Chapter 29: Care of children and young people with gastrointestinal problems

ANSWERS TO SCENARIO 29.1: ZAC

You are on placement with the health visitor and you visit Zac, a 4-year-old boy, who according to mum is a 'picky eater'. Zac has a history of constipation and soiling and is due to start school shortly. His mum has asked for advice.

  • What advice would you give Zac’s mum to help manage his constipation?

Answer: Although Zac’s mum reports a history of constipation, it’s possible this has never been formally diagnosed, so a GP referral is the first step. GP may want to carry out examination and refer for tests to rule out any anomalies or organic cause. Standard treatment is the use of laxatives to disimpact the bowel, followed by diet review, education and regular toileting and medication. Depending on the local service, this may be undertaken by Zac’s health visitor, community nurse, community paediatrician, or nurse-led constipation clinic. A community dietician may also give advice on diet. Zac’s mum may also need advice on reinforcing positive behaviours, through the use of a reward system such as a star chart. The children’s bowel and bladder charity ERIC has a useful resource on constipation for parents available from: www.eric.org.uk/Pages/Category/bowel-problems.

  • What advice would you give to mum regarding school?

Answer: It would be ideal to have resolved Zac’s constipation and soiling before he starts school, but given his history, establishing a toilet routine may take a while. It’s important to recognise that soiling is not deliberate and that Zac’s teachers should be aware of this. If a toileting regime has been established, it’s important to discuss this with the school so they can continue to maintain this during the school day. Zac’s mum should be advised to provide clean pants should these be needed whilst Zac is at school. Zac’s health visitor may be able to arrange for his school nurse to meet Zac’s parents and to assist with any discussions that are needed with the school beforehand. Zac may find it helpful to visit the school and familiarise himself with the toilets there before he starts school.

ANSWERS TO WHAT’S THE EVIDENCE? 29.1

Giving medication to stop vomiting or diarrhoea in gastroenteritis is not normally advised. However ondansetron – an antiemetic licensed for prescription in children and young people for chemotherapy-induced or post-operative nausea and vomiting – has been shown to be of some benefit in treating gastroenteritis. In studies undertaken outside the UK, more children stopped vomiting when given ondansetron compared to children given a placebo and fewer children needed intravenous therapy or hospitalisation to treat dehydration (NICE, 2014).

  • Why might some prescribers be reluctant to prescribe ondansetron to treat gastroenteritis?

Answer: Ondansetron is not licensed for use as an antiemetic in treating gastroenteritis in children and young people. This means that a prescriber who wishes to prescribe ondansetron for this purpose has to prescribe it ‘off-label’, which is a prescription for use of a medication outside the terms of the its licence. Although this is allowed, some prescribers may feel uncomfortable prescribing medication in this way, because the clinical trials required to support the clinical effectiveness of the medication may not be sufficient for a licence to have been granted.

  • Antiemetic and antidiarrhoeal medication is not normally advised – what might be the reason for this?

Many antiemetic and antidiarrhoeal medication are not suitable for use in children and may cause more harm than good due to their side effects. Parents are therefore not advised to self-medicate their children in this way. There is also some belief that using antiemetic and antidiarrhoeal medication prolongs the duration of gastroenteritis as it keeps the causative virus/bacteria inside the body for longer, whereas vomiting and diarrhoea acts to expel the virus/bacteria so that recovery is quicker. The use of oral re-hydration solution is better advised and is safe to use with children.

ANSWERS TO ACTVITY 29.1: CRITICAL THINKING

A gynaecological cause may be the source of abdominal pain and in addition, the pregnancy status of females should be known before surgery. NICE states that all women of childbearing potential should be sensitively asked about the possibility of pregnancy and a pregnancy test carried out with consent, if there is doubt (NICE, 2016a). This is because there are associated risks with anaesthesia during pregnancy. However, this NICE guideline does not apply to young people under 16 years of age.

Consider the following:

  • Should pregnancy checking be routinely carried out on all adolescent females?

Answer: No, The Royal College of Paediatrics and Child Health (RCPCH) are very clear in their guidance that patients who have not yet started their periods do not require checks for pregnancy. This needs to be documented in the medical notes.  However, the subject of possible pregnancy should be approached if the patient has started her periods, but a pregnancy test is not required if the patient states that there is no possibility of pregnancy. The RCPCH have produced guidelines for clinicians and recommends that local protocol is developed for pregnancy checking in the under 16 age group. They recommend using either an enquiry-based approach, or a routine testing approach.

  • If you do discuss the possibility of pregnancy with your patient, should you document this?

Answer: Yes, any conversation held with the patient around pregnancy status must be clearly documented. If a pregnancy test is refused and the patient is pregnant, then it is important a record of the refusal exists, along with a record that the patient has been informed of the associated risks. You should also be aware of the current law on consent and capacity to consent. Young people under the age of 13 are considered by law in England and Wales to be unable to consent to sexual intercourse. Disclosure of sexual activity in this age group would therefore usually require action under the local safeguarding policy. It’s important to recognise that young people may find it difficult to respond to questions about sexual activity and pregnancy, for a variety of reasons, including fear their parents will find out. 

