1. Complex Cases Ophelia Luong OCYL2@cam.ac.uk

2. What’s the Point?  To make you aware of wide range of issues  Not just medical issues  To show how illness affects more than just the child  Siblings, carers, wider society  To make you aware of useful services available for children and families

6. A Case Study

7. George – A 5yo Boy  He lives with his sister, mother and grandparents in a council house. George has suffered repeated chest infections since birth and has remained below his predicted growth curve, falling further behind each year. On arrival in the UK, one of these infections led to his admission to hospital and investigations revealed that he suffers from CF.  His mother is 12w pregnant. She moved to the UK with her husband and his parents 3y ago. Her husband is currently working abroad. Her father-in-law has Alzheimer’s and her mother-in-law has severe OA. They live with her and she is their main carer. She has another child, 2yo, who is currently well and confirmed not to be suffering from CF. Her first child died in his first year from a chest infection.  George started school last September, but his teachers are concerned that he is falling behind, as he misses so much time off school. They have noticed that his mother seems to be very low, and they are worried that she is not coping, as George often looks disheveled and often turns up without a coat or socks. The school nurse has asked the health visitor to visit the family.  Nadia is worried about George’s health, especially as he has missed his “pre-school booster” due to being ill at the time. She has asked her GP for these, as well as a flu jab. She also worries about how likely it is that her unborn child may have CF too.

8. BIO  CF – MDT needed!  Resp  Gastro  Endo  Physio  Dieticians  Specialist nurses  Genetics input  Immunisations  Recurrent chest infections

9. PSYCHO  George  Missing school – and social interactions with other children  Multiple hospital admissions  Chronic condition  Mum  Death of child  Low mood  Stress of caring  Others  Sibling – lack of attention  Dad – unable to bond

10. SOCIAL  George  Lack of social interaction  Falling behind in school  Absent father and busy mother  Neglect  Housing – crowded? poor quality?  Mum  Carer for four (soon-to-be-five)  Probably isolated – immigrant  Is money an issue?

11. ETHICS AND LAW  Genetic Screening  Antenatal screening  Pre-implantation genetic testing  Terminations  Child protection  Neglect

12. PUBLIC HEALTH  Screening  Antenatal  Guthrie  Immunisations  Health visitors  Social services

13. EDUCATION  George is missing lots of school  Hospital school  Should he be home-schooled?  Siblings may also face interruptions in schooling  At school  Medications  Dietary requirements  PE  Teacher education

14. Tips and Extra Info

15. Things to Remember  MDT Approach!!  Specialist nurses  Support groups  Always be aware of child protection and safeguarding issues  You have a duty to report it  Don’t forget about the rest of the family  Carers  Siblings

16. Helpful Tips  Look at complex cases on MedEd for practice  Learn some of the services available (signposting)  Make use of the reading time  Follow the instructions  Keep on talking and look for ticks!

17. Government Schemes  Sure Start Maternity Grant  Healthy Start Scheme  Sure Start Children’s Centres  Childcare  Tax credits or childcare vouchers  Free childcare for 3-4yo (570h)  Free School Meals  Free school transport  Help with school clothing costs

18. Special Needs  Special Educational Needs and Disabilities (SEND)  Used to be called learning difficulty assessment or a statement  Each school or college should have a SEN Co-ordinator  Can request LA to carry out an Education, Health and Care plan for <25yo

19. CAF  Common Assessment Framework  Gathers and records info about child, whom practitioner is worried about  To identify needs and  To decide how needs can be met  Allows coordinated service provision  NEEDS consent  3 areas  Growth and development  Additional educational needs  Family and environmental issues (including needs of parent/carer)

20. Review of mother’s health any pre-existing medical conditions Medications review Smoking cessation (both parents) Folic acid supplements Advice on diet Weight loss if needed Check immunity e.g. Rubella, Varicella Appointment with GP Review of mother’s health any pre- existing medical conditions Medications review Smoking cessation (both parents) Folic acid supplements Advice on diet Check immunity Referral to midwives Family History Genetics Social class GP

21. Vitamin K Guthrie Tests Baby check after birth Breast feeding advisors Newborn hearing screen Follow up at home by midwives then health visitors (Social services) (Child safeguarding procedures) Dating & growth scans Antenatal screening tests (e.g. Nuchal, CVS etc.) Regular checks by midwife / GP Antenatal classes NCT Surestart maternity Grant Statutory Maternity pay Maternity Allowance Start4Life Surestart children’s centres (BCG) Child trust fund voucher Child Benefit Statutory maternity pay Statutory paternity pay Personal Child Health Record (Red book) GP

22. DTaP/IPV/Hib (2 nd dose) Meningitis C vaccination Rotavirus Post natal for mother Baby check DTaP/IPV/Hib PCV (pneumococcal conjugate vaccine) Rotavirus DTaP/IPV/Hib (3rd dose) PCV (2 nd dose) Meningitis C (2 nd dose) Health visitor clinics Surestart Children’s centres Child benefit (OT /Physio / SALT) (Social services) (Child protection register) GP

23. MMR (1 st Dose) PCV (3 rd Dose) Full Health Visitor review Developmental assessment Hib/MenC (4 th Dose Hib, 3 rd Dose Men C) Full Health Visitor review Developmental assessment Flu imms age 2-6 Health visitor clinics Surestart Children’s centres Child benefit (OT /Physio / SALT) (Social services) (Child protection register) Child abuse alert system GP

24. Education (LEA) National Curriculum SEND Special Needs Schools Growth, vision & hearing screening (not all schools) Pre-school check MMR (2 nd Dose) DTaP/IPV (4th dose) Health visitor clinics Surestart Children’s centres Child benefit 15hrs/wk free childcare (OT /Physio / SALT) (Social services) (Child protection register) GP

25. Education (LEA) National Curriculum SEND Special Needs Schools Growth, vision & hearing screening National Healthy Schools programme Personal health (including drug & sex education) Healthy eating Physical activity Emotional health (including bullying) Child benefit Child Trust Fund contribution (OT /Physio / SALT) (Social services) (Child protection register) GP

26. Td/IPV booster Men C booster Chlamydia screening Drug/alcohol awareness Teenage conception HPV Vaccine for girls Cervical Cancer 3 injections in 6 mths Child benefit - 16 & under (16-18yrs in education / approved training) (OT /Physio / SALT) (Social services) (Child protection register) GP

27. Any questions? Good luck!