Community Pediatrics, Preventive Medicine and Ethics
Community and preventive items test the population-level package that keeps children alive: immunisation delivery, growth monitoring, nutrition supplementation, oral rehydration, injury prevention and screening. Ethics items test consent, assent, confidentiality, best interests and end-of-life decisions, often in an adolescent scenario.
The preventive package
- Immunisation through the national schedule, with correct cold chain: most vaccines are stored at 2-8 degrees Celsius and must never be frozen; freeze-sensitive vaccines include DTP, hepatitis B and Hib.
- Growth monitoring at every contact, with prompt referral for faltering growth.
- Vitamin A supplementation, iron and folic acid, iodised salt, and promotion of exclusive breastfeeding for six months.
- Oral rehydration salts plus zinc for diarrhoea; this combination is the single most effective community intervention against diarrhoeal death.
Screening and surveillance
Newborn screening, hearing screening, vision screening, developmental surveillance, anaemia and lead screening where risk exists. Screening is only justified when a test is valid, the condition is important, and effective treatment is available.
Injury prevention
Car seats appropriate for age and weight, water safety and supervision, safe storage of medicines and paraffin, burns prevention from cooking, and window and balcony guards. Injury prevention counselling is more effective when targeted by developmental stage.
Ethics
- Consent for a child is given by a parent or legal guardian, with the child's assent sought as capacity develops. A competent adolescent's views carry increasing weight, especially for chronic illness.
- Confidentiality applies to adolescents but has limits: risk of serious harm, abuse, or a legal duty to report. Explain the limits before taking a history.
- Suspected child abuse triggers mandatory reporting, even without parental agreement.
- Withholding or withdrawing futile treatment is ethically equivalent to allowing natural death; the aim is comfort, not shortening life. Nutrition and hydration debates must be handled with the family and, where relevant, religious guidance.
- Research in children requires ethics approval, minimal risk where possible, and no coercion.
Worked example
A 14-year-old with a chronic condition refuses a course of treatment that his parents want. The correct approach is to assess his capacity to understand the consequences, explore his reasoning, involve him in decisions with his parents, and respect a capable adolescent's refusal for a non-life-threatening issue while continuing to offer support. Seek ethics or legal input if the refusal risks his life.
Traps
Failing to seek assent from an older child, breaching adolescent confidentiality without warning, and reporting abuse only after parental permission.