Reflect on your competence in managing paediatric problems

Professor Ruth Chambers sets a reflective challenge to test how confident you are when managing paediatric health problems

Are you confident at managing common paediatric conditions? (Photograph: SPL)
Are you confident at managing common paediatric conditions? (Photograph: SPL)

What to do
Read each of the 10 scenarios below and ask yourself how confident you are that you could manage the child and if you know whether you should refer them to outpatients or admit them to hospital.

For each scenario, complete the right-hand column of the table and indicate on a scale of 1–5, where 1 = excellent and 5 = poor, how you rate your ability or confidence. The purpose of this exercise is to reflect on whether you are as competent and confident as you should be when the diagnosis or management plan is uncertain.  

If at the end of the exercise you feel that your knowledge and skills could be improved, you could attend a CPD course for GPs in common paediatric conditions, or organise a skills workshop yourself, along with paediatric consultants, for local GPs. 

To take this exercise a stage further, review 10–20 recent paediatric outpatient referrals and/or hospital admissions where you referred or had recently provided care for the child and discuss these cases with another GP.

Then reconsider your self-rating of your competence and confidence in the light of the peer review and discussion of your referrals or unplanned hospital admissions. File everything in your CPD organiser.

Time required
Spend an hour of CPD time completing this reflective challenge. Log your work in your CPD organiser.

The challenge

1. Feeding problems in infants
Jason has always been on the small side. When weighed by the health visitor yesterday he had fallen below the third percentile for the first time.

The health visitor has written you a note to say that the mother is depressed according to the Edinburgh scale, and stopped breastfeeding four weeks ago when Jason was two months old.

How do you rate your ability to: Scale 1–5 
Assess a baby’s failure to thrive.  
Understand the implications of the baby dropping below the third percentile.  
Interpret the Edinburgh postnatal depression scale.  
Gauge the extent of the baby’s failure to thrive so that you can decide whether you need
to refer the baby to outpatients or admit to hospital.
 


2. Child protection/tonsillitis
Eight-year-old Poppy has returned with her fourth episode of sore throat in the last nine months. Her throat is moderately red and she has a few palpable lymph nodes around her neck. You note her temperature is 38oC and that there are a couple of fading bruises at the back of her neck which could be finger marks.

Poppy has seen different doctors in the practice and out of hours service. Her mother demands that you prescribe an antibiotic and refer Poppy to the hospital to have her tonsils taken out, saying that she cannot afford to lose time off work caring for Poppy at home when she is poorly.  

How do you rate your ability to: Scale 1–5
Take a holistic history that includes Poppy’s growth and development, general wellbeing, throat symptoms and family situation.  
Discuss that an antibiotic is not justified for a viral throat infection in a way that convinces the mother.  
Convince the mother that referral to outpatients with a view to tonsillectomy is not warranted (low priority referral; need five episodes of tonsillitis per year).  
Advise about self-care for sore throat.  
Assess whether bruising on Poppy’s neck may indicate abuse; conduct a full examination and initiate the child protection alert system if warranted.  

3.  Diarrhoea in a five-year-old
A five-year-old boy attends with his 17-year-old sister, with a two-day history of diarrhoea. He is fractious and seems to have colicky abdominal pain.

On questioning you find that he has been constipated for several weeks, with his bowels open only every few days; he’s been pretty miserable for those few weeks. 

How do you rate your ability to: Scale 1–5
Take a holistic history that includes his growth and development, diet and nutrition, gastric symptoms, family situation.  
Assess his acute condition of diarrhoea in context of a few weeks of constipation.  
Advise the boy’s sister about self-care for diarrhoea and constipation.  
Communicate with a five-year-old.  
Gauge the extent of family support and parental /carer competence that they can be trusted to monitor the child’s acute state and hydration.  

4.Non-febrile fit
You see Anne (aged six years) in the surgery when she is carried in by her father who has collected her from school because one of the teachers thought that she was having a fit.

You assess Anne and find that her temperature is 36oC, she can answer all your questions, move all limbs and her reflexes are normal.

You ask for more information and it seems as if she jerked one leg for a few minutes, was not incontinent and may have been unconscious for a few seconds.

How do you rate your ability to: Scale 1–5
Take a full history to distinguish a fit, a faint, a vaso-vagal attack or breath holding.  
Judge if such a child needs an acute admission to hospital, an outpatient referral or simply GP management.  
Be the primary clinician managing medication and follow up if Anne turned out to have epilepsy and was discharged from follow-up at the hospital.  

