Dr Shobha Teterwal 1
Dr Prashant Kumar Shukla2
Abstract: Case taking is an art and the hardest part of this art is paediatric case taking. As a paediatrician the hardest part is to get the symptoms from the child as well as from their parents and though in adult case taking we take symptoms by the words of the patient but in paediatrics our observation is the key. For successful treatment and reaching to the cure in any paediatrics case, proper case taking and correct medicine selection is very important. The following article aims at enhancing the knowledge about the paediatric case taking and prescription writing.
Keywords: Paediatrics, Prescription, Case taking, Homoeopathy
Introduction: Paediatric case taking and prescription writing is a very hard part as a physician for not only homoepaths but for any physician. For homoeopathic paediatricians it is very important to have a proper case taking of a paediatric case because for prescription writing we require totality and this is why it is said that the hardest part when dealing with a paediatric case is case taking. In paediatric case taking observation is the key as the questions during case depend on observing the behaviour of a kid. That observation gives more data about the children than the children themselves. To ascertain the constitution of an infant history of mother and obstetrics history works as a guiding anchor. In few words, the case taking in a paediatric case is not centric on just patient as in any adult case, in such cases there are multiple factors such as mother’s history, obstetrics history, relationship of mother/parents and child and most important, observation of physician.
How to deal with a paediatric case as a physician?
- The hardest part when dealing a paediatric case is not to decide a remedy or potency because as a homeopath we all know to decide a remedy we need a totality of symptoms and for potency we need susceptibility, nature of disease and nature of medicine.
- But to come at this point we need proper data of a patient and this is where all physicians (even allopaths) struggle when they handle a case of paediatric age group.
- Data collection or case taking is the hardest part in paediatric because our patient sometimes not able to or may not be in a position to give a detailed symptoms we need for homoeopathic prescription.
- Basic and frequently asked question we get when we handle a paediatric case is how we should approach our case taking?
The “ART” of paediatric case taking!
- One thing which come out of every book or experience of senior doctors is OBSERVATION. As Dr. Pravin said in his book “Essentials of paediatrics” the art of paediatric case taking lies in 3 points, “Observation, interpretation and confirmation from the parents.”
- He further stated, “The crux of paediatric case taking depends on observations. One has to understand what to observe in a child. After careful observation, proper interpretation of these observations has to be made. Once this is done, direct questioning to the mother to confirm your observation completes the first aspect of case taking.”
- Why we should prefer mother for confirmation? About that Dr Desai has stated in his book, ‘Bring up healthy children with homoeopathy’, “The mother is usually the most reliable person to provide the necessary details, as she watches the child more closely most of the time.”
- It is essential to ask leading question when you take paedia case. Dr Pravin wrote “In paediatric case taking it is essential and safe to confirm your interpretations from the parents.” Many times parents presents a different picture from what you observe hence it is very important to confirm your observation through direct questions.
- One such example Dr Pravin Has given in his book, “Once a mother took an appointment for her 10 year old son complaining of atopic dermatitis since childhood. She said that her son is very obedient, and affectionate. He will always care for everyone. He will share his toys with other children. Teacher says that he is very good and well behaved in class. From this preliminary information he made up his mind to give phosphorus to this child.
- When the child came to his clinic, the mother and child had to wait outside in the waiting room, as he was seeing another patient. When their turn came, the child first refused to come inside the clinic. On enquiring, the mother confided that since they had to wait long, the child was upset. After a lot of persuasion the child came inside his cabin, but he could see dissatisfaction in his eyes. He avoided his presence and refused to answer any of his questions. When he tried to probe further and started asking questions to the child, the child got annoyed. This observation made me rethink his prescription of phosphorus.
- So the prescription should be always based on your observations, and not just on the history provided by the parent. Most of the parents initially say that their child is very good in studies, obedient etc. He is very cordial with his friends. But when the child comes to your clinic you observe an opposite trait. When you observe such disconformities, you have to confirm your observation by asking leading and tricky questions to the parents. Often the parents will confirm your observation.
So what should we ask?
- There are no fixed formats of questions or observations which can be asked or done in every case. A child grow very rapidly hence the questioning and interpretations change every month. So, there cannot be any standard or regulated pattern of history taking. But, we can learn about the development of a child, which gives us an insight of what to consider normal and what to abnormal.
