This month‘s newsletter has a link to a good parent information leaflet on Medically Unexplained Symptoms. Also a few eyes peeping out of the newsletter – red ones of Kawasaki’s with a note on atypical presentations and swollen ones of periorbital cellulitis which are usually treatable with oral antibiotics. The overlap between ASD and ADHD and grieving children “puddle-jumping”.
October’s edition is joint again this month on account of my right radius being fractured and its being too difficult to type and format text boxes with just my left hand… I am obviously not quite as good at ice-skating as I thought I was. All the topics this month should be of interest to both the ED and primary care teams anyway: a paper on paediatric early warning scores, the start of our neurodevelopment series, an update on services for bereaved children and their families and some useful links on the subject of head-lice.
One of our current paediatric SpRs, Dr Anil Krishnaiah, has been looking at some papers on the various paediatric warning scores that are in existence. Here is his summary of a paper from Sunderland in 2008:
Emerg Med J 2008;25:745-749 doi:10.1136/emj.2007.054965
The PAWS score: validation of an early warning scoring system for the initial assessment of children in the emergency department
Existing UK paediatric early warning scoring systems (PEWS) were developed mainly for hospitalised patients and may be less useful for initial assessment in the ED. Until recently these are mainly used to look at admission to the HDU and PICU and trying to produce a system which would recognize those children at risk of admission.
Assessment of paediatric patients is complicated by the range of normal parameters in different age groups. Inexperienced staff may find it difficult to interpret the significance of physiological readings over a wide range of ages.
This pilot study was conducted in Sunderland to validate the scoring system by performing a retrospective analysis of 50 consecutive children attending the ED who required admission directly to the paediatric intensive care unit (PICU). A control group of 50 consecutive children who were admitted from the ED to the general paediatric ward within the same time period was also identified from the ward admission book. They compared the Paediatric Advanced Warning Scores (PAWS) scores between the two groups in order to see whether the PAWS chart would be able to identify those children in need of admission to a critical care area. Primarily the aim of this study was to design and validate a scoring system to identify children attending the ED in need of urgent medical assessment and appropriate intervention. At a trigger score of 3, the PAWS score was able to identify those children requiring admission to the PICU with a sensitivity of 70% and a specificity of 90%.
This pilot evaluation demonstrates that the PAWS chart shows promise as a ‘‘rule-in’’ tool for PICU admission.
Since the introduction of the 4 hour target in the ED, departments have been under increasing strain to assess, treat and admit patients (if required) as quickly as possible. Few studies have been designed to identify if the PEWS score could be used as a triage tool, to detect those patients who will need admission and therefore speed up the process of admitting children to the ward.
Dr Anil Krishnaiah, Paediatric SpR
My problem with this paper, Anil, is that I want a tool that will “rule-out” predictably ie. one that will tell me reliably which ones I am safe to send home – without overloading the system with too low a threshold for admission. Anyone got one of those?
It is not unusual for us to see children in clinic with non-specific ailments who have been bereaved and are still trying to come to terms with their loss, sometimes years later. I am sure it is not uncommon in General Practice either. Whenever a child dies at my hospital I worry about how the siblings are going to feel. Children experience death differently according to their age and stage. There is some good advice on “Explaining death to children” and some other useful links at www.bbc.co.uk/health/emotional_health/bereavement/bereavement_childtalk.shtml. www.childbereavement.org.uk/For/ForBereavedFamilies/SuggestedReadingandResources lists some very helpful reading material for all ages of bereaved people.
This month I have been across to the Margaret Centre at Whipps where our Psychological Support Service (PSS) is, to try and get a clearer idea of what sort of support there is in Waltham Forest for bereaved children and their families.
The Zig Zag Children’s Service accepts referrals from health professionals of children aged 3-11 in Waltham Forest with pre- and post-bereavement difficulties. This would include children with a life-limiting illness themselves or those with a family member with a life-limiting illness as well as those who have been bereaved. There is also a service for bereaved young people (11-17yr olds) and adults. Contact the PSS on 0208 539 5592 or by post at The Margaret Centre, Whipps Cross Hospital, Whipps Cross Road, E11 1NR for further information.
They do not offer crisis counselling but there is no stipulated amount of time a family or individual has to wait before being offered an appointment. In the ED we refer the family of a child who has died under our care to this service straight away, a letter is then sent to them suggesting that they ask their GP for a referral if they wish to make use of the child bereavement service. You can download their referral forms here:
You may be reading this from outside our region. Nationally I can recommend the Child Bereavement Trust which is a UK charity supporting families when a child dies or is bereaved. It also trains health professionals to deal with the effect that a bereavement has on a family and indeed on us, the health professionals. http://www.bereavement.org.uk/home/html_index.asp?p=222 seems to have information on other bereavement services in London. Do leave a comment below if you want to recommend any other services you are aware of.
Some of the Zig Zag staff have added comments below which I think all of us who come across bereaved families will find helpful.