  • Should a pregnancy test be carried out without consent?

Answer: No, never. The RCPCH guidance is extremely clear that consent for a pregnancy test must always be obtained. Under no circumstances should urine obtained for a standard dipstick test be used to test for pregnancy without patient/carer knowledge and consent. Where it is not possible for the patient to provide consent, e.g. learning disability, then the consent of the parent/carer should be sought.

  • What elements of privacy and dignity do you need to consider?

Answer: Young women under the age of 16 have the right to be asked about sexual activity and the possibility of pregnancy without parental knowledge. You could explain that as the patient is almost an adult, you have some private questions, which they might like to answer by themselves in private and ask the parents to leave the room. Consider also the type of cubicle the patient is in – is it a separate room with a door, or a cubicle with curtains? Who else can overhear the conversation?

  • Does your placement area have a protocol for pregnancy checking in adolescent female patients? Discuss this with your mentor.

Now read the RCPCH document Pre-procedure Pregnancy Checking in Under 16s: Guidance for Clinicians available from: www.rcpch.ac.uk

References

NICE (2016) Routine Preoperative Tests for Elective Surgery NICE Guideline [NG45]. Available from: www.nice.org.uk/guidance/ng45 (accessed 30 March 2017).

Royal College of Paediatrics and Child Health (2012) Pre-procedure Pregnancy Checking in Under 16s: Guidance for Clinicians. London: Royal College of Paediatrics and Child Health.

ANSWERS TO SAFEGUARDING STOP POINT 29.1

Malnutrition is defined as a lack of proper nutrition and can refer to either undernutrition, when a child/young person does not get enough nutrients, leading to poor growth and development, or overnutrition, when a child/young person receives more nutrients than is needed, leading to obesity.

There are multiple reasons why a child may be underweight for their age. However as children’s nurses, it’s important to recognise that one cause could be the deliberate withholding of nutrition by the child’s parent/carer.

  • What signs might a child who is being deliberately starved display?

Answer: Signs might include visible weight loss, lack of concentration, lethargy, complaining of hunger or stomach ache, stealing food from other children’s lunchboxes or trying to obtain extra food from other children.

  • When a teacher or a healthcare professional is concerned about a child, it is common for them to speak to the child’s parent/carer, but who else should they speak to?

Answer: They should speak to the child. This is especially important where there are concerns for a child’s welfare, as the parent’s story may be a cover. Current safeguarding advice is to question behaviour if something seems unusual and to try and speak to the child alone.

  • If you think a child is at risk of harm, who should you report your concerns to?

Answer: Document your concern and refer to your mentor immediately. As a nursing student, you have a duty to respond to any concerns about a child. Your mentor may also seek advice from the named person for safeguarding within their organisation.

Now read the ‘Daniel Pelka serious case review: lessons to be learned briefing’ from the link below:

www.staffordbc.gov.uk/live/Documents/PolicyAndImprovement/Serious--Case-Review---Daniel-Pelka.pdf

ANSWERS TO SCENARIO 29.2: MATTHIS

You are looking after Matthis who is 3-weeks-old and was born with gastroschisis. Matthis has a nasogastric tube in place and feeds are slowly being introduced. A feed is due now – when you test the tube for its correct position, you cannot draw back any aspirate.

  • What should you do now?

Answer: You should inform your mentor and together, you should follow the local policy on confirming the position of nasogastric tubes. This is likely to offer several options including:

  • Positioning patient on their side and re-aspirating the tube
  • Inject small volume of air (dependent on age of child) into the tube to dislodge any obstruction, then re-aspirate the tube
  • Advance or retract nasogastric tube, then re-aspirate the tube
  • Remove and re-pass the tube (providing this is not contraindicated)
  • Consider x-ray – discuss with medical colleagues

Under NO circumstances should the position of the nasogastric tube be confirmed by listening for air (the ‘whoosh’ test). The misplacement of a nasogastric tube, and subsequent failure to confirm correct placement is a ‘Never Event’.

Read the policy on nasogastric feeding for your placement area

  • What does the policy advise?

Answer: Here is a clinical guideline for you to use if you have not been able to locate one from your placement: www.gosh.nhs.uk/health-professionals/clinical-guidelines/nasogastric-and-orogastric-tube-management

  • How practical is this advice for children in the community who have nasogastric feeds?

Answer: For children in the community, the policy for confirming the correct placement is likely to be similar, but failure to obtain an aspirate is problematic and may necessitate a trip to hospital for x-ray confirmation. Again, the local policy for the child’s community nursing service should be followed.

Discuss and document your thoughts with your mentor.