Ethics, law and paediatric medicine

Medicine is practised within an ethical and a legal framework. Doctors must obtain the broad consent of their patients before treatment begins, and tell them of their choices and the material risks inherent in treatment. Where children are the patients, it is their parents or guardians who must give their consent, unless the situation is an emergency or the children have been removed from parental custody and care. Today, mature teenagers may consent to their own medical treatment. Doctors must protect their patients' confidential information, however acquired. There are very limited exceptions where confidential information may be revealed, and a few where revelation is mandatory. Effective communication between doctors and their patients, or their parents, is of signal importance.     

Child and adolescent obesity

Obesity and overweight are a pandemic that has been building since the 1980s. The causes are multi-factorial, and the solutions are ultimately political. The consequences, however, are medical. Admissions to hospital with obesity-related illness increased 4-fold between 2000 and 2009, and paediatricians regularly see comorbidities in their clinics and on their wards. Broaching the subject of obesity and overweight when we are talking to young people and their families is difficult. Detailed history and examination, in a systemic and non-judgemental way can identify these comorbidities so that they may be treated. Not to do so is a missed opportunity. Interdisciplinary working can support the child and their family to manage their weight. This article offers some personal experience and practical advice for health care professionals who want to make a real difference to the children in their care.     

Thinking about Head Injuries in Children

The number of head injuries in children is rising annually and the number is by no means insignificant. Although the relatively small number of severe injuries has been acknowledged to produce profound and long-term effects, the majority of injuries are comparatively mild. In the past, mild injuries have not been thought to produce significant cognitive or psychological sequelae. This view is now being challenged, suggesting that professionals need be aware of the subtle sequelae that can effect children's functioning in the home and classroom. Children, once seen as having an advantage over adults with regard to their recovery, may in fact be more vulnerable and have poorer prognoses. Adequate rehabilitation provision for the unique complexity of problems following head injury is rarely met by Health and Education Authorities. Children with head injuries are neither sick nor mentally handicapped, and they need a rehabilitation service that fits their special needs. Finally, little within the literature of children's head injury has been written on children's own experience of their predicament. One notable exception is the work of McCabe and Green (1987). Children are often acutely aware of their difficulties once they begin to recover, mourning the loss of past skills and abilities, and the loss of freedoms they once had. Yet they are only partially able to understand how their world is so different. Frustration, fear, anger and sorrow are not uncommon feelings expressed either verbally or through their behaviour. In thinking about head injury in children it is their experience of this trauma that must be foremost in our minds.     

Diagnostik und Therapie von Aufmerksamkeitsstörungen

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common reasons for parents to seek help from child therapists or pediatricians. Parents are often notified by the school, if their child cannot follow lessons properly and disturbs other pupils during their work. Often, the report card contains corresponding remarks. Conflicts during homework are also common. Children with ADHD are unable to focus their attention and/or are hyperactive and impulsive. In order to select a proper intervention, it is necessary to specify the presented subtype using neuropsychological tests and to determine the severity of the disorder.     

Aspects psychologiques de la drépanocytose en pédiatrie

ObjectiveAnalysis of how subjects with sickle cell disease experience their disease. More specifically, we are interested in the impact of their condition, their adherence to treatment and their emotions concerning their illness and their desire for therapeutic education.MethodologyWe submitted the adaptation of the “Brief Illness Perception Questionnaire” to subjects aged from 7 to 19.ResultsThe sample consists of 45 subjects, the majority of whom come from the Congo. Half of our subjects come from the first generation of migration. The majority of subjects consider themselves to be in good health. The impact of the disease on their daily lives at home is low and they feel they have a good understanding of their condition. Overall, they experience few variable emotions when thinking about sickle cell anemia. These emotions are correlated with migration, and they find it difficult to associate with their disease.ConclusionsSickle cell disease is experienced rather positively, but severely affected subjects are more psychologically distressed. In addition, the sadness, the anger and the fear that the subjects experience about the disease are correlated. Migration also has a significant negative effect on the way our subjects are affected by their disease. Sickle cell disease remains difficult to imagine for those affected. It is essential to continue the work of societal information, in Belgium as well as in Africa.     

Malignant arterial hypertension and Ito's hypomelanosis

Hypomelanosis of Ito is a rare neurocutaneous syndrome and several abnormalities are often associated. Malignant hypertension and polycythemia are very unusual; their occurrence in a 12 year-old girl is not related to any classical etiology and their place in Ito disease is discussed.     