- During every stage of development, some normal pattern of behaviour will be regarded as abnormal if we fail to understand the normal child. For example, stealing is considered as normal in preschool children, but if it continues in schooling children, it is abnormal. Hence we have to understand ‘normal development’ which consists of 3 aspects:
- Physical development.
- Social and Emotional development.
- Intellectual development.
- All children follow a similar development pattern with one stage leading to the next. Babies stand before they walk. Toddlers start drawing circles before they draw squares.
- Though many fellow homeopaths might consider this out of place, but a proper understanding of the normal developmental pattern is helpful in many ways. Once these patterns are clear to you:
- You know what you are dealing with.
- You know what to observe.
- You know how to interpret.
- Helps you to formulate a questionnaire for a particular age group.
‘Must have’ in paediatric case taking
Here are two pointers which are must during a paediatric case taking:
- Mother’s history during pregnancy
- Obstetrics history(Also include after breast feeding history)
- Mother’s history during pregnancy :
- This is very important when treating infants. The environment in which the child lives before birth – the mother’s womb – is very significant and plays a major role in the development of the child. Maternal stress during pregnancy is an important factor affecting the temperament of the child.
- Maternal stress upsets the normal functioning of the maternal endocrine system. This leads to a hyperactive state of the thyroid and adrenal glands – the glands of the endocrine system that prepare the body for increased activity during an emotional state. These endocrine secretions are transmitted to the prenatal environment in the uterus and result in a change in that environment, affecting the developing child.
- From the homeopathic point of view, these maternal stresses have to be persistent, to be taken as a key point in history taking. It should also be noted that this history is significant only as far as infants and toddlers are concerned, for as the child grows he starts developing his own individuality. The same history becomes less significant for preschool and schooling children.
- Obstetrics History – Few Questions that will give vital clues:
- Was the mother unconscious (under sedation) after delivery?
- How soon were the mother and the child brought together after delivery?
- For how many months was breast feeding continued?
- How was the delivery?
- Occupation of mother?
- To understand the significance of these questions we need to understand about the effects of breast feeding through Erik Erikson’s Psycho-social stages. The mother gives nourishment, comfort, attention and love. The infant responds with warmth and pleasure. If there is a proper bondage between the mother and infant, the infant learns to have confidence in the orderliness and predictability of his environment; if not, he is likely to become fearful, apprehensive, and panicky.
- It is observed that a child who is brought in close contact with the mother immediately develops the “basic trust” and the child who is not breast-fed immediately or breastfeeding is stopped early, develops “basic distrust”. Emotional bonding is a very significant step for development of the child. In cases where the childbirth is not normal (cesarean etc), or the child develops some complication and is kept away from the mother in the initial period, the emotional bond between the child and the mother is not developed and such children’s may suffer psychological problems. They may be withdrawing or develop a forsaken feeling.
- If the mother is a working lady, then she has to resume her duty as early as possible after a fixed maternity leave. Either she discontinues the breast-feeding at an early stage or breast-feeds the child only after she returns from work. How it will affect the child?
Let’s understand with the help of a case from Dr Pravin Jain’s book.
Case: This was a case of a teacher’s son. The teacher was living alone with her daughter. Husband was working in another city 500 kms away, and used to come to meet her every fortnight on weekends. She used to miss her husband a lot. During pregnancy, she had a constant anxiety about how she would handle the responsibility alone. She delivered a healthy baby boy. When the child was 3 months old, she had to re-join her job in school. The maidservant looked after the child. She used to feed her child after coming back from school. The child had developed respiratory tract infection with wheezing after vaccination.
Explanation: The child was born healthy, but inherited the insecure and wanting love state from the mother. But this state was dormant. When the mother resumed work, the child was left with the maidservant. So this inherent dormant state of lack of love got excited. When the child was vaccinated, this added fuel to the fire and he started suffering from respiratory tract illness. In this case, He took – A/F unhappy love, as the eliminating symptom. The mother’s history during pregnancy, and the situation of mother after delivery was significant. The child was approaching, and hyperactive. All these points made him prescribe Hyoscyamus and the child improved very nicely with Hyoscyamus.
How to deal with an adolescent or teenagers?
- When taking a history from an adolescent or young adult, it is important to address the health risk behaviours that are more prevalent in this population, as well as the young person’s resilience factors. The HEEADSSS acronym is a useful tool for exploring this area of the history.
