Gillick competency and Fraser guidelines

The terms ‘Gillick competence’ and ‘Fraser guidelines’ are frequently when consenting children to medical treatment. These are often used interchangeably despite there being a clear distinction between them.

Gillick competence (assessment of a child's maturity and intelligence) is concerned with determining a child’s capacity to consent while Fraser guidelines are used specifically to decide if a child can consent to contraceptive or sexual health advice and treatment. Confusion and misunderstanding these terms may have profound medicolegal implications. 

Gillick competence

In UK law, a person's 18th birthday draws the line between childhood and adulthood. Therefore, an 18-year-old enjoys as much autonomy as any other adult. To some extent, 16 and 17 year-olds can also take medical decisions independently of their parents. The right of younger children to provide independent consent is proportionate to their competence i.e depends on their Gillick Competency.  For instance, we have all seen very sensible 16-year-olds who are at par with 20 years old. More commonly, we encounter 22 years old who still behave like a teenager. Therefore, child's age alone is an unreliable predictor of his or her competence to make decisions.

Children under 16 can consent if they are Gillick Competent i.e. if they have sufficient maturity and intelligence to fully understand what is involved in a proposed treatment, including its purpose, nature, likely effects and risks, chances of success and the availability of other options. Decision making competence does not simply arrive with puberty; it depends on the maturity and intelligence of the child and the seriousness of the treatment decision to be made.

The rule in Gillick must be applied when determining whether a child under 16 has the competence to consent. The aim of Gillick competence is to reflect the transition of a child to adulthood. Legal competence to make decisions is conditional on the child gradually acquiring both:

• Maturity - That takes account of the child's experiences and the child's ability to manage influences on their decision making such as information, peer pressure, family pressure, fear, and misgivings.
• Intelligence - That takes account of the child's understanding, ability to weigh risk and benefit, consideration of longer-term factors such as the effect on family life and on such things as schooling.

It is not just an ability to choose but it is an ability to understand, where the child must recognize that there is a choice to be made and that choices have consequences and they must be willing, able and mature enough to make that choice.

If a child passes the Gillick test, he or she is considered ‘Gillick competent’ to consent to that medical treatment or intervention provided if the consent was given voluntarily and not under influence or pressure. The understanding required for different interventions will vary, and capacity can also fluctuate such as in certain mental health conditions. However, where the same child refuses consent then they may obtain it from another person with parental responsibility who can consent to treatment on the child's behalf.

If a child does not pass the Gillick test, then the consent of a person with parental responsibility (or sometimes the courts) is needed in order to proceed with treatment.

Gillick test is not a blood test! It forms a part of the assessment requiring an examination of how the child deals with the process of making a decision based on an analysis of the child's ability to understand and assess risks. It is a high test of competence that is more difficult to satisfy the more complex the treatment and its outcomes become. Where a child is considered Gillick competent then the consent is as effective as that of an adult and cannot be overruled by a parent.  

If a Gillick competent child refuses medical examination or treatment then the law does allow a person with parental responsibility to consent in their place. Where a health professional accepts the consent of a Gillick competent child it cannot be overruled by the child's parent. However, where the same child refuses consent then they may obtain it from another person with parental responsibility who can consent to treatment on the child's behalf.

What if a 10 years old appears to meet Gillick Competency? Can we treat him without consent?

There is no lower age limit for Gillick competence or Fraser guidelines to be applied. That said, it would rarely be appropriate or safe for a child less than 13 years of age to consent to treatment without a parent’s involvement. When it comes to sexual health, those under 13 are not legally able to consent to any sexual activity, and therefore any information that such a person was sexually active would need to be acted on, regardless of the results of the Gillick test. 

If a person under the age of 16 is not Gillick competent then he/she deemed to lack the capacity to consent, it can be given on their behalf by someone with parental responsibility or by the court. However, there is still a duty to keep the child’s best interests at the heart of any decision, and the child or young person should be involved in the decision-making process as far as possible.

