The role of the GP in the care of children and young people
As a GP, your role is to:
- be the first point of contact for the unwell child
- be responsible for ensuring high-quality evidence-based care for children and young people with both acute and chronic conditions, and demonstrate appropriate competence in child safeguarding
- make every contact count, with opportunistic interventions during scheduled and unscheduled contacts in primary care
- play a key role in co-ordinating truly holistic care through multiprofessional conversations with services across health, social and educational sectors. This will have a crucial impact on the adult health and life chances of children and young people
- identify and support at-risk children, and adolescents who may fall through the gaps in services, particularly in the context of safeguarding and mental health
- identify vulnerable children when seeing adult patients who have experienced their own health and social problems, such as domestic violence or substance misuse
- support the transition to adulthood and the transfer from paediatric to adult services
- understand that social determinants of health are particularly important in vulnerable sectors of society, especially with rising incidences of child poverty and inequality, and engage in reducing inequality of access to services.
Emerging issues
- Mental health post pandemic
- Increased recognition of neurodivergence in children and young people
Knowledge and skills guide
For each problem or disease, consider the following areas within the general context of primary care:
- the natural history of the condition including whether acute or chronic
- the incidence and prevalence, including in different demographic groups
- typical and atypical presentations
- recognition of normal variations throughout life
- risk factors, including lifestyle, socio-economic and genetic factors
- diagnostic features and differential diagnosis
- recognition of ‘alarm’ or ‘red flag’ features
- appropriate and relevant investigations
- interpretation of test results
- management, including initial and continuing care, chronic disease monitoring and emergency care
- patient and carer information and education, including self-care
- prognosis.
The normal child
A very important element of child health in general practice is the recognition of the range of normality in physical, psychological, and behavioural development. These include:
- normal developmental milestones and assessment of development delay, including language, gross and fine motor skills and social development
- normal growth, including interpretation of growth charts
- normal maturation, including puberty
- normality in the neonatal period, including screening
- normality of physical development with normal variations (for example, orthopaedic variations such as genu valgus/varus and plagiocephaly)
- normal development of emotional and psychological maturity and normal variation in childhood behaviour
- awareness of norms and referral standards when undertaking newborn and infant physical examination (NIPE) programme examinations.
Symptoms and signs
A key feature of knowledge about child health is the interpretation of common symptoms and signs in different age ranges. For example, back pain or abdominal pain in childhood, adolescence and adulthood will most likely have different underlying causes and natural histories. This can have significant and potentially serious consequences if not fully recognised when considering differential diagnoses.
Attention should also be paid to specific paediatric themes, such as:
- behavioural problems
- developmental problems
- faltering growth
- features of the acutely unwell child, including fever, rashes, irritability, breathing and circulatory signs
- mental health problems, including bullying, stress, self-harm and suicidal thoughts
- adolescents and young people aged 10–25 years as a distinct group with respect to brain development, physiology and pharmacokinetics
- Adolescence as a developmental stage and its particular issues, in particular the importance of being opportunistic in assessing mental well-being and sexual health
- gender identity issues. Lesbian, gay, bisexual and transgender (LGBTQ+) patients face inequalities in their experience of NHS healthcare.
Common and important conditions
Many of the problems and diseases are classified by body system, reflecting the wide scope of general practice in the UK. There is inevitably overlap between system classifications and generic areas such as child health.
