Children and young people for MRCGP AKT

A mother declines the MMR vaccine for her 13-month-old son because of things she has read online. She is polite but firm, and asks not to be pressured. Which is the most appropriate approach?

1. Refer the child to safeguarding for medical neglect Wrong. Declining MMR alone, in a child who is otherwise well cared for, is not neglect.
2. Offer separate single vaccines instead Wrong. Single vaccines are not part of the NHS schedule, there is no evidence they are safer, and offering them suggests her worry is justified.
3. Tell her the online information is nonsense and she is putting her child at risk Wrong. Confronting her usually makes the hesitancy stronger and ends the conversation you need to keep going.
4. Ask about her specific worries, give accurate information, record the talk, and offer to discuss it again correct Correct. Hesitant parents respond to being listened to more than to being corrected. Knowing the exact worry lets you answer it, and keeping the door open means the decision can change.
5. Remove the family from the practice list Wrong. Declining a vaccine is a parent's lawful choice and is not a reason to remove a family.

The point: Vaccine hesitancy is not refusal. Find out the specific worry, give real figures, be honest where there is uncertainty, record the conversation and keep the relationship so you can come back to it.

Source: UKHSA: Immunisation against infectious disease (the Green Book) UK Health Security Agency · tier 1, national regulator or guidance

A 6-year-old boy has been tired and pale for three weeks. His mother noticed small red spots on his legs this week. He has had no recent fever, injury or illness. On examination he has pinpoint red spots on his legs and trunk that do not fade when a glass is pressed on them. His liver edge and spleen tip are both palpable. According to current NICE guidance, which is the most appropriate action?

1. Very urgent full blood count, with review when the result is back Wrong. This is the right step for pallor and tiredness on their own. He also has unexplained pinpoint spots and an enlarged liver and spleen, which need a faster route than a blood test.
2. Suspected cancer pathway referral to be seen within two weeks Wrong. Two weeks is too slow for a child with these signs. NICE asks for immediate assessment because leukaemia can progress within days.
3. Routine blood tests at the next phlebotomy clinic Wrong. A routine test delays the diagnosis. His signs already point to a bone marrow problem, so he needs specialist care now, not a later result.
4. Monospot test and review in one week Wrong. Glandular fever can enlarge the spleen, but it does not explain the pale colour and the non-fading spots. Waiting a week risks missing leukaemia.
5. Immediate referral for specialist assessment correct Correct. Unexplained pinpoint spots (petechiae) or an enlarged liver and spleen in a child need immediate specialist assessment for leukaemia. He has both.

The point: NICE NG12 has two speeds for suspected leukaemia in children. Unexplained petechiae or hepatosplenomegaly means immediate specialist assessment. Pallor, persistent tiredness, unexplained fever, persistent infection, generalised lymph node swelling, persistent bone pain, bruising or bleeding mean a very urgent full blood count. Do not send a child with petechiae and an enlarged spleen for a blood test first.

Source: NICE NG12: Suspected cancer: recognition and referral NICE · tier 1, national regulator or guidance

A 12-year-old girl has had pain and swelling above her right knee for five weeks. The pain sometimes wakes her at night. She has not fallen or hurt the leg. She is otherwise well and has no fever. There is a firm, tender swelling over the lower thigh. Knee movement is normal and there is no redness. According to current NICE guidance, which is the most appropriate next step?

1. Referral to physiotherapy Wrong. Her pain wakes her at night and she has a swelling after no injury. This is not a strain that exercises will fix.
2. Very urgent direct-access X-ray of the thigh and knee correct Correct. Unexplained bone swelling or pain in a child needs a very urgent X-ray to look for a bone tumour. She has a firm swelling, night pain and no injury.
3. Reassure that these are growing pains and review in four weeks Wrong. Growing pains are in both legs, come in the evening and do not cause a swelling. A one-sided lump with night pain is a red flag.
4. Ultrasound scan of the knee joint Wrong. Her knee moves normally and the swelling is above the joint, so this is not a joint effusion. Bone needs an X-ray first.
5. Blood tests for ESR, CRP and full blood count, then review in one week Wrong. Normal bloods would not rule out a bone tumour, and waiting for them delays the X-ray she needs.

The point: NICE NG12 advises considering a very urgent direct-access X-ray for children and young people with unexplained bone swelling or pain. If the X-ray suggests bone sarcoma, refer very urgently, with an appointment within 48 hours. Night pain, a lump and no injury should make you think of a tumour, not growing pains.

Source: NICE NG12: Suspected cancer: recognition and referral NICE · tier 1, national regulator or guidance