Fraser guidelines

The ‘Fraser guidelines’ specifically relate only to contraception and sexual health. They are named after one of the Lords responsible for the Gillick judgment but who went on to address the specific issue of giving contraceptive advice and treatment to those under 16 without parental consent. The House of Lords concluded that advice can be given in this situation as long as:

1. He/she has sufficient maturity and intelligence to understand the nature and implications of the proposed treatment (Is he/she Gillick competent?)
2. He/she cannot be persuaded to tell her parents or to allow the doctor to tell them
3. He/she is very likely to begin or continue having sexual intercourse with or without contraceptive treatment
4. His/her physical or mental health is likely to suffer unless he/she received the advice or treatment
5. The advice or treatment is in the young person’s best interests.

Health professionals should still encourage the young person to inform his or her parent(s) or get permission to do so on their behalf, but if this permission is not given they can still give the child advice and treatment. If the conditions are not all met, however, or there is reason to believe that the child is under pressure to give consent or is being exploited, there would be grounds to break confidentiality.

Fraser guidelines apply to contraceptive advice and treatment, decisions about treatment for sexually transmitted infections and termination of pregnancy.

What about taking consent in 16-17 year olds? 

Young people aged 16 or 17 are presumed in UK law, like adults, to have the capacity to consent. However, unlike adults, their refusal of treatment can in some circumstances be overridden by a parent, someone with parental responsibility or a court. This is because we have an overriding duty to act in the best interests of a child. This would include circumstances where refusal would likely lead to death, severe permanent injury or irreversible mental or physical harm.

Summary

Gillick competence is the principle we use to judge capacity (maturity and intelligence) in children (<16 years old) to consent to medical treatment. If a child passes the Gillick test, he or she is considered ‘Gillick competent’ to consent to that medical treatment or intervention but If a Gillick competent child refuses consent then they may obtain it from another person with parental responsibility who can consent to treatment on the child's behalf. 

Fraser guidelines apply to contraceptive advice and treatment, decisions about treatment for sexually transmitted infections and termination of pregnancy.

There is no lower age limit for Gillick competence or Fraser guidelines to be applied. That said, it would rarely be appropriate or safe for a child less than 13 years of age to consent to treatment without a parent’s involvement. 

Further Reading

• Wheeler R (2006) Gillick or Fraser? A plea for consistency over competence in children. BMJ 332(7545): 807
• Gillick v West Norfolk & Wisbech AHA & DHSS [1983] 3 WLR (QBD)
• Axon, R (on the application of) v Secretary of State for Health [2006] EWHC 37 (Admin)
• Mental Capacity Act 2005 
• https://www.gmc-uk.org/static/documents/content/0_18_years.pdf
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1432156/pdf/bmj33200807.pdf

Posted by:

              

     Lakshay Chanana

     

     Speciality Doctor

     Northwick Park Hospital

     Department of Emergency Medicine

     England

     @EMDidactic

Neonatal Problems - Part 2

Gastroesophageal Reflux and Vomiting 

Regurgitation of small amounts of milk or formula is common in neonates due to reduced lower esophageal sphincter pressure. Parents often confuse regurgitation with vomiting. Adequate weight gain in a baby with GER is reassuring but those who fail to thrive or have respiratory symptoms related to feeding should be investigated for anatomic causes of regurgitation. Reflux can be reduced with  thick feeds and feeding in upright position. Regurgitation with stridor and cough should be evaluated for anatomical defects. Potential causes of vomiting include tracheoesophageal fistula with esophageal atresia, GI obstruction or midgut malrotation, intussusception, necrotising enterocolitis  It may also be a symptom of sepsis, raised ICP, inborn errors of metabolism, incarcerated hernia. 

Diarrhea and Dehydration 

Neonates are susceptible to dehydration and electrolyte abnormalities associated with severe diarrhoea. Bloody diarrhoea may be a symptom of volvulus, intussusception, or necrotising enterocolitis. Abdominal distention may also occur in association with diarrhoea, bowel obstruction, constipation, necrotizing enterocolitis, or ileus due to sepsis. Obtain serum electrolytes, glucose, stool testing and a urine sample in the setting of fever to evaluate for UTI.