- Early and undifferentiated presentations, and recognition of a seriously ill child (and urgent intervention when appropriate)
- Acute paediatric emergencies (such as febrile convulsions, anaphylaxis, asthma, septicaemia, meningitis and surgical conditions)
- Urgent resuscitation in line with Resuscitation Council UK guidelines
- Appropriate acute and repeat prescribing and reviews
- Behavioural problems (such as enuresis, encopresis, food refusal or fussy eating and tantrums)
- Childhood infections, including exanthemata (such as mumps, measles, rubella, chickenpox, herpes simplex, parvovirus, Coxsackie, Kawasaki and other infections listed under dermatological disorders below)
- Childhood malignancies (such as leukaemias, lymphoma, brain tumours, retinoblastoma, neuroblastoma, nephroblastoma and sarcoma)
- Chromosomal disorders (for example, Down’s syndrome, Fragile X, Klinefelter’s syndrome, trisomy 18, Turner syndrome)
- Congenital abnormalities (such as congenital heart disease, hypothyroidism, musculoskeletal and neurological abnormalities and sensory impairment)
- Dermatological disorders in childhood (such as seborrheic dermatitis, atopic eczema, infections such as impetigo and fungal infections especially tinea capitis and kerions, alopecia areata, vitiligo and infantile haemangiomas)
- Diagnosis and management of diseases relating to children (for example, asthma, diabetes, epilepsy, respiratory infections such as pneumonia, bronchiolitis and croup)
- Disease prevention, wellbeing and safety, including in the following areas:
- health benefits of breastfeeding, infant feeding, effective milk transfer, and breastfeeding substitute guidelines
- healthy diet
- social and emotional wellbeing
- immunisation
- smoking
- avoiding the use of volatile substances and other drugs
- minimising alcohol intake
- Faltering growth and underlying causes, including ineffective intake, for example due to lack of breast milk or inadequate nutrition, undiagnosed conditions (such as cystic fibrosis and coeliac disease), chronic infection, non-medical causes such as abuse or neglect
- Gastrointestinal (GI) conditions that present in childhood (for example, appendicitis, Meckel’s diverticulum, intussusception, malabsorption such as coeliac disease, cows’ milk protein allergy, cystic fibrosis, the risks and treatment of iron deficiency, and inflammatory bowel disease and other chronic malabsorption conditions that might be confused with other conditions such as eating disorders)
- Immunisation in children (routine primary schedule and other immunisations, contraindications to immunisation)
- Neurodivergence in children, including conditions that fall under the neurodivergence umbrella such as autistic spectrum disorder and related conditions, attention deficit hyperactivity disorder (ADHD), developmental language disorder, developmental co-ordination disorder (dyspraxia), specific learning difficulties (dyslexia, dyscalculia), tic disorders
- Intellectual disability and global developmental delay
- Behavioural and mental health problems such as depression, eating disorders, substance misuse and self-harm, risks and consequences of bullying, including cyberbullying and increasing impact of social media (see also the Mental health and Smoking, alcohol and substance misuse topic guides)
- Musculoskeletal problems relevant to children, for example, inflammatory arthritides (infective, autoimmune), osteochondritis, Osgood-Schlatter’s, Perthes’ disease, slipped epiphysis, injuries such as greenstick fractures, pulled elbow)
- Neonatal issues, including:
- congenital abnormalities (listed above)
- feeding problems (breastfeeding and bottle-feeding), gastro-oesophageal reflux, hypoglycaemia
- jaundice (such as breastfeeding, haemolytic and haemorrhagic disease of the newborn, biliary atresia)
- respiratory problems such as respiratory distress syndrome and sleep apnoea
- skin conditions such as birthmarks, erythema neonatorum, miliaria and neonatal acne
- complications of prematurity such as chronic lung disease and cerebral palsy
- Neurological problems relevant to children, including seizures (such as febrile convulsions, epilepsy), awareness of rare degenerative neurological diseases (for example, Rett syndrome, Batten disease)
- Sleep physiology and pathology of sleep disorders in infants and adolescents
- Obesity in childhood: long-term health effects and interventional strategies for weight reduction
- Poisoning: accidental ingestion, iatrogenic, overdose and deliberate self-harm, and deliberate harm by carers
- Refugees and asylum seekers or migrant populations and the additional health needs of their children
- Renal diseases relevant to children (including recurrent urinary tract infections, structural anomalies such as posterior urethral valves, renal pelvic dilatation, haemolytic uraemic syndrome, nephrotic syndrome and glomerulonephritis)
- Safeguarding children, such as:
- recognition of non-accidental injury including physical, emotional and sexual abuse, including risk of female genital mutilation, and appropriate actions
- maltreatment and neglect, parental problems including domestic violence and abuse, substance and alcohol misuse and mental health problems
- recognising the significance if a child is not brought to an appointment and taking appropriate action
- balancing children's rights and wishes with professional responsibility to keep children safe from harm
- Sex identity and intersex, appearance of genitals including fused labia, hypospadias, clitoral hypertrophy
- Gender dysphoria, providing appropriate medical and psychological support for the individuals and their families, and referral to appropriate services
- Teenage pregnancy, risks of sexually transmitted infections and child sexual exploitation
- Transitional issues from child to adolescent and from adolescent to adult. This applies to all children but especially those who are vulnerable
- Consent and competence in older children and adolescents
- Paediatric palliative patients: children and young people living with life-limiting and life-threatening conditions including at transition from paediatric to adult services
Examinations and procedures
- Age-appropriate clinical examination and normal variation in biometrics
- Perform accurate measurements such as peak flow
- Indication and administration of injections and immunisations
Investigations
The decision to undertake investigations in children can be complex. It needs to take account of the emotional and physical impact in the context of the probability and possibility of detecting significant underlying disease.
