind?

The back of an ambulance must be one of the scariest environments a child could encounter. As prehospital practitioners, assessing and treating children in this environment is a huge challenge. Seeing a distressed child, sick and in pain, is daunting. Trying to treat their ailments and instil some calm, even more so. How do we do this? How can we do it well…. or better? What is available to us to make this easier and how can we improvise to improve the patient experience for the ones we want to mind the most?

The Bumbleance

In Ireland, we have an amazing dedicated paediatric transfer ambulance service, designed inside and out with nothing but kids in mind. The Bumbleance Children’s National Ambulance Service operates vehicles equipped with social media streaming, wi-fi, PlayStation, DVDs, games, books, colouring, sensory lighting, Netflix, iPad Air, Beats headphones, Apple TV and Apple Music…providing endless entertainment for the kids that require transfer and minimising the potential impact of clinical care on their journey. While these phenomenal assets are used for scheduled trips and appointments, these features are not in the frontline Emergency Ambulances.

Without reliable access to fun electronic gadgets and gizmos, Emergency pre-hospital practitioners rely more on the fundamentals of paediatric care to maximise their comfort during the call and transfer – getting down to their level to communicate, utilising effective distraction techniques, optimising pain management and using appropriate positioning (with the help of Mum and Dad) are always good places to start.

How about…

Glove Puppets

Straight from the “International Paramedic Practice of Improvisation”! Some creative practitioners have been known to use ECG dots as eyes. Simple and easy and the kids seem to love them. Plenty of evidence out there to support it too.

Bubbles

Don’t forget” these! We are excellent at ensuring we have our clinical stock checked for each and every shift, but should we have paediatric play / distraction gear checked too? Some astute crews keep bottles of bubbles in their kit bags for the distressed paediatric patients they encounter. Deescalating an upset child, while gaining trust and instilling a fun memory, can add in no small way to positive case outcomes. Importantly, play stimulates and assesses the patient’s level of interaction – what is their level of alertness and are their reacting normally? Now they want to play – excellent, they are obeying commands and blow bubbles just like you do too!

Smartphones

Many practitioners use their devices to pacify patients during the initial assessment, treatments, and transferring onwards to the ED. Having a spare charger for your shift is a good idea. Be up to speed on the latest hit shows, know some characters by name and description, and expect serious brownie points for being able to mimic the voice of their favourite character!

A Bear called Teddy

Another paediatric kit bag essential? An excellent source of comfort and reward for bravery. Where possible and appropriate, be sure to show them how to check Teddy’s oxygen saturations, auscultate his chest, and check his blood sugar level… desensitisation to the experience of clinical assessment, while reducing anticipatory anxiety, can allow you to examine your paediatric patient more thoroughly and pick up subtle objective signs.

Blood Sugars

It might be an idea that whoever is driving on the day are the one to carry out the fingerprick glucose test. This way the child doesn’t have to be in their company immediately afterwards and so it is usually forgotten about by the time they arrive in the ED. Novelty cartoon or superhero plasters will be the most welcome addition to any paediatric kit bag.

Openness and honesty are key in assessing and managing a child. Communication breakdowns lead to loss of trust and a worsening of pain and distress during the prehospital phase of care. Be clear about what you would like to do and what this will involve. This will make them feel better once it’s over. Expect trust to evaporate if you tell them a painful procedure won’t hurt. Use any teddy or toy props available to demonstrate if you can and demystify the process by involving the patient.  Lever off parents as and guide them, when needed, to improve your chances of completing a vital clinical task.

Of course, parental anxiety will increase a child’s anxiety. While having them accompany their child in the ambulance is a legal requirement, treating the parent is just as important as treating the paediatric patient themselves. This might be their first time dialling 999/000, their first sick or injured child, or their first time encountering prehospital services. Be conscious that separation may cause great anxiety, keep them in the eyesight of the patient as much as possible. Encourage the carer to keep talking, telling stories, or singing songs. Providing the best possible care is depends on providing adequate emotional support for an unwell child. These core principles are particularly important to remember in cases involving serious paediatric traumatic injury. Minimising distress can have a huge impact on post-event emotional recovery.

While we are very lucky in Ireland to have an impressive number of medications available to both paramedics and advanced paramedics, non-pharmacological means of providing analgesia to patients should not be underestimated. Managing the prehospital phase of care in a safe, fun, and efficient manner will undoubtedly improve the chances of the journey to the ED, and beyond, going much more smoothly.