Consent for the examination or treatment of teenagers

Examination and treatment of any patient requires their consent. This may be verbal or written and involves giving adequate information and ensuring that this is understood. The patient must consent freely, may withdraw consent at any time, and should be competent. At 16, young people are competent to consent, but their refusal of treatment may be overridden by their parents or the courts until they are 18. Below 16, young people may be competent, and this is a judgement for the clinician to make using recognized criteria. Any treatment should be in the best interests of a young person. Teenagers value honesty and appreciate involvement in decisions about their care. There is a balance between empowering young people to make adult decisions and protecting them. It is good practice to offer to see young people and their parents separately. There is scope for honest disagreement in applying these principles.     

A Phenomenological Exploration of the Role of Digital Technology and Media in Children’s Subjective Well-Being

This phenomenological study examined children’s subjective well-being (N = 22) in rural and urban areas of the Midwestern United States, as part of a larger multinational comparative qualitative study of children’s well-being. Children (8 to 12 years old) completed an extended, semi-structured qualitative interview and mapping exercise that prompted them to draw and describe the scope, aspects of, and influences on their subjective well-being. Phenomenological analyses of children’s responses were conducted to identify aspects of their contexts, including their use of digital technology and media (DTM), that were linked to children’s subjective well-being. Two main themes emerged; 1) children reported that DTM is not essential to their well-being but 2) DTM is important to their well-being. Six sub-themes emerged under the DTM is important theme. Children reported that DTM is rewarding and valuable to them, and it contributes to their life satisfaction. They also reported that DTM use enhances their connections to others, self-acceptance, autonomy, and competence and skills. Results are discussed in regards to children’s self-identified hedonic and eudaimonic aspects of their well-being, and are placed within a contextual framework of child well-being. Implications, strengths, and weaknesses of the study are discussed.     

Manufactured Environmental Toxins and Children’s Health: An Evidence-Based Review and Anticipatory Guidance

Manufactured environmental toxins (METs) are a global problem, causing or contributing to health maladies across socioeconomic classes. This article is intended to educate pediatric nurse practitioners (PNPs) about select METs and their effects on the health of children. Infants and children are especially vulnerable to the effects of METs because of their physiological and developmental characteristics. Moreover, PNPs are obligated to be informed about METs and share their knowledge with families via anticipatory guidance so that caregivers can make informed decisions. PNPs should advocate for proper regulation of METs and prevention of their harmful effects.     

Munchausen by proxy: presentations in special education

Munchausen by proxy is a disorder in which a child is victimized through a form of child abuse called pediatric condition falsification (PCF). PCF has been documented for psychological and psychiatric conditions including one such form presented here in which educational disabilities are the focus of falsification. Parents meet their own self-serving needs through "impostering" as good mothers. This maternal mental disorder is called factitious disorder by proxy. This article presents a series of cases in which children have PCF that primarily consists of educational disabilities. Characteristics of the children, their mothers, and their families are outlined and outcomes for the 9 children in the sample are discussed. Guidelines for identification of children with PCF in educational settings are provided, and special guidance is offered in differential diagnosis.     

Sudden infant death syndrome. Acute loss and grief reactions.

This paper provides guidelines for health professionals in dealing with the particular grief reactions experienced by families of babies who die of the sudden infant death syndrome (SIDS). Time and privacy are needed to work through the anguish of grief. However, the SIDS families who cope best are those who are also guided throughout their grieving process by a caring physician who is comfortable in his supportive role. It is hoped that through an increased understanding of acute loss, the medical community will be better able to help SIDS parents and their surviving children regain their psychologic energy.     

Nasal dermoids: the significance of a midline punctum.

Nasal dermoids are rare and their diagnosis is often delayed until complications occur. Signs such as a midline nasal punctum may be noted at birth but the significance of this finding frequently passes unrecognised. The cases are reported of two patients which illustrate the typical presentation of these lesions and their subsequent management is discussed.     

Complementary and alternative therapies: considerations for families after international adoption

Children who are internationally adopted are at increased risk of developmental and behavioral concerns, including attention disorders, learning disorders, and autistic spectrum disorders. In attempting to promote their child's optimal development and well-being, parents of internationally adopted children are faced with the additional stress of having many unanswered and unanswerable questions about their child's early origins. As a result, internationally adopted children and their parents need the support and counsel of their pediatrician as they grow and develop into adulthood. A combination of traditional, complementary, and alternative therapies is the rule rather than the exception for most children with developmental challenges.     

Twins: a neonatal perspective

Multiple gestational pregnancies have become more common with the development of assisted reproductive technologies and increasing maternal age. It is important to be aware of the factors that need to be considered when expecting their impending arrival to the neonatal unit. Their antenatal course has unique considerations and monochorionicity can complicate their antenatal and postnatal course so closer monitoring is required. Perinatal interventions for optimal outcomes are undertaken according to local policies, NICE and RCOG recommendations. Short and long term outcomes depend on various factors and their neonatal course of stay should they need admission to the unit. Families need support when they are expecting twins as there are considerable socio-economic implications of a twin pregnancy. This short article provides advice to healthcare professionals looking after twins and their families.     