- Appropriate investigations for common diseases such as asthma or urinary tract infection need to be clearly understood
- Liaison with specialist colleagues when considering invasive or complex investigations and their correct interpretation
- Appropriate use of sedation and pain relief and managing anxiety of the child undergoing investigative procedures
Service issues
- Providing the best care for child health services requires collaboration between professionals. The traditional separation of primary and secondary care services needs to be replaced by multiprofessional working across well-defined clinical sectors, enabling care closer to home
- Respect for the sensitivities of young people regarding their health attitudes, behaviours and needs; impact of attitudes to treating children and young people equitably, with respect for their beliefs, preferences, dignity and rights; issues of confidentiality and consent and sharing information with other agencies
- Appropriate autonomy and involvement of children, carers and families in care planning and delivery; parental responsibility and who can make decisions for a child; confidentiality balanced with the parents’ need for information and shared decision-making with you as their GP; awareness of the legal framework for consent in children and young people
- Prevalence and incidence of illness in the community and the specific circumstances of the patient and family; healthcare needs of the paediatric population of your community and the socio-economic and cultural features that might affect health
- Workload issues raised by paediatric problems (such as the demand for urgent appointments and the mechanisms for dealing with this)
- Organisation of care, including care pathways and local systems of care; child-focused clinical governance and risk management, such as safety of treatment and care, safeguarding, the use of evidence-based practice, clinical audit, effective prescribing and referrals
- Multi-agency working (working across professional and agency boundaries) and the principles of information sharing, including the role of the health visitor in child health surveillance
- Appropriate use of referrals; co-ordination of care with other primary care professionals, paediatricians and other appropriate specialists, leading to effective and appropriate care provision
- Taking an advocacy position for the child, young person or family when needed, balancing the child’s rights and wishes with the professional responsibility to keep them safe from harm. This will include complex situations such as safeguarding issues and end-of-life care
- Information, advice and support to enable children, young people and families to manage minor illnesses themselves, using community pharmacists and triage services where appropriate and accessing appropriate services when necessary
- Legal and political context of child and adolescent care; delivering services for young people relating to access, communication, confidentiality and consent
Additional important content
- Childhood immunisation schedules. These should be kept under review as they can frequently change
- Communication skills specific to child and adolescent health and ‘three-way consulting’ (consulting with both parent and child); having to address parental and patient’s ideas, concerns and expectations; recognition and assessment of behaviour as a form of communication; recognition of the importance of seeing adolescents alone; use of tools (such as HEADSSS) for structured psychological assessment in adolescents
- Prescribing and advising appropriately about the use of medicines in newborn babies, children and young people, being competent at calculating drug doses, understanding the risks and benefits of medicines in relation to children, and cultural differences in beliefs about illness and the use of medicines; best evidence in clinical management and prescribing of medicines for children, and licensing implications
- Pain management in children
- Comorbidities in the child, young person and family with additional vulnerability or special circumstances
- Access for young people to confidential contraceptive and sexual health advice services that are tailored to meet their needs
Case discussion
James Green, a 14-year-old boy, attends your morning surgery with his parents. On reviewing his record, you discover that he has been diagnosed recently with juvenile idiopathic arthritis (JIA) affecting both his knees and hips.
