Are the kids all right?

Dr Craig Brown offers a trainee’s perspective on dealing with suspected child abuse and neglect. 

JUNIOR doctors can experience many frightening firsts – the first day on the job, the first night shift (hopefully not the same as the first day on the job), the first cardiac arrest, the first time having absolutely no idea what to do in a situation. The list could go on and might also include the first time you come across a child protection issue.

A number of recent high-profile cases in the media, including that of Baby P, have kept child protection in the forefront of our attention. Such cases can look daunting to any healthcare professional and in this article I am going to discuss some of the important factors regarding child protection from the perspective of a junior doctor. Where might it crop up in practice? What signs commonly raise suspicion? What should be done if you suspect child protection issues? I will also identify some sources of guidance that can be useful when considering child protection.

Troubled families

In the document 0-18 years: guidance for all doctors, the General Medical Council highlights why child protection is important: “Early identification of risks can help children and young people get the care and support they need to be healthy, safe and happy, and to achieve their potential.”

Child protection issues may present in a number of contexts – and not just when you are working in paediatrics or paediatric emergency medicine. In the AMAU (acute medical assessment unit) you may get a parent who presents intoxicated or with an overdose, or in general practice you may get children who attend looking malnourished or unkempt. Just in asking the question “Where and how are the children?” for all patients you will find that there are a number of families out there needing additional support. The GMC requires doctors who work with children or young people to have the knowledge and skills to identify abuse and neglect. GMC guidance states:

“Doctors play a crucial role in protecting children from abuse and neglect. You may be told or notice things that teachers and social workers, for example, may not. You may have access to confidential information that causes you to have concern for the safety or wellbeing of children.

“Doctors should always act in the best interests of children and young people. This should be the guiding principle in all decisions which may affect them. But identifying their best interests is not always easy. This is particularly the case in relation to treatment that does not have proven health benefits or when competent young people refuse treatment that is clearly in their medical interests. There can also be a conflict between child protection and confidentiality, both of which are vitally important to the welfare of children and young people.”

Knowing the red flags

Child protection issues fall into various categories including physical, emotional and sexual abuse as well as neglect. Just as certain features in the history or examination of a patient with, say, back pain can act as ‘red flags’ pointing towards suspicious disease, so too with child protection. Red flags and pattern recognition can lead us to suspect that something is not quite right.

Concerns may arise from the patient history. Consider the following:

● “He fell down the stairs” – this from the mother of an 8-month-old. Obviously this is an implausible story if the child is not crawling or walking.

● “He fell off his bike a week ago” – delayed presentation seeking help for medical illness.

● “She was at her gran’s,” said to the triage nurse and then to the doctor: “She was upstairs playing alone” – inconsistency in history.

These are just a few examples of clues from the history that there may be more going on than first appears.

Particular features and patterns indicating child protection and welfare issues can also emerge on examination. These include unusual bruise patterns compared to common bruising for age and stage of development (for example babies aren’t mobile therefore shouldn’t generally bruise by bumping into things), malnourished and unkempt look, markings consistent with non-accidental injury such as being struck with a belt, hand or rod, or cigarette burns. It is important to remember the differences between adults and paediatric populations in terms of anatomy and physiology, i.e. children have “springy ribs” therefore serious internal trauma may have occurred without apparent broken ribs. This highlights the importance of a thorough physical examination and documentation in patients for which child protection may be an issue.

Making the call

What do you do if a potential child protection issue arises? Don’t panic – there is guidance available to junior doctors and you will not be expected to face the dilemma alone.

Remember that you must act in the child’s best interests and the first thing to do is discuss the case with your consultant or another senior member of the team. They will often know the best way to proceed, what the main issues are and will be able to re-evaluate the history with the benefit of greater knowledge and experience of the red-flags and pattern recognition relevant to child protection.

Other useful sources of help are the local child protection team – a mixture of social workers, paediatricians and other multi-disciplinary team members who can often provide further information on particular families and children that are known to them, or just offer some advice where needed. The child protection team and/or your consultant will be able to advise you on what to do with the patient at the present time, what to say to the parents/guardians and how best to document in the hospital notes any relevant discussions.

Disclosure and confidentiality

GMC guidance also offers a number of practical points and advice in regard to disclosure and confidentiality in potential child protection cases. It states:

“Your first concern must be the safety of children and young people. You must inform an appropriate person or authority promptly of any reasonable concern that children or young people are at risk of abuse or neglect, when that is in a child’s best interests or necessary to protect other children or young people. You must be able to justify a decision not to share such a concern, having taken advice from a named or designated doctor for child protection or an experienced colleague, or a defence or professional body. You should record your concerns, discussions and reasons for not sharing information in these circumstances.”

This is important advice, empowering the doctor to make the safety of the child our first concern even if confidential information has to be shared. It is worth mentioning here that what is shared must be proportionate and relevant and it is often worth discussing what you will share with somebody more senior and seeking further advice if necessary.

Other guidance and support

The Scottish Government currently has a programme called ‘Getting it right for every child’ (GIRFEC) which offers a set of values and principles with multi-agency emphasis and includes ‘Keeping children and young people safe’. GIRFEC provides guidelines for all people working with children and young persons in a multi-agency approach with a standard framework for discussing child welfare issues. This allows information sharing and action between agencies in terms of child protection issues (see below for link to more information).

Another way of becoming better prepared for dealing with child protection is by attending local or national courses in child protection, for example ‘Safeguarding children: Recognition and response in child protection’ available from the Advanced Life Support Group (ALSG).

Child protection issues can be frightening and uncomfortable for the junior doctor to deal with and may arise in unexpected places but there is support out there and it is our responsibility to act on any concerns we may have. Recognising the red flags in history and examination findings, thinking of the safety of the child as our first concern and having some knowledge of what to do and of the guidance available can make the issue much less daunting and will enable early identification of children who need further support to become healthy, safe and to achieve their full potential. Resources

● ALSG Safeguarding Children, Recognition and Response in child protection – www.alsg.org

● National Society for the Prevention of Cruelty to Children (NSPCC) – www.nspcc.org.uk

● The Scottish Government GIRFEC programme

Dr Craig Brown is a CT2 in Emergency Medicine at the Aberdeen Royal Infirmary