The Great Ormond Street Hospital Manual of

Children’s Nursing Practices

The GOSH website http://www.gosh.nhs.uk contains helpful information for parents, children, teenagers and healthcare professionals. Under ‘Healthcare Professionals’ further clinical guidelines and integrated care pathways can be accessed.

The Great Ormond Street Hospital Manual of

Children’s Nursing Practices

Edited by

Susan Macqueen OBEPrevious Lead Nurse and Director of Infection Prevention and Control

Great Ormond Street Hospital for ChildrenLondon, UK

Elizabeth Anne BruceClinical Nurse Specialist, Pain Control Service

Great Ormond Street Hospital for ChildrenLondon, UK

Faith GibsonClinical Professor of Children and Young People’s Cancer Care

Great Ormond Street Hospital for Children and London South Bank University London, UK

A John Wiley & Sons, Ltd., Publication

© 2012 Great Ormond Street Hospital for Children NHS Foundation Trust. Published 2012 by Blackwell Publishing Ltd.

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Library of Congress Cataloging-in-Publication DataThe Great Ormond Street Hospital manual of children’s nursing practices / edited by Susan Macqueen, Elizabeth Anne Bruce, Faith Gibson. p. ; cm. Manual of children’s nursing practices Includes bibliographical references and index. Summary: ‘Clinical skills are a fundamental aspect of nursing care of children and young people. The Great Ormond Street Hospital Manual of Children’s Nursing Practices is an evidenced-based manual of practical skills in children’s nursing, which builds on the extensive expertise developed at Great Ormond Street Hospital. It encompasses all aspects of children’s nursing from the most basic aspects of everyday practice to advanced practice in high dependency and intensive care to provide a comprehensive resource for all qualified nurses, students, and other health-care professionals involved in caring for children, both in the hospital and the community setting’–Provided by publisher. ISBN 978-1-4051-0932-1 (pbk. : alk. paper) – ISBN 978-1-4443-6118-6 (e-book) I. Macqueen, Susan. II. Bruce, Elizabeth (Elizabeth A.) III. Gibson, Faith, 1960– IV. Hospital for Sick Children (London, England) V. Title: Manual of children’s nursing practices. [DNLM: 1. Pediatric Nursing–methods. 2. Adolescent. 3. Child. 4. Infant. WY 159] 618.92'00231–dc23 2012009759

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Also available in other electronic formats• e-book, ISBN 978-1-4443-6118-6• Kindle, see www.amazon.co.uk• Wiley Desktop Edition, see http://eu.wiley.com/WileyCDA/WileyTitle/productCd-1118307798,descCd-ebook.html

Set in 9.5/11 pt Minion by Toppan Best-set Premedia Limited

1 2012

Every effort has been made in the writing of this book to present accurate and up-to-date information from the best and most reliable sources. However, the results of caring for individuals depend upon a variety of factors not under the control of the authors or the publishers of this book. Therefore, neither the authors, or Great Ormond Street Hospital, nor the publishers assume responsibility for, nor make any warranty with respect to, the outcomes achieved from the procedures described herein.

Contents

Foreword ixAcknowledgements xListofcontributors xiIntroduction xvii

  1  Assessment  1Introduction 2Measuringvitalsigns,heightandweight 6Reviewofsystems 13Bloodpressure 21References 35

  2  Allergy and anaphylaxis  38Introduction 39Allergyandtheimmuneresponse 39Diagnosisandmanagementofallergy 40Managementofanaphylaxis 41Foodallergy 43Respiratoryallergy 46Allergensinthehealthcaresetting 48Conclusion 51Keytexts 51References 51Usefulwebsites 52

  3  Biopsies  53Introduction 54Liverbiopsy 54Punchskinbiopsy 60Renalbiopsy 66Bonemarrowaspirateandtrephine 69References 72