His parents are seeking further information from you regarding the condition, management and prognosis, as the shock of the diagnosis during their initial hospital consultation meant that they could not take in much information at the time of diagnosis. James asks you if the illness will affect his ambition to become a professional footballer – before he became unwell, he had just been selected to play for the county junior team but is now struggling to walk because of his joint pain. His parents tell you they have stopped him from playing any sport, fearful he will damage his health.
Questions
These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case-based discussion with your educational supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.
| Core capabilities | Questions |
|---|---|
Fitness to practise This is about professionalism and the actions expected to protect people from harm. This includes the awareness of when an individual’s performance, conduct or health, or that of others, might put patients, themselves or their colleagues at risk. | What are my own personal values and assumptions regarding this young person’s diagnosis and how might these affect my judgements and behaviours? |
An ethical approach This is about practising ethically with integrity and a respect for equality and diversity. | What happens if there is a conflict between the child’s and parents’ wishes? What are the ethical dilemmas? |
Communicating and consulting This is about communication with patients, the use of recognised consultation techniques, establishing and maintaining patient partnerships, managing challenging consultations, third-party consulting, the use of interpreters and consulting modalities across the range of in-person and remote methods. | How might I adapt my consultation to take account of the differing needs of James and his parents? How confident am I in explaining prognosis? How do I explain it differently to adults compared with to a teenager? Which consultation models would help to improve my skills in managing this case? |
Data gathering and interpretation This is about the gathering, interpretation and use of data for clinical judgement, including information gathered from the history, clinical records, examination and investigations. | How should I investigate early childhood arthropathy? Could there be a genetic element to this? What is the prevalence of early childhood arthropathy in primary care? Could I detect an arthropathy at an earlier stage? What do the terms ‘sensitivity’ and ‘specificity’ mean in the interpretation of laboratory investigation? |
Clinical examination and procedural skills This is about clinical examination and procedural skills. By the end of training, the GP registrar must have demonstrated competence in general and systemic examinations of all the clinical curriculum areas, including the five mandatory examinations and a range of skills relevant to general practice. | What investigations, such as blood tests, would be appropriate to undertake in primary care? How do I assess functional impairment in this age group? |
Decision-making and diagnosis This is about having a conscious, organised approach to making diagnosis and decisions that are tailored to the particular circumstances in which they are required. | How would I diagnose and manage JIA (perhaps bringing in the principle of recognising acutely ill children and rare diseases)? Should I advise James to stop playing football? Is there anyone I can speak to for more advice if I am uncertain? |
Clinical management This is about the recognition and a generalist’s management of patients’ problems. | How confident am I to prescribe in this age group? How does JIA present? How do I manage these patients in the long-term? Do I need to consider any other comorbidities or health problems that may occur? |
Medical complexity This is about aspects of care beyond the acute problem, including the management of comorbidity, uncertainty, risk and health promotion. | What are the risks of prescribing and monitoring disease-modifying drugs in primary care? How will care be coordinated with other professionals in the practice and in other services? Would any other interventions be helpful for James at this stage? |
Team working This is about working effectively with others to ensure good patient care and includes sharing information with colleagues and using the skills of a multiprofessional team. | Which other members of the multidisciplinary team would I involve (such as school nurses, faith organisations, psychologists, family counsellors, occupational therapists and physiotherapists)? How can I work with my local paediatric services to manage a child with newly diagnosed JIA? How do we coordinate care and maintain shared responsibility rather than simply handing over care to the specialist team? |
Performance, learning and teaching This is about maintaining the performance and effective CPD of oneself and others. The evidence for these activities should be shared in a timely manner within the portfolio. | What mechanisms exist in my practice to ensure that I am kept up to date with a diagnosis of JIA? Should I be doing more to promote an awareness of JIA in my clinical practice and how do I do this? How might resource constraints prevent me from providing the best quality care to patients with this diagnosis? What might be important to consider when thinking about managing long-term illness in a child? |