- It’s important to reassure the adolescent that the content of the conversation will remain confidential. However, it’s also important that the young person understands that confidentiality cannot be assured if they’re at risk of harm – to themselves, or others.
- Home and relationships (H)
- Education and employment (E)
- Eating (E)
- Activities and hobbies (A)
- Drugs, alcohol and tobacco (D)
- Sex and relationships (S)
- Self-harm, depression and self-image (S)
- Safety and abuse (S)
Points to remember when deal a paediatric case
- Soft, gentle and caring are the most important qualities that every homeopath should have. Be smiling and polite to children and never get angry with children even if they are at their worst.
- Comfort the child when he comes in your clinic. Approach the child with a smiling face and treat him as a child and not as a patient. Never start examining the child as soon as he enters the clinic. Try to build a rapport with the child and then only examine him.
- The body gesture should show a friendly attitude. You should literally come down to the level of the child, both physically and mentally to elicit cooperation.
- Toys and chocolate should be kept in the clinic for our little friends, it make the atmosphere truly friendly. Infants and young children should be offered a soft toy to establish a rapport.
- Questioning children should be avoided at the very beginning of the interview. Ask the mother about the child’s behaviour, but observe the child constantly during the interview. Answers from the mother are less relevant than the observations you make while you are interviewing the mother.
- Observation of each and every movement of the child should be noted properly. Avoid staring at the child because they are often scared if you intently look into their eyes. Spend maximum time on observation. Remember no two human beings are alike and this include children.
- Anxiety of the parents should be allayed. Overanxious parents will ask many questions about the child. Proper explanation in context to the questions and relevant developmental milestones of a normal child along with its normal variations should be explained to allay the anxieties of the parents.
How to select of medicine and potency?
- Selection of medicine is same in paediatrics as any other branch, with the help of repertory. We make totality according to the case we had taken and then with the help of repertory we find the similimum medicine.
- Now the hard part is to select the right potency and repetition. It is also the most talked and controversial aspect of homoeopathic paediatrics.
- Hence, Dr. Desai in his book said, “Potency is really an open question which the prescriber has to decide for himself taking into account,
- The nature of the disease, i.e. acute, serious acute, sub-acute or chronic
- The nature of medicine, i.e. superficial or deep acting, short or long acting, whether an organ remedy and whether the true similimum
- The nature of patient, his age, constitution, temperament, vital power, occupation, susceptibility, etc
- In short, selection of potency in paediatric cases follows the same principal as of any other case and we should select potency same as we select for any other case.
- Though there is no generalization in homoeopathy, Dr Desai in his book suggested, “Children need medium and higher potencies, as their sensitivity to potencies is highest. This susceptibility diminishes with the age.”
- But he also warned that the selection of higher potencies for infants should be done very carefully.
Few Tips and Tricks to Improve Paediatric OPD
- Greetthe child, their parents/carers and any other siblings who are present.
- Make sure to maintain a comfortable distance from the child at the beginning of the consultation, whilst trying to build rapport with the family as a whole.
- Observe how the child is playing and interacting with any siblings and their parents/carers.
- Make sure to address questions to the child when appropriate. Depending on the child’s age, they will hold a wealth of knowledge about their current condition and their history. Be mindful to allow the child time to answer and do not interrupt.
- Negotiating both talking to parents without the child present and talking to the child alone requires tact and consideration. It is a good idea to speak to the parents first, then the adolescent or young adult – to provide some reassurance that the confidential information imparted to the doctor is not going to be immediately disclosed to the parents.
- Ask about schools, hobbies, their interests and their friends at the start to make them feel comfortable.
- Use a checklist to maintain proper case handling.
A helpful checklist for reference
- Essentials of Paediatrics By Dr. Pravin Jain
- Bring up healthy children with homoeopathy By Dr. Bhanu D. Desai
- Organaon Of Homoeopathy By Dr. C. F. S. Hahnemann
- Fozi & Wood (2016). HEEADSSS Assessment. Nottingham Children’s Hospital. Nottingham University Hospitals NHS Trust.
Dr. Shobha Teterwal 1
Dr. Prashant Kumar Shukla2
1M.D. (Hom), Associate Professor, HOD- Department of Paediatrics, Swasthya Kalyan Homoeopathic Medical College and Research Centre, Jaipur, Rajasthan, India.
2M.D. (PGR), Paediatrics, Swasthya Kalyan Homoeopathic Medical College and Research Centre, Jaipur, Rajasthan, India.
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