Pre-hospital paediatric challenges during COVID-19

Managing unwell or injured children in the prehospital environment was plenty challenging before the COVID-19 pandemic.  Adding PPE into the mix has represented a significant challenge to all healthcare providers and prompted reflection on communication and distraction techniques alike.  The introduction of a facemask, goggles, gown and gloves as contact precautions, has made many adult patients feel uncomfortable. This new work outfit doesn’t lend itself to creating less distress amongst kids either. PPE greatly restricts our ability to communicate with children, removing our core non-verbal expressions, that friendly smile or silly excited face, that we relied on so much before.

How can we tackle this as prehospital practitioners to ease the anxiety that our PPE may cause? Maybe the following points could help in mitigating this problem:

Say it like you mean it

We need to rely and focus more on how we speak to the child by keeping our voice friendly and using our tone, pitch and intonation more to convey excitement. How your message is heard might be different when wearing goggles vs visor so do test this out on a colleague and get feedback when trying out different PPE.

Smile with your eyes

Again, practice makes perfect! This can be difficult if your eye protection keeps fogging but being aware of it will help you anticipate and adjust your strategy as needed.

Show yourself at your best

Perhaps having a printout of a picture pinned to your PPE might help. At least the child will know what you really look like. A mini collection of silly faces would be ideal of course.

It is still Halloween, right?!

Costume wear is now a year-round thing, apparently. This has gotten a few laughs and a few eyerolls too for good measure. Any form of icebreaker that works is a good one!

Cartoon Visors

Creating memories while providing care. Some paediatric departments have sourced visors with cartoon characters and animals on them. Others have taken to showing off their creative side! It has shown to comfort the children and promoted good interactions whilst the healthcare workers go about their job assessing and treating their patient. Prizes should be encouraged for champion efforts!

Creating magical memories while providing excellent prehospital care is achievable with good preparation and acknowledgement of the unique elements involved in transporting the distressed, sick, or injured child.

The journey really does make the destination!

References

Oulasvirta J, Pirneskoski J, Harve-Rytsala H, Laaperi M, Kuitunen M, Kuisma M, et al. Paediatric prehospital emergencies and restrictions during the Covid-19 pandemic: a population-based study. BMJ Paediatrics Open. 2020;4:1-8.

Cowley A, Durge N. The impact of parental accompaniment in paediatric trauma: a helicopter emergency medical service (HEMS) perspective. Scand J Trauma Resusc Emerg Med. 2014;22:32.

Samuel MD N, Steiner IP, Shavit MD I. Prehospital pain management of injured children: a systemic review of current evidence. American Journal of Emergency Medicine. 2014.

Jones J. Analgesia for Acute Care. Children’s Hospital Ireland; 2019. p. 5.

StatPearls. 2020. https://www.ncbi.nlm.nih.gov/pubmed/32119430

Cartoon visors cheer young patients hse.ie2020 [Available from: https://www.hse.ie/eng/about/our-health-service/making-it-better/cartoon-visors-cheer-young-patients.html.

Bumbleance – The Children’s National Ambulance Service 2020 [Available from: https://www.bumbleance.com/?doing_wp_cron=1611411187.1207330226898193359375.

Fogarty E, Dunning E, Koe S, et al. The ‘Jedward’ versus the ‘Mohawk’: a prospective study on a paediatric distraction technique. Emergency Medicine Journal 2014;31:327-328.

Head injury – the 4-hour observation clock…

Cite this article as:
Patrick Aldridge. Head injury – the 4-hour observation clock…, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32331

You have just seen a 3 year old boy who, one hour earlier, was running along the street, fell over and hit his head. There was no loss of consciousness, no vomiting and he’s running around the Emergency Department (ED) completely unaware of ‘social distancing’ practices. On examination he’s got a small forehead abrasion but nothing else concerning. The parent was initially concerned (so came to ED) and now wants to go home.