  4  Administration of blood components and products  74Introduction 75Anoverviewofbloodtransfusion 75Administrationofredcells 76Administrationofplatelets 76Administrationoffreshfrozenplasma(FFP) 76Administrationofcryoprecipitate 76Administrationofalbumin 80Administrationofimmunoglobulin 80Administrationofcoagulationfactors 86Conclusion 86References 86

  5  Bowel care  87Introduction 88Constipation 88

Treatmentofconstipation 89Diarrhoea 91Transanalcolonicirrigation 95Stomacare 97References 101

  6  Burns and scalds  103Introduction 104Commoncausesofburnsinchildren 104Overviewofanatomyoftheskin 104Classificationofburns 104Firstaidfollowingaburn 105Fluidresuscitationformajorburns 108Woundhealingandwoundcare 108Whichdressing? 111Nutrition 112Psychologicalcarefollowingaburn 112References 115

  7  Child protection  117Introduction 118Thehospitalsetting 118Anindividualandcorporateresponsibility 118Definingchildabuseandneglect 119Theeffectsofabuseandneglect 120Sourcesofstressforfamilies 120Childrenwithdisabilities 121Differenceandculture 122Thelegalframework,nationaland

politicalinfluences 122Learningfromseriouscasereviews 123Asafeguardingculture 125Implicationsfornursingpractice 126TheCommonAssessmentFramework(CAF) 126Practiceguidanceforthechildren’snurse 127ProfessionalresponsibilitiesofstaffatGreat

OrmondStreetHospital 127ProceduresforchildrenattendingA&E 128Proceduresforchildrenadmittedtohospital 129Fabricatedorinducedillness:concernsorsuspicion 130Pre-dischargeplanningprocedure 130Afinalword–communicationwithotheragencies 131Acknowledgements 131References 131

  8  Cytotoxic drugs  134Chemotherapy administration 135Legislation 135Consent 135Safehandling 135

vi  CONTENTS

Reconstitutionandpreparationofchemotherapeuticagents 135

Personalprotectiveequipment 136Workpractices 136Safeadministrationofchemotherapy 136Routesofadministration 138Intrathecalroute 140References 141

  9  Fluid balance  142Introduction 143Fluidbalanceintheillchild 143Vascularaccess 149Haemofiltration 151Peritonealdialysis 158Interventions 163References 164Furtherreading 165

10  Personal hygiene and pressure ulcer prevention  166Introduction 167Bathing 167Toileting 174Nappycare 180Nailcare 187Oralhygiene 189Eyecare 202Earcare 206Pressureulcerprevention 208Conclusion 216References 217Usefulwebsites 220

11  Immunisations  222Introduction 223Routinechildhoodimmunisationschedulein

UK–2010 223Specialriskgroups 224Immunity 224Typesofvaccine 225Generalconsiderations 225Specificdiseasesandthevaccines 227Storageandadministrationofvaccines 231Ensuringgooduptake 231Vaccinesafetyscares 233Immunisationofhealthcareprofessionals 233Conclusion 234References 234Furtherresources 235

12  Infection prevention and control  236Introduction 237Financialburdenofhospitalacquiredinfection 237Freedomofinformation 238Bioterrorism 238Thechainofinfection 238Standardprecautions 240Handhygieneandskinprotection 241Personalprotectiveequipment 245

Isolationnursing 249Asepticnon-touchtechnique 257Managementofexposuretobloodandbodyfluids 259Reportingofinjuries,diseasesanddangerous

occurencesregulations 260Bloodspillage 260Decontaminationofequipmentand

theenvironment 261Laundrymanagement 262Wastedisposal 263Pestcontrol 264References 264Furtherreading 266

13  Intravenous and intra-arterial access  267Intravenousaccess 268Peripheralvenouscatheters 268Peripherallyinsertedcentralcatheters 290Non-tunnelledshort-termpercutaneouscentral

venouscatheters 292Tunnelledcentralvenouscatheters:Hickman

andBroviaclines 292Implantableports 293Removalofcentralvenouscatheters:possible

complications 309Arteriallines 310References 321Appendix13.1Suppliersofstickersandcertificates 324

