The art of all successful care-giving is to learn to see things from the patient's point of view. Perhaps the biggest single mistake we make in caring for children is to think that they see things as we do. In the great activity of our busy clinics and wards full of acutely ill or dying children, it is all too easy to overlook this aspect of care. In so doing we may save lives but leave emotional scars. Each age group is at risk.
Newborn babies
Many parents and professionals caring for babies see
attention but mindless. Others may say, even of very young infants, that they are deliberately naughty or spiteful. Both these attitudes are wrong. Although babies are dependent on others for food and care, they also show a personal responsiveness which indicates a deep-seated interest in other people. It seems that, to them, personal relationships matter most. We now know that the sensory pathways of a newborn baby (touch, taste, smell, sound and vision) are all set at birth to respond best to human contact. 5 Breast-feeding babies can indicate at five days that they know their own mother by smell. On the first day of life, the most interesting pattern for a baby to look at is that of a face and the distance at which the child's eyes focus best is that between the parent's face and the holding arm (Fig. 1. 7.2).
Because babies are born to relate, it may be very hurtful to remove them at birth to recover from the shock of being born, either alone or in a nursery with other babies in the same state. Should not each newcomer receive a loving welcome from their nearest and dearest? Instead, babies are subjected to being weighed, injected, bathed and swaddled - all extra-ordinary experiences after the confines of the womb and usually done by busy and sometimes impersonal hands.
In many countries now, cultural traditions have been changed to allow the father into the delivery room and to allow both parents to have time with their baby right from the start, surely a fitting climax to all their expectations as well as being a comfort to the child.
Even if the baby is ill and needs special care, this early contact is to be encouraged. It has been shown that there is less cross-infection, not more, if parents are taught and allowed to handle their own children. The
them almost like dolls - interesting and needing Fig.1.7.2 The baby's focal distance.
Fig.1.7.3 A photograph for use between visits.
child becomes used to their organisms (to be met at home eventually anyway) and at the same time their relationships are all strengthened. Sadly, there are still centres where parents are kept out, even though at least one study has indicated that there is a risk of child abuse later if early attachment is interfered with in this way. 6
The roots of a relationship, present before birth, must be encouraged to grow stronger as soon as the child is born. Wealthier countries have the practice of giving a photograph of the baby to parents to keep the feelings warm (Fig. 1.7.3). Poorer countries could experiment with drawings, or giving a piece of the baby's hair as a momento.
The first year
A child in close contact with parents may indicate within weeks that their faces are familiar when seen in a group. By five months, a parent who has been away will be welcomed back with open arms and a broad smile.
How children see our treatment of them 123 By about ten months a child will start to search for a hidden object, so showing that what is not seen is still known to exist. This is known as the concept of permanence and until it is grasped, out of sight is out of existence. This is true of people as well as objects. If a child without this concept is admitted to hospital alone (or a mother admitted without her baby) there will be bewilderment and a sense of loss without any real knowledge of what has happened. Once the concept of permanence is achieved, however, the child will know that the parent is somewhere else and the sudden inter-ruption of a previously close relationship (as when a child has been breast-fed but is separated from the mother) will cause acute misery and pining. In the child's eyes, this abandonment is impossible to understand (Fig. 1. 7 .4). In countries where the physical closeness has been the greatest, the sense ofloss will be greater still, yet sadly it is in these very countries that weaning practices may include sending the child away. From riding on his mother's back, sharing her bed and having access to her breast, the child is suddenly out in the cold and has no idea that this was done with good intention. For some, the subsequent misery may be at least in part responsible for the advent of kwashiorkor (a syndrome associated with severe calorie and protein deficiency) and could be provoked by hospital admission if the mother did not come too (see pp.335-57). We must therefore clarify the relationship of any attendant in hospital, neither assuming that she is the mother nor that she will be the permanent care-giver. Teaching about the child's needs must be given to the person who will give ongoing care and must include instruction on emotional as well as physical needs.
One to six-year-olds
As the years go by, a child's experiences will train intelligence and understanding but (although we were all children once) it surprises most adults to be shown how long it takes for a child to learn that things are not always what they seem. Imagine that you are already feeling quite ill, but are taken out of your own bed to see an alien person, three times your size and wearing strange clothes, who at once removes you from your family . You are taken into a big white room full of unfamiliar objects and the stranger holds you down on a table whilst someone else starts to torture you with sharp instruments pushed into your arm, head or back.
How terrifying this would be and you might emerge scarred for life. Yet this happens all the time to small children when it is hospital practice to exclude parents whilst procedures are being performed. Everyone but the child knows that this is intended for their good and
124 Parents and children in hospital
Fig. 1.7.4 Abandonment is impossible for a child to Fig.1.7.5 Recovery is quicker with a parent present.
understand.
very few stop to think of the damage actually being done.
Children cannot be spared confusion and even distress, but to be lovingly supported through such experiences helps them to grow up instead of being permanently hurt. It is important both to offer comfort after inflicting a necessary pain and also to have on hand someone familiar and trusted to offer further reassurance. Hospitals with staff shortages may actually do their patients a good turn if they depend on parents for nursing care. Even uneducated village people can be taught simple nursing procedures (such as guarding a drip) which upset a child far less when done with care by relatives than they would if performed by a busy professional (Fig. 1.7.5).
Six to 12-year-olds
It is a sad fact that this age group may still be nursed on adult wards when paediatric beds are limited, or the
special needs of children are unrecognized. Yet an adult way of thought does not emerge until adolescence and it is not in the child's best interests to be out of a paediatric environment. Even though younger children may copy adult phrases or behaviour, this is done entirely without insight. A child will still match experiences and ideas with those previously encountered and the ability to perceive differences and make correct deductions takes years to develop. It takes even longer to see things in depth and to understand double meanings.
If a family member stays with a child, or at least visits regularly, there is someone familiar to ask, but we must warn relatives (and staff) not to laugh at a child's misconceptions. To be humiliated means not to ask again and so to suffer unnecessary confusion and distress.
Over 1 2 years
Children now begin to understand adult behaviour and thought a little more, though inexperience and
immaturity mean that such understanding is still incomplete. Also, we all become less confident in unfamiliar surroundings. Even an adult admitted to hospital can feel very overwhelmed, so that regular visiting by family and friends is important as reassurance, although a constant attendant is not as necessary at this age.