You think this is sensible and speak to your senior who advises that you observe him for 4 hours post-injury. You think he’s got a ’trivial head injury’ with no risk factors and ask why they need to wait a further 3 hours in ED. ‘That’s what we do’ comes the reply…

Paediatric head injuries, arguably, make up a significant proportion of children attending hospital. It’s been suggested and subsequently shown  that a fair proportion could be sent home by a competent nurse at triage even during a worldwide pandemic…

PREDICT have done some wonderful work recently with their ‘Guideline for Mild to Moderate Head injuries in Children – Algorithm’ (2021) – answering questions I have often wondered myself. However, I personally feel the two most ground-breaking of all these recommendations appear to have been glossed over. This may be because they are soooo obvious, simplistic and pragmatic but that makes me love them even more…

Trivial head injuries

Children with trivial head injuries do not need to attend hospital for assessment; they can be safely managed at home’. 

  • How many children in your own experience fall (boom boom) into this category and attended for review?
  • How much money and time (the families and the health services) could be saved if these children stayed at home?

A lot’ would be the assumption for both of these questions. However, this is currently an evidence void in need of answers.

Extended observation OR discharge

It is made very clear that children who do not fall into one of the assorted risk categories have ‘no need for observation’ aka discharge home.

  • No need to stop, pass go or take up sacred ED seating until 4 hours after their medically innocuous injury (agreed, to a parent an injury may not have been innocuous but by medical head injury rules it is).
  • The child stays for no longer than it took to see and assess them. This may be a hard practice to change in many ED’s.

4 hours

How many paediatric head injuries in your own clinical practice do you or someone else say/write the immortal words “Observe 4 hours from injury’? 

Do all the children observed for 4 hours across the world require this?

How many children, that you have seen in your practice, have deteriorated?

Why does this practice exist and what is the evidence base?

Well, there is a clear consensus on who should be observed for 4 hours from injury. In the UK, the National Institute for Health and Care Excellence (NICE) Head injury: assessment and early management CG176, 2014 – – suggests children with the following require observation for at least 4 hours from the injury:

  • Loss of consciousness lasting more than 5 minutes (witnessed)
  • Abnormal drowsiness
  • Three or more discrete episodes of vomiting
  • Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist or vehicle occupant, fall from a height of greater than 3 metres, high-speed injury from a projectile or other object)
  • Amnesia (antegrade or retrograde) lasting more than 5 minutes

The latest PREDICT guideline is slightly more prescriptive (especially around age groups) and suggests those with the following risk factors need observation for up to 4 hrs…

But why 4 hours? Why not 3 hours, as someone previously suggested with wheeze?  Why observe them at all and just CT the lot? Well, at the end of the day this is all about risk stratification. A CT scan is not without risk (that small thing called radiation?) and the actual number of abnormal CT’s (ciTBI/TBI-CT) has been shown to be quite low (2.3%) in a large group (19 920) of children with head injuries.  We want to scan those children deemed ‘high risk’ who are more likely to have an abnormal scan not those deemed medium/low risk who are less likely to have an abnormal scan.

The evidence for 4 hours

What evidence is 4 hrs observation based on? Umm, not a lot. Like many practices in medicine, it’s based on consensus and pragmatism. Many institutions follow a 4 hour target for patients to be admitted or discharged from the emergency department. Children with asthma/wheeze seem to require inhalers every 3-4 hours until discharge too and there are, no doubt, countless other examples within the medical world. Four hours observation post-injury is the consensus view and currently established practice from experts with specialist knowledge in this field. It probably came about when you had to sell your kidney to the Radiologist to get a CT scan and radiation doses delivered per scan were a lot higher than present ‘modern’ machines. It was easier to just observe the child and if they deteriorated you could then more easily argue for a scan. This is my best guess but is probably not far from the mark. Could this time be shortened in these at risk groups? Probably. But trying to research this would, no doubt, be an ethical minefield.

The clock is ticking…

There are a small select group of children with head injuries who require a period of observation post-injury, as suggested by national guidelines, decision rules and clinical gestalt. I would argue many children in ED’s across the world that are observed for ‘4 hours post-injury’ do not fall into any of the categories mentioned above and the root cause for observation being clinician preference based on defensive or outdated practice. This is understandable in those who see children infrequently, but should this be accepted going forward?

In the COVID-era we are living through, I believe there will be an increased focus on reducing unnecessary hospital footfall, ED crowding and time in a potentially risky environment. One potential quality improvement project would be to look at your own institution – how many children stay ‘4 hours post-injury’ and how many really needed to…?

Treating big people (adults) with COVID…

Cite this article as:
Vicki Currie. Treating big people (adults) with COVID…, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32313

Reflections from a Paediatric Registrar

‘I won’t touch the feet- I’ll do ANYTHING else’. Avoiding adult feet was one of the reasons I chose a career in paediatrics was one of my responses when I found out that the PICU I was working in was being converted to an adult COVID ITU. I chose paediatrics as a career for so many other reasons, but this was the first thing that popped into my head. 

