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A new module for doctors treating toddlers

JAIPUR: Health care intervention provided to children and adolescents needs a new orientation under a “developmental framework” to match children’s casual reasoning, language ability and self-understanding as well as to cater to their environmental perspective. It will also help in making a correct clinical assessment of the young patient’s condition.

Such a framework will go a long way in complying with the three basic principles of paediatric practice: primacy of patient welfare, respect for patient autonomy, and promotion of social justice, says a new module of International Paediatric Association (IPA) on the training of paediatricians in ethics developed by two Indian doctors.

The module – the first of its kind for doctors treating toddlers – has been authored by noted Jaipur-based paediatrician Ashok Gupta and Delhi-based Swati Bhave, who is also Deputy Executive Director of IPA. It covers a wide array of ethical norms to be followed during treatment and deals with the dilemmas often faced by paediatricians in life-threatening conditions.

The IPA Governing Council approved of the draft module at its meeting held in Athens recently. Dr. Ashok Gupta, who attended the meeting as a member of the IPA Ethics Committee, said here on Monday that the ethical code, with its basic structure rooted in the values of empathy, motivation, affection and respect for children’s sentiments, was widely acclaimed by the global paediatric community.

The module has for the first time underlined the significance of communication in paediatric practice to address children’s concern about separation from parents and family and unfamiliar environment. Depending on the age of the child, different strategies should be used for calming, establishing rapport and obtaining information on medical history in a child-friendly environment.

Dr. Gupta, who is also president of the International Society of Tropical Paediatrics, said motivational interviewing had emerged as an effective method for fostering rapport with both the children and their parents.

Children actively participating in this therapeutic alliance demonstrate greater reception to treatment.

The module, while pointing out that no single intervention is likely to be effective from early childhood through adolescence, says it is important to understand the influence of social environment, family, peers, school and the larger community on a child’s efforts to modify health-related behaviour.

For the adolescent patients, the module favours use of “developmental competency” as a significant incentive for health-related behaviour change: “As adolescents develop coherence in their beliefs and values while asserting greater independence from parents, they should be included in the intervention efforts and the parental involvement should be restricted.”

However, parent-directed behavioural intervention should be adopted to reduce distress and pain associated with routine immunisation, dental treatments and burn treatments.

The deep-breathing distraction techniques could also reduce distress levels among young children, says the module.

The module recognises the moral and legal authority of parents to make health care decisions for their children and points out that pain relief is an emerging legal and ethical frontier of medicine.

It says a structured protocol should be followed for all children who receive sedative medications and family presence should be offered as an option during painful procedures.

Dealing with the arduous task of delivering “bad news” to the parents, the module says that if handled improperly, it could result in long-term emotional consequences for the family.

“Paediatricians should use their interpersonal skills while facing this predicament and make an attempt to console the parents,” said Dr. Gupta, recalling instances during his paediatric practice.

The module advocates respect for informed consent and the right to refuse treatment.

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