Organisation, management and leadership This is about understanding how primary care is organised within the NHS, how teams are managed and the development of clinical leadership skills. | What mechanisms are in place in my practice to ensure that JIA patients and their relatives are reviewed on a regular basis? How might I use my leadership skills to act as an advocate for James? |
Holistic practice, health promotion and safeguarding This is about the ability of the doctor to operate in physical, psychological, socio-economic and cultural dimensions. The doctor is able to take into account the patient’s feelings and opinions. The doctor encourages health improvement, self-management, preventative medicine and shared care planning with patients and their carers. The doctor has the skills and knowledge to consider and take appropriate safeguarding actions. | How do I plan to follow up James and his family? How might I manage the psychological impact of his disease on James and his family? How can I manage issues around potential school absence? How do I manage the James’ and his parents’ ideas, concerns and expectations? |
Community health and environmental sustainability This is about the management of the health and social care of the practice population and local community. It incorporates an understanding of the interconnectedness of health of populations and the planet. | Which voluntary sector and support organisations might be helpful to James and his family? What are the care services available in my area for children? What psychological support services are available locally to children and adolescents? Who can advise on benefits if one parent gives up working to become a carer? |
How to learn this area of practice
Key knowledge areas in child health include child development (starting with normality), diagnosis of acute and serious illness, and prescribing for children. Be aware of your potential lack of knowledge around minor conditions commonly seen in the community, which you may not have previously encountered in hospital settings (good examples are molluscum contagiosum, ringworm and headlice). Many conditions may not require significant intervention and it is important to recognise normal childhood findings and know when to appropriately reassure parents.
Work-based learning
The focus of the clinics is around a sharing of ideas and learning in both directions. The GP registrar leads the consultation for some patients; in other consultations, the child health-related experience of the paediatric specialty registrar allows them to be the natural lead. This balance helps to foster a culture of peer learning.
Learning occurs on a number of different levels (such as clinical management of the condition, public health aspects, health promotion, case management and working with primary care nurses, for example).
In addition to gaining experience and building competence in consultation and clinical skills, these clinics gave GP registrars the opportunity to develop new insights and perspectives into the challenges and opportunities of seeing children and young people jointly within a primary care setting.
Learning together in paediatric services
Appropriate management of emergencies supported by focused learning allows acquisition of skills and some confidence in this area.
Community-based paediatric services offer a great opportunity to learn about a wide range of conditions, including the long-term needs of the child with complex problems, safeguarding, neurodisability and health promotion.
Learning with other healthcare professionals
Much of the care of children in the NHS is provided by nurses, health visitors, social workers, pharmacists, physiotherapists and many others. Learning arises directly from clinical contact with these professionals – such as with midwives delivering antenatal and postnatal care, health visitors visiting children at home or specialist nurses managing young patients with chronic diseases. Many hold skills that should at least be understood by the doctor and acquired in the context of multiprofessional learning.
The shared experience of training and learning encourages better communication and working relationships between the members of healthcare teams and will create better healthcare outcomes.
Structured learning
The RCGP and Royal College of Paediatrics and Child Health (RCPCH) provide a selection of courses across the UK in both child and adolescent health, including child health issues, child protection, immunisation and child development. This will stimulate reflection on real cases seen in your work and help you as a professional to develop the knowledge, skills and attitudes required for high-quality, collaborative care.
Examples of how this area of practice may be tested in the MRCGP
Applied Knowledge Test (AKT)
- Recognition of normality and disease at different ages in children and young adults
- Prescribing in children
- Contraindications for childhood immunisations
Simulated Consultation Assessment (SCA)
- A 15-year-old girl requests the contraceptive pill
- Phone call: a health visitor is concerned about the welfare of a baby in a vulnerable family. You are due to see the baby’s mother later that day
- A mother expects her three-year-old son to be potty-trained and wants to discuss why he is not
Workplace-based Assessment (WPBA)
- Case-based Discussion (CbD) about a mother who is very emotional about her young son’s diagnosis of a brain tumour when he is also in the room
- Log entry reflecting on a consultation with a teenager who appears unco-operative
- Log entry about attending and contributing to a case conference for child safeguarding
- Clinical examination and procedural skills (CEPS) demonstrating a competent six-week baby check