The world has been turned upside down by this pesky virus.If one year ago you would have told me that I would be looking after adult ITU patients with this new disease I would have refused to believe it. For so many, working lives have changed, roles have been adapted or learnt at lightning speed and working outside your ‘comfort zone’ has become part of the ‘new normal’. 

After a few weeks of looking after adult COVID ITU patients on a PICU I have had some time to reflect on how different things have been. Some things will change my practice forever, some of the big differences in ways of working between those looking after big and littler people. As a general paediatrician doing a stint on PICU, intensive care was new but the steep learning curve after 6 years of looking after ‘littler people’ was even steeper. 

After working closely with adult ITU team members for the last few weeks, we have had a chance to see how each other works. It has proven an opportunity to learn form each other. There are a lot of similarities, and a few differences. There are also some things which both sides can hopefully take forward into our future practice. 

Handover

As paediatricians we LOVE a handover- in some places I have worked it can feel like handovers take over the entire day. One of the biggest differences is the way the adult team do handover.  It seems so much more business-like – especially at the end of a nightshift. There’s no messing around. Any issues? Who is stable or not\? Salient points only. The paediatrician’s in the room added their own twists ‘Had the family been updated? What had they eaten today? What did their poo look like? And how had they slept?’

After a few weeks a happy medium had been found. There was a nice balance achieved between getting the night team off on time, and reducing information that could be found out easily on the morning round whilst including some of the more holistic aspects of care.

Communication with relatives and patients

Those who look after children are used to having to flip between conversing with patient and family. This is a great advantage. We are constantly thinking about updating relatives and keeping family informed. Using FaceTime allowed us to communicate with relatives. They could see their loved ones when they could not be with them. 

The adult team, who have had much more practice with the difficult conversations, seemed to be so slick, having the same realistic and honest conversations. It was business-like and well-rehearsed. Delivering the information succinctly meant that time could be spent talking to more families. 

Patients told me that the way medical and nursing staff spoke with them was different when they made the move to the PICU. Many patients told me that they could tell we were used to dealing with children. The way we spoke was cheery, informal, and most importantly, personal.  I wonder if this was always what they wanted though, especially when delivering difficult news. With the help of the adult ITU team, a delicate balance was maintained. 

Attachment

The adults with COVID in the ITU seem to be long- stayers.Having the same set of patients for a few weeks is great in some ways; and hard in others. Often, with PICU patients, there can be prolonged stays but one of the things the adult team found hard was the attachment they formed to their patients  from seeing them shift after shift. Couple this with the need to look after so many patients on adult ITU , whilst rotating through different pods. On PICU it was one area with the same patients.

On the plus side, you knew the patients REALLY well. You understood things in detail things, like what ventilation strategies they responded to- or didn’t. You knew what previous infections they had been treated for and you knew what families had been told. The downside: you became more attached. It was harder, emotionally, when a patient you knew deteriorated or didn’t better. I wonder if we carry more of an emotional burden in paediatrics because of this. Any doctor will get emotionally attached to certain patients. But are we more likely to do so by seeing fewer patients but more often than our adult counterparts? 

Teamwork

Without question, the amazing paediatric ITU nurses stepped up to the challenge of looking after grown-ups. The incredible camaraderie, between nursing staff, paediatric doctors and the adult ITU team, proning the most unwell patient at 2 in the morning is something which should be bottled up and stored for reuse when this is all done. Truly working together to pull, not only the patients but also each other through the difficult shifts. 

The adult ITU team helped whenever they were needed. They supported us and also credited us paediatricians on many occasions for out strict attention to detail – with anything from charting blood results to charting fluid balances. 

This has been an eye-opening experience. It has been challenging, terrifying, devastating at times. It has also provided opportunities to work with amazing colleagues and witness teamwork between medical and nursing staff like never before. It has been a unique opportunity for adult and paediatric teams to work side by side and siphon bits of each other’s practices. 

As for the feet- it wasn’t as bad as I expected- but I drew the line at a request for a foot massage!

An excellent resource for those working on the front line who are struggling or just looking for that little bit of extra support…

https://www.rcpch.ac.uk/key-topics/your-wellbeing-during-covid-19-pandemic