14  Investigations  325Generalintroduction 326Introductiontoradiology 326Generalradiology 330Fluoroscopy 330Intravenousurography 331Micturatingcystourethrogram 332Dysphagiaswallowusingvideofluoroscopy 333Uppergastrointestinalseries 333Tubeoesophagram 334Bariumfollowthrough 335Bariumenema 335Contrastenema(andGastrografinenema) 335Airenema 336Tracheobronchography 337Linogram 338Ultrasound 339Computedtomography 339NuclearMedicine 340Magneticresonanceimaging 342Interventionalradiology 342Collectionofmicrobiologicalspecimens 344Bloodsamples 346Biopsymaterial 347Cerebro-spinalfluid 347Takingswabs 347Faeces 350Fungalsamplesofhair,nailandskin 351Gastricwashings 351

CONTENTS  vii

Naso-pharyngealaspirate 352Sputum 352Urine 353Vesicularfluidforherpespolymerasechain

reaction(PCR) 354References 355

15  Administration of medicines  357Introduction 358Childdevelopmentconsiderations 359Drugcalculations 360Oraladministration 364Enteraltubeadministration 366Buccalandsublingualadministration 369Intranasaladministration 370Inhalationadministration 372Rectaladministration 376Injections 378Intradermaladministration 380Subcutaneousadministration 382Intramuscularadministration 384Intravenousadministration 387Intraosseousadministration 387Intrathecaladministration 389Epiduraladministration 393Skinpatchesadministration 393Acknowledgements 394References 394Furtherreading 395

16  Moving and handling  397Introduction 398Legislation 398Riskassessment 399Injury 400Documentation 405Equipment 406Restraintandtherapeuticholding 412References 415

17  Neonatal care  416Introduction 417Neonatalthermoregulation 417VitaminKadministration 424Umbilicalcare 426Newbornbloodspotscreening(formerly

Guthrietesting) 428Phototherapy–neonataljaundice 431References 434

18  Neurological care  436Introduction 437Neurologicalobservations 437Seizures 443Externalventriculardrainage 447Lumbarpuncture 462References 464Bibliography 465Appendix18.1TheGOSHComaChart 466

Appendix18.2Typesofpainfulstimuli 470Appendix18.3Examplesofmotorresponses 470Appendix18.4Anexampleofanalgorithmfor

aconvulsingchild 471

19  Nutrition and feeding  473Introduction 474Nutritionalrequirements 474Nutritionfrompretermtoadolescence 474Breastfeeding 480Enteralfeeding 485Parenteralnutrition 499Shamfeeding 506References 509Supportingbreastfeeding–someusefuladdresses 511

20  Orthopaedic care  512Introduction 513Neurovascularobservations 513Plastercare 519Crutches 526Careofachildintraction 530Keytexts 538References 538

21  Pain management  539Introduction 540Generalprinciplesofpainmanagement 540Painassessment 542AdministrationofEntonox 548Epiduralanalgesia 554Patientandnursecontrolledanalgesia(PCA/NCA) 566Preventionandmanagementofopioidrelated

complications 570Sucrose 573Keytexts 574References 574

22  Palliative care  577Introduction 578Assessmentofsymptoms 578Nauseaandvomiting 579Constipationanddiarrhoea 580Dyspnoea 581Anorexiaandreducedfluidintake 582Externalhaemorrhage 583Seizures 583Signsofimpendingdeath 584Afterthechilddies 585Preparationofthebody 591Movingthechildwhodiesinhospital 593Aftercare 594Acknowledgements 596Keytexts 596References 596