Blood in Diaper 

Potential causes include blood from genital tract in girls, anal fissure, swallowed maternal blood, coagulopathies, necrotizing enterocolitis, allergic or infectious colitis, congenital defects or idiopathic. A newborn with a single event of hematochezia and no concerning findings may be observed as an outpatient. Persistent symptoms or concerning exam findings should be further evaluated. 

Constipation 

Infrequent bowel movements in neonates do not necessarily mean that the infant is constipated. Infants occasionally may go without a bowel movement for 5 to 7 days and then pass a normal stool. However, if the neonate has never passed stools, especially if there has not been a stool in the first 48 hours of life, consider intestinal stenosis, Hirschsprung’s disease, or meconium ileus associated with cystic fibrosis. Neonates with constipation should have a careful evaluation of thyroid function and lumbosacral spine for evidence of occult neural tube defects. The diagnosis of Hirschsprung’s disease is supported by absence of feces on rectal examination, a tonic or tight sphincter tone, and an abrupt change in bowel luminal size on barium enema, and is confirmed by a rectal biopsy demonstrating absence of ganglion cells. 

Neonatal Jaundice

Jaundice signifies hyperbilirubinemia and can represent normal new-born physiology or a pathologic process. 

Physiologic jaundice is characterized by a slow rise in bilirubin (<5 milligrams/dL per 24 hours), with a peak of 5 to 6 milligrams/dL during the second to the fourth days of life and a decrease to <2 milligrams/dL by 5 to 7 days. Decreased neonatal hepatic glucuronyl transferase activity, a shortened life span of neonatal red blood cells and relative polycythemia, and decreased intestinal bacterial colonization all lead to an increase in enterohepatic circulation that produces the normal rise in bilirubin seen in physiologic jaundice. 

Breast milk jaundice occurs be due to the presence of substances that inhibit glucuronyl transferase in the breast milk; it may start as early as the third to fourth day and reaches a peak of 10 to 27 milligrams/dL by the third week of life. Cessation of breastfeeding is not routinely recommended. It is unlikely to cause kernicterus and usually can be treated with phototherapy, when necessary. 

Breast feeding (starvation) jaundice occurs when a newborn is exclusively breastfed and the mother’s milk supply is still inadequate. Poor oral intake leads to reduced bowel movement and less bilirubin excretion through the GI tract. Treatment is optimizing the neonate’s feeding pattern with supplementations or donated breast milk. Severe hyperbilirubinemia may require treatment.

Excessive hyperbilirubinemia can lead to permanent brain injury (kernicterus). 

Distinguishing between physiologic and pathologic neonatal jaundice is important, and the timing of the onset of jaundice in the newborn provides useful clues. 

Timing:
<24hrs - Congenital or Acquired  infections, ABO/Rh incompatibility, Hematoma (Cephal/IM)
2-3 days - Physiologic
3-7days - Congenital or Acquired  infections, CN Syndrome, Giblert's Syndrome
>7 days -  Acquired infection, Breast milk jaundice, Congenital or acquired hepatitis, Biliary Atresia, RBS membrane of enzyme defects, Metabolic (galactosemia, fructosemia)

Key questions to evaluate jaundice:

• Day of onset
• Blood group and Rh status
• Maternal infections during pregnancy
• Maternal blood type and RhoGAM® administration
• Color of stool 
• Fever
• Family history of hemolytic anaemia 
• Conjugate or Unconjugate Hyperbilirubinemia

Scleral icterus is typically noted with serum bilirubin >5 mg/dL. 

