Children have been able to access paediatric emergency departments for a long time now. Children benefit from a child-friendly waiting area, an assessment that recognises the way that children are different from adults and treatment by clinicians who are specifically trained in child health. Perhaps that makes it all sound very exclusive and mysterious. What are these differences of which you speak? Well, none of them are a great secret, but as is often the case, having something explained often helps it to be understood better, even if you already knew it.
So, here's something that you probably already knew, but was a fact that you hadn't necessarily known what to do with: Children have a considerable lack of body awareness.
A child's approach to anatomy and physiology is fairly simple: I eat, I wee and I poo. I pick things up if I want them. If I want to do any of those things in a different location then I move. If the world isn't the way I want it to be, I make noises.
One of my top tips when teaching paediatric clinical examination is that children don't have a chest before they go to school. To them, the space between mouth and stomach is presumably some sort of giant food processing area. Functions like breathing and circulation only truly become a reality when a child is much older. For that reason I never tell a young child that I am going to listen to their chest. It only confuses them if you say that. I tell them I am going to listen to their tummy and tell them what I can hear. Usually, the answer is sausages.
Besides helping me to know what to say to children, my knowledge of their lack of body awareness is crucial when it comes to understanding visceral presentations in children. The important thing to understand is that children seem mostly unable to recognise the significance of visceral symptoms. In other words, the feelings in their bowel and bladder either make no sense to them, or they are unable to articulate these feelings. For whatever reason, young children have a tendency to leave bowel and bladder symptoms unreported, and so the presentation of problems such as urinary tract infection (UTI) and constipation are always delayed.
Take this case history example:
A two year old child presents with a 12 hour history of dysuria and frequency of urine. They have no fever or abdominal pain.
Well, that's all very well, but that's just not how it goes. Let's try something more realistic:
A two year old presents with a three day history of fever. The child first presented two days ago and was diagnosed as having viral gastroenteritis. The child is vomiting intermittently. There is no blood or bile in the vomit. The child does not have diarrhoea.
Today the parents have noticed that their child is more unsettled and they think that the child has abdominal pain, although the child has not specifically said that their tummy hurts.
Why is it important to recognise this peculiarity of children?
The first reason is that we need to be aware that UTI is a diagnosis that we have to actively seek in children. UTI in younger children does not have specific (urinary) symptoms. Instead, all of the features are those also found in the more common viral infections such as gastroenteritis or URTI.
This does not mean that all unwell children should have a urine tested. Routine testing would be great if it were painless for the family and the clinician. Neither of these things are true. Getting an uncontaminated sample (a 'clean catch') is hard work much of the time. Interpreting the results and making sense of conflicting information is a challenge once a sample is obtained. For that reason I would not routinely ask for a urine sample in a child who has an obvious otitis media for example.
The things that make UTI more likely in children include:
- previous UTI
- abdominal pain/ tenderness
- vomiting without diarrhoea
- a report of odd smelling urine
- absence of signs or symptoms of URTI
- new urinary symptoms (enuresis, dysuria)
The second reason is that we need to be aware that both UTI and constipation are likely to be well established by the time they are diagnosed. This means that in children, we have to take each of these diagnoses a little more seriously.
Although most children with UTI are well at presentation, they probably have an infection that is a little more than what would be considered cystitis. They may not have a proper pyelonephritis yet, but they are likely to have a more established infection than a young adult would have. It is for this reason that we need to make sure that we do pick up a diagnosis of UTI as early as possible. Every day left untreated increases the risk of renal scarring.
With constipation, the significance of the way it presents is more to do with the length of treatment needed to resolve the problem than the urgency to start treatment (as with UTI in children). By the time that the child and parent are aware of the problem, constipation is usually very well established. The child's bowel has been full of stool for weeks or months. The bowel is stretched, weak and insensitive. Prune juice and porridge are simply not going to do the job of resolving the constipation by the time that a child gets as far as their first medical assessment.
At this point, a short course of treatment for constipation simply will not suffice to truly resolve the problem. Macrogol laxatives (the treatment recommended by the UK's NICE guideline) will do a great job, in almost every case, of clearing out the bowel. This is not the same as treating the underlying condition. We need to continue treatment until the bowel has a chance to do its thing again.
The effective treatment of idiopathic constipation in children requires two things. Firstly, it requires adequate doses the right laxative (I avoid lactulose) for as long as it takes to allow the return of strength, shape and sensation to the bowel. The consensus on this is that this will take about six months of maintenance therapy to achieve.
The second thing needed is some sort of modification to lifestyle that will help to avoid the return to constipation once treatment is stopped. Changing diet, fluid intake and toileting habits may make all the difference, once the treatment has given the child their normal bowel back.
So I would suggest that we never think in terms of 'just a UTI' or 'a little bit of constipation' in children. The delay in presentation, coupled with the extra time it may take us to actually get to the diagnosis means that neither of these terms apply.
I suspect that this could all be applied to the elderly with a little modification, but I'm not about to start GPseniorsTips.blogspot.com. I'll just leave that thought with my innovative colleagues at the Norfolk and Norwich University Hospitals.
Disclaimer - While I know deep down that it would be a terrible idea, part of me wants to combine a Paediatric Emergency Department with a Senior Emergency Department. I can imagine how the two patient groups would be quite good for each other. And that folks, is why I should never be allowed to have ideas.