Some chronic obstructive pulmonary disease will originate in neonatal intensive care units

Chronic lung disease is the most common adverse outcome in survivors of prematurity. These infants experience frequent hospitalisation because of respiratory-related illness in their first year, as well as persistent cough, wheeze and oxygen dependence. Although the severity of respiratory illness decreases and supplemental oxygen is needed less as their lungs mature, childhood is still complicated by persistent wheeze, cough and reduced exercise tolerance in comparison with their peers. Although there is little longitudinal follow-up data beyond adolescence, imaging studies suggest that these infants are highly likely to suffer with respiratory problems akin to chronic obstructive pulmonary disease in later adulthood. The nature of their long-term respiratory problems, the impact of cigarette smoking and the effect on life expectancy are all unanswered questions that need addressing as these infants grow up.     

Coping with distressed and aggressive parents

Illness is distressing, not only for the sick child but for parents worried simultaneously about their child's prognosis and the hospital system they are caught up in. Staff may become just as distressed as those in their care. When badly handled, such distress is easily turned into distrust, to anger and to blame, in parents who feel their complaints are unheard, who feel they have no-one close to turn to, who feel kept in the dark or assaulted by bad news insensitively given, who feel left out of the care of their child and decisions about the future, and who feel discriminated against. The challenge for the paediatrician is to get beyond the defensive stereotypes, to try to understand why the parents of a child have become so angry, and to learn from the experience. Three archetypal ‘cases’ are offered for discussion.     

Review of medical reports on pedophilia

The present report is a review of all 554 papers published on Medline on pedophilia. The first discussion is the history of the disorder from ancient Greece to the present time, especially the influence of the liberal country of the Netherlands, the North American Man-Boy Love Association, and the sexual crisis in the Catholic Church. One important question is the relationship between homosexual pedophilia and adult homosexuality. Evidence for and against this relationship is presented. Next discussed are the characteristics of the victim and the long lasting serious effects of sexual abuse. Laboratory correlations are included, especially phallometric tests in order to objectively measure the physical responses to sexual stimuli. Electrophysiological and radiographic tests are also mentioned, including electroencephalography, computed tomography, magnetic resonance imaging, and positron emission tomography scans. An important section is the characterization of pedophiles with emphasis on their frequent previous sexual abuse, their past, their present, and their anticipated future. The final topic is treatment of this disorder with surgery, medication, behavioral therapy and the combination of medication and behavioral therapy.     

On the pharmacological treatment of acute spasmodic laryngitis (Pseudo-Croup) (author's transl)]

Three aspects of the pharmacological treatment of pseudo-croup are discussed in this article. Sedatives should be given only when close clinical supervision is guaranteed. Otherwise the apparent drowsiness observed in patients passing from stage III to stage IV of the disease may be masked or misinterpreted due to these sedatives. Emetics used occasionally in the USA, and also frequently administered in Europe to the turn of the present century, are no longer used for treatment in Germany. There are no controlled studies showing their effectiveness. In contrast to the common practice in Germany, glucocorticosteroids are less frequently used in the USA. Theoretical considerations suggest their usefulness, but to data there is still no convincing proof of their clinical effectiveness.     

L’évaluation thérapeutique pour enfant : théorie,procédures et illustration

Therapeutic assessment (TA) is a relatively new paradigm in which psychological tests are used as the centerpiece of a brief therapeutic intervention. TA is a semi-structured form of collaborative psychological assessment, and clients are involved as co-investigators in many aspects of the assessment. Although TA was originally elaborated for adult clients, it has since been researched and used in clinical practice with children and families. TA with children (TA-C) is conceived of as a brief family therapy intervention through which parents are helped to develop a more coherent, empathic, accurate, and useful understanding of their child. It is believed that this changed view of the child leads to healthier family interactions, and that these often are sufficient to resolve the presenting problems. The goal of this article is to introduce the reader to TA-C by means of a comprehensive case example. The theoretical underpinnings of TA-C are described and each of the semi-structured steps is explained and illustrated. These steps include the collection of individualized assessment questions from parents, psychological testing of the child, parental observation of certain stages of the assessment, a family session designed to explore systemic hypotheses about the child's difficulties, and the provision of assessment feedback to both parents and the child. The case illustrated involves the O’Hara family and their 7-year-old son, an only child. The parents sought psychological testing of their son at the urging of their pediatrician, who had been treating the boy for several years for persistent nighttime enuresis. Over the course of the assessment sessions, the parents came to realize that their son's difficulties were a reflection of emotions that they had been unable to tolerate regarding the loss of an important family member. With the emotional support of the assessor and their extended family, the parents gradually were able to acknowledge, accept, and integrate these emotions, and their son's enuresis disappeared.