23  Peri-operative care  598Introduction 599Preoperativepreparation 599

viii  CONTENTS

Perioperativecare 603Recovery 606References 608

24  Play as a therapeutic tool  609Introduction 610Thedevelopmentofplayinhospital 610Normalplayfordevelopment 611Theimportanceofplayforchildreninhospital 611Preparationforsurgeryandprocedures 615Distractiontechniques 617Therapeuticplay–1:1sessions 620Keytexts 623References 623Furtherreading 624

25  Poisoning and overdose  625Introduction 626Non-accidentalingestionandself-harm 626Commoningestions 627Initialmanagementfollowingpoisoning

oroverdose 628Treatmentofingestedpoisons 629Gastriclavage 630References 634

26  Respiratory care  635Introduction 636Airwaysuction 636Oxygentherapy 642Chestdrainmanagement 648Keytextsandwebsites 660References 660

27  Resuscitation practices  663Introduction 664Aetiologyofcardiorespiratoryarrest 664Airwaymanagement 664Recoveryposition 668

Advancedairwayandbreathingmanagement 668Circulationmanagement 671Basiclifesupport 676Choking 681Cardiorespiratoryarrestmanagement 684Defibrillation 688Medicationsincardiorespiratoryarrest 689Potentiallyreversiblecausesof

cardiorespiratoryarrest 690Post-resuscitationcare 690Ethicalconsiderations 690References 691

28  Tracheostomy: care and management  693Introduction 694Caringforanewlyformedtracheostomy 694Humidification 699Managementofanestablishedtracheostomy 700Resuscitation 706References 714Appendix28.1Tracheostomytubesforchildren 715

29  Urinary catheter care  718Introduction 719Insertionofindwellingurethralcatheters 719Emptying,drainageandflushing 726Obtainingacatheterspecimenofurine 729References 732

30  Drug withdrawal – prevention and management  734Introduction 735Withdrawalprevention 736Withdrawalassessment 737Withdrawalassessmenttools 738Managementofwithdrawal 740Weaningprotocols 741References 744

Index 746

Foreword

It is a great pleasure to be able to introduce the first edition of The Great Ormond Street Hospital Manual of Children’s Nursing Practices. Great Ormond Street Hospital for Children has an international reputation in the care and treatment of sick chil-dren. The underpinning nursing practice principles can be adopted by nurses working across all settings. We hope this manual will be viewed by children’s nurses across the world as a comprehensive evidence base which they can draw upon to support their day-to-day practice.

Healthcare for children and young people has changed beyond all recognition over the last thirty years. These developments have been in response to a number of factors including advances in medical science, technology and pharmacology, and more and more children are surviving long-term, life-limiting and life-threatening conditions.

Excellent nursing practice makes a significant contribution to the work of the healthcare team and the overall care of the child and family. As a result clinical colleagues, children, families and the public expect nurses to deliver high-quality patient care with exemplary nursing skill in a highly complex and emotionally charged environment. To maximise this contribution requires the development of sound clinical skills: an ability to critically analyse a particular situation; to gather comprehensive and rel-evant information to make an accurate clinical assessment ensuring early detection and recognition of deterioration; decision-making and taking appropriate action.

This requires a nurse to be well informed, knowledgeable and keep up-to-date. This can be challenging – to meet these many priorities, and balance the demands of practice in a wide range of busy clinical environments. It is hoped this manual will help children’s nurses to ensure their practice is evidence-based and up-to-date.

Predominantly written by nurses from Great Ormond Street Hospital there are a number of highly respected contributors to this long-awaited book from several organisations and clinical settings representing the breadth and complexity of children’s services. The coordination required to produce this manual has been no mean feat for the editors, Susan Macqueen, Elizabeth Bruce and Faith Gibson, whose tenacity is to be admired. The importance of collaboration across the wider healthcare team outweighs the challenges to produce this text which emphasises the delivery of seamless care across a range of settings and pro-fessional groups.

Liz MorganChief Nurse

Great Ormond Street Hospital for Children NHS Foundation Trust

Fiona SmithAdvisor for Children & Young People’s Nursing

Royal College of Nursing

Acknowledgements

The Editors and Wiley-Blackwell would like to thank the many reviewers who provided welcome feedback and recommenda-tions on individual chapters within the Manual.