Unconjugated hyperbilirubinemia is much more common, presents earlier in the neonatal period, and is related to the normal or abnormal breakdown of hemoglobin, although inherited enzyme deficiencies or infection may be pathologic causes. Conjugated hyperbilirubinemia results from the inability to excrete bilirubin into the bile and intestines and is usually the result of primary hepatic or biliary disease such as biliary atresia or hepatitis. Conjugated hyperbilirubinemia is always pathologic and often presents later in the neonatal period with jaundice, acholic stools, and dark urine.

The treatment of hyperbilirubinemia depends on the cause, but for most cases of unconjugated hyperbilirubinemia, phototherapy is sufficient. For severe cases, exchange transfusion may be required. 

References;

Tintinalli's Emergency Medicine 8th edition

Posted by:

              

     Lakshay Chanana

     

     Speciality Doctor

     Northwick Park Hospital

     Department of Emergency Medicine

     England

     @EMDidactic

  

Neonatal Problems - Part 1

Emergency Department visits in neonates are often due to unclear and nonspecific symptoms. Subtle signs may not point to a specific illness. For instance, Respiratory, Cardiac, Abdominal and Metabolic pathologies can all cause respiratory distress. Many visits just need reassurance and understanding of what constitutes normal for a neonate but the key remains to differentiate benign symptoms from potentially life-threatening underlying disease.

Normal Neonatal Patterns

1. Feeding pattern are quite erratic in the few weeks of life. Breastfed infants take shorter and more frequent feeds (q1-3hrs) as compared to formula fed ones. Adequate Intake is considered if weight gain ranges between 20-30gms/day in the first three months. It is important to remember that neonates loose up to 12% (may be more in exclusively breast fed infants) of their body weight in the first week and are back to their birth weight by 15th day of life. 

2. Just like feeding, bowel movements also varies in number, colour and  consistency. 

Meconium (fist stool) is passed within the first 24 hours after birth. Color changes from black->dark green->yellow seedy by day 4. Failure to pass meconium in the first 48 hours of life may suggest Hirschsprung’s disease or cystic fibrosis.  Breastfed infants may occasionally go 5 to 7 days without a bowel movement. In contrast, overfeeding or use of formula that is too high in sugar content also can produce loose stools.

3. Normal respiratory rate in neonates is 30 to 60 breaths/min. Neonates increase minute ventilation almost entirely through an increase in respiratory rate rather than inspiratory volume. A resting RR >60 breaths/min requires evaluation. Observe respirations to determine if breathing is thoracic or abdominal. Since neonates are obligate nose breathers, even nasal congestion may cause respiratory distress. Periodic breathing (alternating periods of a normal/fast/slow rate with pauses of 3-10 seconds between breaths) is common in pre-term infants. Prolonged Apnea (>20 seconds) or apnea accompanied by bradycardia, cyanosis, or a change in muscle tone is abnormal and requires evaluation. 

4. Infants sleep pattern is fragmented ranging from from 20 minutes to 6 hours cycles spread throughout the day and night. By 6 months, most infants are sleeping through the night. It is important to look for any physical reason of unexplained nighttime cry. Benign causes of cry include Reflux, Wet or Soiled Nappies, Hunger, Too hot or too cold, Teething etc. Carefully look for other pathologies in an episode of acute, inconsolable crying. 

Crying

Inconsolable crying requires a thorough history and head-to-toe examination. Here is a list of illnesses presenting as crying. 

CNS: Intracranial Bleed (NAI, VIt K deficiency), Meningitis and Raised ICP
ENT: Choanal Atresia, Otitis Media, URTI
Eye: Corneal Abrasion, FB eye
CVS: Arrythmias, Heart Failure
RS: Pneumonia
GI: Oral Thrush, Stomatitis, Volvolus, Intussusception, Hernia, Anal Fissure, reflux, UTI, Diaper Rash, Gastroenetritis
GU: Testicular torsion, hair tourniquet, paraphimosis
MSK: NAI, Hair tourniquet 
Metabolic: Inborn errors, hypoglycaemia, Congenital Adrenal Hyperplasia 

If a careful history and complete physical examination does not reveal any source and the infant remains quiet during the ED observation period, reassure and advise follow up with the general practitioner. 

