Surviving Paediatrics as a GP Trainee- a short handy experience

by Abeera Khan

Paediatrics is one rotation every GP trainee wishes to have in the training, and I would say Yes, it’s very important and you learn a lot. However, it can be a bit daunting and hectic.

If you don’t have a Paediatric rotation, try to attend some Paediatric clinics or if you have an A&E rotation, get some exposure of Paediatric A&E. It will help you a lot.

My experience is based on the training structure I had in the department where I trained. It would be different from other hospitals. However, the main aim is to give an idea what to expect and achieve by the end of rotation. I had my GP rotation after Paediatrics, and I felt comfortable in seeing children at my practice. However, you can discuss this with your ES if you haven’t had Paediatric rotation before seeing children (especially under a year) in GP placement on your own.

Paediatric department roughly has:

Children ward and Children Assessment Unit (CAU)

Neonatal/Postnatal ward

Neonatal ICU (NICU)/ Special Care Baby Unit (SCBU)

Paediatric Immediate Life Support Course (p ILS)

We had it in our trust induction. It was a one-day course which was organised by the Trust. We did not have to pay anything. It was mandatory to attend before starting the on-calls. It is valid for one year.

The Neonatal Life Support was taught by the Consultant. It was not a proper course but we had short practise/simulation sessions organised by the department every week to keep the juniors in practise and routine.

On-calls:

This varies in hospitals. If you are working in a department where there is NICU, its likely you will have two on-call teams (one for ward and one for Neonates) both on days and nights on-call.

However, my rotation was in a hospital which only had SCBU, so we had two SHO’s on call for day (one SHO for ward/A&E and one SHO covering Postnatal ward/SCBU) but for Night on-call, there would be one SHO and one Registrar covering everywhere ( Ward, A&E referrals, Neonatal ward and SCBU).

CAU (Children Assessment Unit):

This is a short stay unit. Children can be admitted/observed here for couple of hours and then either discharged home or admitted to the ward if they are not well enough to be sent home.

They come to CAU from A&E, GP referrals/ community midwives, Health visitors. If they have any concerns, they will speak to the on-call doctor (In my trust, the Registrar used to take GP/community midwives Referrals and then advise whether they are stable enough to come to CAU directly or would need to come to A&E.

Usually there are ANP (Advanced Nurse Practitioners) supporting the doctors in CAU. They are very well trained and would see patients independently, do bloods and make the plans. You can also ask them for help if you are not confident in doing bloods.

Children can then either be discharged from CAU after assessment from a senior or admitted to the ward.

The Ward:

Ward would have patients who are under 16. These can be under Paediatricians, Surgeons, Orthopaedics etc. Even if they are surgical patients, most of the children are under joint care of Paediatricians and the other team.

Commonly seen conditions:

Bronchiolitis

Croup

Asthma exacerbation

Viral induced wheeze

(Above four more commonly seen if you have a rotation during the winters)

Rashes (various kinds)

Viral Gastroenteritis

Viral URTI

Febrile seizures

Afebrile seizures in known epileptics

Infections (Acute tonsillitis, otitis media etc)

UTI

Children with suspicion of NAI (non-accidental injury)

Children with long term conditions (e.g children with feeding tubes, cerebral palsy, children who have open access to ward). Meaning that if they have any concern, parents can ring the ward and come straight there rather than going through A&E.

Follow your trust’s antimicrobial guidance.

Neonatal Ward:

The most important thing to familiarise and getting tuned to is the NIPE check (Newborn and Infant Physical examination).

NIPE: This is the baby check you would be doing on the postnatal ward. It must be done ideally within 72 hours but in our trust the target was to do in 48 hours. Baby checks are done preferably 6 hours after birth.

You will be told this in detail in your departmental induction and would be shown how to do it by your Registrars. I will just touch base.

Always check Maternal Notes, Mum’s medical history, antenatal history, serology, blood group and history of GBS (Group B Strep). If possible, check for antenatal scans (any anomaly, oligo/polyhydramnios)

Before starting baby checks, Ask Mum

  • the ethnicity of both parents
  • history of DDH
  • Family Hx of congenital heart disease or eye problems in children
  • And if child has passed meconium (48 hours) and urine (24 hours)
  • Child breastfed or bottle fed

You need to get hands on the NIPE check as there is a baby check at 6 weeks which is done by the GP. So as a GP, you should be slick in doing these.

There is a lot of information of the gov website, link below

https://www.gov.uk/government/publications/newborn-and-infant-physical-examination-programme-handbook/newborn-and-infant-physical-examination-screening-programme-handbook

You can also have a read on this in OHGP (Oxford Handbook of General Practice)

Important things to know in New-born

Key thing is NOT to miss suspected sepsis in the newborn. It is worthwhile giving a read of NICE guidance, link below especially Table 1 and 2

https://www.nice.org.uk/guidance/cg149/chapter/1-Guidance#risk-factors-for-infection-and-clinical-indicators-of-possible-infection-2

What I have seen commonly in my rotation is, Tachypnoea in neonates. This is a red flag. Please don’t miss it. Screen the baby for sepsis, start antibiotics and wait for culture results.

Other commonly seen neonatal problems:

  • Hypoglycemia in newborn
  • Hypothermia in newborn
  • Jaundice (within 24 hours of birth and after 24 hours)
  • Grunting in newborn

If in doubt, ALWAYS ask for Senior help.

When covering Postnatal/SCBU/NICU, you will be asked to attend Instrumental deliveries and Caesarean sections. Make yourself familiar with the resuscitaires. Again, if not sure, ask for help. The senior midwives are very supportive and know a lot. We had NLS (Neonatal Life Support cards) tied with all resuscitaires and it is good to go through it every time you are attending a delivery.

Jaundice: Jaundice within first 24 hours – Red Flag

Consider Hemolytic disease of newborn/Sepsis

Do bloods (FBC, LFTs, CRP, DAT)

Discuss with the Registrar and consider starting Phototherapy before the results are back

Jaundice after 24 hours is Physiological Jaundice. Do bloods, plot on the Phototherapy graph. These would be shown to you I am sure. This is called ‘Treatment Threshold graphs for neonatal Jaundice’. Make sure you plot on the right gestation graph and at the correct time. I am mentioning this because this is a common mistake.

Clinics:

Some clinics you can attend in your rotation are

Dermatology clinic – would be very useful

Developmental clinic

Asthma/ Respiratory Nurse Clinic

Epilepsy clinic

Diabetic clinic

Some tips:

  • Familiarise yourself with the NICE guidelines and your Trust guidelines
  • Consult BNF C (for children) Keep the app in your phone. It comes very handy
  • Always plot Height, weight, Head circumference on the growth charts
  • If you are not confident in doing bloods in children, ask for help. You will always find ANPs, Nurses, HCAs doing this and they would be happy to help you out.
  • Be careful and not to make decisions on your own especially with children who are on child protection register, safeguarding issues, query of NAI.
  • And most important, when in doubt, Always Ask and don’t assume.

I have kept it very brief just to give an idea and outline. Best is to learn from your own experience. Hope it helps everyone out there who will be doing Paediatrics.

 

 

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