They would also like to thank other staff at Great Ormond Street Hospital who contributed to the development of the Manual, including Sarah Allen (Chapter 14), Jennifer Grehan (Chapter 14), Jane Stevens (Chapter 3) and Crispin Walklin-Lee (Chapter 13).

Every effort has been made to acknowledge by name the many staff at the Great Ormond Street Hospital for Children NHS Foundation Trust who have contributed to earlier drafts of the Manual. The Editors and Publisher are very grateful for their assistance and would like to apologise for any inadvertent omissions.

List of contributors

Editorial Panel

Breidge Boyle MSc, BSc (Hons), RN (Child), RN (Adult), ANNPAdvanced Neonatal Nurse PractitionerGreat Ormond Street Hospital for Children NHS Foundation TrustLondon, UK

Chris Caldwell RN (Adult), RN (Child), RNT, BSc (Hons), MSc, PGDip EdAssistant Director of Education and Organisational Development (Assistant Chief Nurse)Great Ormond Street Hospital for Children NHS Foundation TrustLondon, UK

Kathryn Halford RN (Adult), RN (Child), BScAssistant Chief NurseGreat Ormond Street Hospital for Children NHS Foundation TrustLondon, UK

Joy Hayes RN (Child), BSc (Hons), MSc, Dip Nurse EdMatron for PaediatricsWhittington Health NHS TrustLondon, UK

Kate Khair RN (Adult), RN (Child), MSc, MCGINurse Consultant, HaemophiliaGreat Ormond Street Hospital for Children NHS Foundation TrustLondon, UK

Lindy May RN (Adult), RN (Child), MSc (Neuroscience), Diploma in CounsellingNurse Consultant, NeurosurgeryGreat Ormond Street Hospital for Children NHS Foundation TrustLondon, UK

Liane Pilgrim RN (Child), BSc (Hons)SisterHaemodialysis UnitGreat Ormond Street Hospital for Children NHS Foundation TrustLondon, UK

Vanessa Shaw MBE, MA, RD, FBDAHead of Dietetics, Honorary Associate Professor University of PlymouthGreat Ormond Street Hospital for Children NHS Foundation TrustLondon, UK

Elisabeth Smith RN (Adult), RN (Child), Advanced Diploma in Child Development, MSc Child DevelopmentLead Advanced Nurse Practitioner & ECMO CoordinatorCardiorespiratory Services, Paediatric Cardiology and Cardiac SurgeryGreat Ormond Street Hospital for Children NHS Foundation TrustLondon, UK

Mark Whiting PhD, MSc, BNursing, RGN, RSCN, HV Cert, DN Cert, PGDip (Ed), RNTConsultant Nurse, Children’s Community and Specialist NursingHertfordshire Community NHS TrustPeace Children’s Centre, Watford, Hertfordshire, UK

List of Contributors

Katie J. Allen RN (Adult), RN (Child), Bsc (Hons) Professional PracticeChildren’s Neuroscience UnitGreat Ormond Street Hospital for Children NHS Foundation TrustLondon, UK(Chapter 18)

Katrina Anthony RN (Adult), DipHE (child)Pre-Admission Nurse Specialist, UrologyGreat Ormond Street Hospital for Children NHS Foundation TrustLondon, UK(Chapter 29)

Tina Banks DCR (R)Former CT Superintendent Radiographer, MRI research radiographerGreat Ormond Street Hospital for Children NHS Foundation TrustLondon, UK(Chapter 14)

xii List of Contributors

Helen Bedford BSc, MSc, PhD, RN (Adult), RHV, FFPH, FRCPCHSenior Lecturer in Children’s HealthCentre for Epidemiology and BiostatisticsUCL Institute of Child HealthLondon, UK(Chapter 11)