Colic: Unknown pathophysiology. Sudden onset of paroxysmal crying, a flushed face, circumoral pallor, tense abdomen, drawn up legs, cold feet, and clenched fists. Colic is defined as a paroxysm of crying for ≥3 hours per day for ≥3 days per week over a 3-week period. It is a diagnosis of exclusion. Rule out other sinister causes of irritability.

There is no specific treatment for colic and casual administration of drugs or sedatives is contraindicated. Colic creates immense stress among caregivers stress. 

Cough/Cold: Cough/Runny nose and Sneezing are usually due to Viral URTI. Neonates with underlying pulmonary or heart disease may develop respiratory failure with even mild URTIs. Check for ill contacts and perinatal infectious risk factors. Respiratory symptoms related with feeding might suggest reflux and aspiration or congenital tracheoesophageal fistula. Respiratory difficulty when quiet and improvement during crying suggest choanal atresia. Treat the underlying condition. Do not give cough suppressants to neonates. Treat nasal congestion with instillation of saline drops and bulb suctioning.

Abnormal Airway Sounds: May be related to benign problems. Distinguish between:

1.Stertor (snoring sound due to soft tissue vibrations in nasopharynx). Stertor can be a symptom of choanal stenosis which can be confirmed by inability to pass a small nasogastric tube through the affected nostril is diagnostic of this condition. 

2. Stridor (sign of upper airway obstruction, can be inspiratory or expiratory) commonly occurs due to laryngomalacia. Stridor may also be a symptom of congenital anomalies causing a fixed obstruction (webs, cysts, atresia, stenosis, clefts, and hemangiomas) anywhere from the nose to the trachea and bronchi. Stridor from fixed lesions is often biphasic. 

• Stridor worsening with cry: laryngomalacia, tracheomalacia, or subglottic hemangioma 
• Stridor accompanied by feeding difficulties: vascular ring, laryngeal cleft, or tracheoesophageal fistula. 
• Stridor with hoarseness or weak cry suggests vocal cord paralysis.
• Stride post intubation: maybe due to subglottic stenosis 
• Stride with fever: croup, epiglottitis, and abscess 

When the diagnosis is uncertain, admit for observation and evaluation. 

Periodic Breathing: Periodic breathing must be differentiated from apnea. Apnea is cessation of breathing for ≥20 seconds, or cessation of breathing for a period <20 seconds accompanied by bradycardia, cyanosis, or a change in muscle tone. It signifies critical illness and warrants investigation and admission for monitoring and therapy. Apnea usually indicates respiratory muscle fatigue and impending respiratory arrest. Provide airway and ventilatory support, and search for the cause. If no obvious cause is found, presume sepsis, obtain cultures, and initi- ate broad-spectrum antibiotics and acyclovir if there is concern for herpes simplex virus. 

Abnormal Movements: 

1. Benign sleep myoclonus: Rhythmic myoclonic jerks observed when the infant is drowsy or in quiet sleep and can be suppressed upon touching and/or waking the infant

2. Startle Reflex: Single myoclonic jerk with extension of the arms and legs triggered by noise or tactile stimulation.

3. Seizures: Present with subtle manifestations, such as eye deviation, tongue thrusting, eyelid fluttering, apnea, pedaling movements, or arching, rather than generalized activity. Neonatal seizures usually indicate a severe underlying structural or metabolic problem and are rarely idiopathic.