5. Eczema
Lucy’s mum complains that Lucy, a three-year-old girl, is always scratching and her sleep is often disturbed. She has tried aqueous cream which hasn’t helped much. You look at her skin. She has obvious eczema. 

How do you rate your ability to: Scale 1–5
Enquire about possible allergens that provoke the eczema.  
Prescribe effective topical therapy to control the eczema.  
Prescribe night sedation to reduce nocturnal scratching.  
Recognise infective eczema and judge when it is appropriate to use topical or oral antibiotics.  
Advise on self-care to avoid trigger factors and improve the skin.  

6. Viral wheeze
Jag has been short of breath at nursery school today and his grandmother, who has brought him in, had to collect him early.

You examine his respiratory state by looking for rib recession, checking his heart rate, oxygen saturation, and examining his throat and ears. Listening to his lung fields you note wheeze in this four-year-old boy.

How do you rate your ability to: Scale 1–5
Confirm if Jag has asthma.  
Rate the oxygen saturation level of a child and act on the information.  
Manage acute asthma attack in a child (for example, treat with inhaled beta-agonists in the surgery and assess the response).  

7. Newborn check
Mahmood is aged three days and you are performing the newborn check at the surgery. He came out of hospital two days ago and his parents seem happy. 

He’s feeding well, has normal muscle tone, is responsive, and examination is fine – except you are unsure about the presence of a heart murmur.

Before completing the examination you go back and listen again and hear a quiet murmur which you think is systolic in nature.

How do you rate your ability to: Scale 1–5
Recognise a heart murmur in a newborn baby.  
Assess whether Mahmood needs an emergency admission or outpatient check or follow up by you as GP.  
Relate your uncertainty to the baby’s parents without alarming them inappropriately.  

8. Pyrexia of unknown origin
Tina’s mum has brought her to the doctor’s because she’s not been well for two days and is off her food. You examine the two-year-old girl and find her temperature is 39oC, her throat is red, lungs are clear, respiratory rate normal, and she has no rash.

Her mother tells you she gave Tina paracetamol about 30 minutes ago. Tina wriggles off her mother’s knee and starts capering around the surgery grabbing at the things on your desk.

How do you rate your ability to: Scale 1–5
Assess a febrile child and weigh the relative risks of unnecessary hospital admission or parents who are not capable of responding if a child deteriorates.  
Judge how to manage a child with a high temperature in safe and effective way.  
Advise on self-care and dosing frequency for paracetamol and ibuprofen in babies and children of different ages.  

9. Urine infection/abdominal pain
Rob is back again with tummy pain and has wet himself twice today already. You examine him and find loin tenderness. His mother comments that his urine smells.

He has had a similar episode once before a few months ago, but it was a Friday night so he was given an antibiotic for a presumed urine infection but no urine testing seems to have been done.

How do you rate your ability to: Scale 1–5
Organise initial investigations for UTI; know when to organise a renal ultrasound scan in line with NICE guidance.  
Recognise and deal appropriately with asymptomatic bacteruria.  
Recognise serious underlying pathology associated with urine infection.  
Prescribe antibiotics at an appropriate dose/time period for a child who is acutely ill with high fever associated with UTI.  
Prescribe antibiotics at an appropriate dose/time period for a child with recurrent troublesome UTI.  

10. Ear infection
Lily’s mum is one of your most frequent consulters. She’s brought Lily to evening surgery because of the pain in her ear. Looking at her notes you see it is the sixth time this year that she has been to see the GP with a sore throat or ear pain and she was sent into hospital last winter with an ear infection.

Her Mum is demanding that you give Lily antibiotics. Examining Lily you find that this four-year-old girl has a temperature of 38oC, both ear drums are very red, her throat is red, lungs are clear, respiratory rate is normal and she seems reasonably well. 

How do you rate your ability to: Scale 1–5
Assess a febrile child with ear pain and inflamed ear drums and decide whether antibiotics are justified.  
Advise the parent/carer how to manage a child in safe and effective way when they have a high
temperature.
 
Explain the natural course of ear infection and reassure parent/carer that there is no need to seek urgent assessment at hospital (by A&E or admission).  
Decide when it is appropriate to arrange a hearing test in a child with recurrent ear infections.  

 

Reflect on this article and add notes to your CPD Organiser on MIMS Learning

  • Contributed by Professor Ruth Chambers, a GP in Stoke-on-Trent and an honorary professor at Staffordshire University. With acknowledgements for advice from Dr Andy Spencer, consultant paediatrician University Hospital North Staffordshire

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