Eye Discharge: Clear eye discharge with crusting over the eyelashes without associated conjunctival redness or irritation, is commonly seen in neonates and infants and results from narrow or obstructed nasolacrimal ducts. This condition usually resolves sponta- neously and requires antibiotics only when complicated conjunctivitis or dacryocystitis. Ophthalmologic consultation in needed if problem persists past 12 months of age or  if associated with recurrent infections. Causes of Red Eye include Corneal Abrasion, Acute Glaucoma, Conjunctivitis (Gonococcal, Chlamydial, Herpes Simplex) 

References;

Tintinalli's Emergency Medicine 8th edition

Posted by:

              

     Lakshay Chanana

     

     Speciality Doctor

     Northwick Park Hospital

     Department of Emergency Medicine

     England

     @EMDidactic

  

Acute Bronchiolitis

Bronchiolitis is a common LRTI in ≤2 years age group and it is also one of the the leading cause for hospitalization in infants. The most common bus associated with bronchiolitis is RSV (other possible agents are human metapneumovirus, adenovirus, influenza, rhinovirus, and parainfluenza viruses. Following an episode, cough may persist for up to 3 weeks. 

Pathophysiology
The viral infection in bronchiolitis causes inflammation of the lower respiratory tract leading to edema, necrosis, increased mucus production and bronchospasm eventually causing  air trapping, atelectasis, and hyperinflation of the lower airways and increased work of breathing. 

Symptoms
The peak of symptoms is often between the third and fifth day after onset

• Coughing. 
• Rhinorrhea, tachypnea
• Wheezing and Crackles 
• Use of accessory muscles and subcostal and intercostal retractions
• Nasal flaring
• Low grade fever 
• Irritability, cyanosis, and poor feeding
• Apnea in infants
• Dehydration due to increased insensible losses

Risk Factors for severe disease

• Chronic Lung Disease
• Age < 3moths
• Premature Birth
• Congenital Heart Disease
• Immunodeficiency 
• Neuromuscular Disorders

Diagnosis

• Bronchiolitis is a clinical diagnosis. 
• No lab tests are useful 
• Blood tests and CXR: indicated only if other diagnoses need to be excluded or in cases of severe disease (high O2 requirement)

Differential Diagnosis

• Asthma
• Pneumonia
• Foreign Body
• Cystic Fibrosis

Treatment 

• Oxygen Target oxygen saturation of >92%.
• Instillation of saline into the nares followed by suctioning
• Frequent and smaller feeds to prevent dehydration
• Caretakers should use frequent hand washing to minimise spread

Controversial Treatment Options:

• Bronchodilators do not offer any clear benefits and thus should not be given routinely.
• Inhaled epinephrine should be considered only in severe disease
• Steroids do not provide any benefit if used alone. However, current guidelines do advocate consideration for steroid use in combination with epinephrine in the treatment of bronchiolitis.
• Nebulized Hypertonic Saline: Mixed evidence and not recommended for routine use. It improve mucociliary clearance by loosening mucous plugs through osmotic draw of fluid from submucosal and adventitial spaces. 
• Ventilatory Support: Noninvasive ventilation may prevent intubation. 
• Heliox: Heliox does not affect the rates of intubation or mechanical ventilation or length of intensive care admission

Admit if:

• Risk Factors for severe disease
• Premature birth
• Persistent symptoms despite therapy
• Dehydration, 
• Spo2 <90% on room air)
• Episodes of apnea 

Take Home: 

• Bronchiolitis affects <2year age group and RSV is the most common bug.
• Supportive Care and Hydration is the key
• Most treatment modalities are controversial and thus are not recommend for routine use. Consider using in rapidly deteriorating

References and Further Reading:

1. Fernandes R, Bialy L, Vandermeer B, et al: Glucocorticoids for acute viral bronchiolitis in infants and young children. Cochrane Database Syst Rev 6: CD004878, 2013. [PMID:23733383]
2. Ralston SL, Lieberthal AS, Meissner HC, et al: Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics 134: e1474, 2014. [PMID: 25349312]
3. http://pediatrics.aappublications.org/content/early/2014/10/21/peds.2014-2742
4. https://www.nice.org.uk/guidance/ng9/chapter/1-Recommendations#management-of-bronchiolitis 
5. http://pedemmorsels.com/bronchiolitis-seriously-what-should-i-do/

Posted by:

              

     Lakshay Chanana

     

     Speciality Doctor

     Northwick Park Hospital

     Department of Emergency Medicine

     England

     @EMDidactic