Fiona Bell BSc (Hons) Children’s Nursing, ENB 147Lecturer Practitioner, Nephro-urologyGreat Ormond Street Hospital for Children NHS Foundation TrustLondon, UK(Chapter 29)

Nikki Bennett-Rees RN (Child), RN (Adult), Diploma advanced nursingClinical Nurse Specialist, Bone Marrow TransplantGreat Ormond Street Hospital for Children NHS Foundation TrustLondon, UK(Chapter 3)

Margaret Bird RN (Adult), RN (Child), BSc Hons, MScClinical Lead NurseChildren’s Community Nursing Team, Children’s CentreNorwich, UK(Chapter 23)

Fiona Blackwell RN (Child), RN (Adult), Dip Child DevelopmentMatron for Children’s ServicesWye Valley Trust, Hereford County Hospital, Hereford(Chapter 14)

Breidge Boyle MSc, BSc (Hons), RN (Child), RN (Adult), ANNPAdvanced Neonatal Nurse PractitionerGreat Ormond Street Hospital for Children NHS Foundation TrustLondon, UK(Chapter 17)

Emma Brady BSc (Hons) PhysiotherapyPhysiotherapistPhysiotherapy DepartmentGreat Ormond Street Hospital for Children NHS Foundation TrustLondon, UK(Chapter 20)

Eileen Brennan RN (Adult), RN (Child), ENB 147, MScNurse Consultant in Paediatric NephrologyGreat Ormond Street Hospital for Children NHS Foundation TrustLondon, UK(Chapters 1, 9)

Kathryn Bridgwater RN (Child), BSc (Hons) Child Health, Advanced Diploma in Child DevelopmentNurse Practice Educator, OrthopaedicsGreat Ormond Street Hospital for Children NHS Foundation TrustLondon, UK(Chapter 20)

Joanne Brind RN (Adult), RN (Child), MSc, Dipl (IPresc)Clinical Nurse SpecialistGreat Ormond Street Hospital for Children NHS Foundation TrustLondon, UK(Chapter 19)

Elizabeth Bruce MSc, BSc (Hons), RN (Adult), RN (Child)Clinical Nurse Specialist, Pain Control ServiceGreat Ormond Street Hospital for Children NHS Foundation TrustLondon, UK(Chapters 15, 21, Editor)

Sue Chapman RN (Adult), RN (Child), Advanced Diploma (child development), MSc Paediatric Critical Care (advanced nursing practice), ENB100Nurse Consultant, Acute and High Dependency Care and Associate for Safer Care (Paediatrics)NHS Institute for Innovation and ImprovementGreat Ormond Street Hospital for Children NHS Foundation TrustLondon, UK(Chapters 1, 16)

Robert Cole RN (Child), RN (Adult), MA Ed, PGDip Ed, BSc (Hons)with ENB Higher Award, ENB 199, ENB998, ENB A53.APLS InstructorNurse Lecturer/ PractitionerKing’s College LondonFlorence Nightingale School of Nursing and MidwiferyLondon, UK(Chapter 25)

Sue Cole RN (Adult), RN (Child), DipHE Children’s Oncology NursingPaediatric Oncology CNS, Paediatric WardSouth London Healthcare NHS TrustKent, UK(Chapter 13)

Amber Conley Bachelor of Health Science Nursing, BSc Nursing Studies (Child), MSc NursingMatron and Lead Principal Treatment Centre Nurse for Children and Young PeopleThe Royal Marsden NHS Foundation Trust and St George’s Healthcare NHS TrustSutton, Surrey(Chapter 8)

List of Contributors xiii

Joanne Cooke TD, MSc, BSc (Hons), RN (Adult), RN (Child)Nurse Practitioner, Tracheostomy CareGreat Ormond Street Hospital for Children NHS Foundation TrustLondon, UK(Chapter 28)

Catherine Dunne Dip PT, MSc PhysiologyClinical Specialist PhysiotherapistCardiorespiratory PhysiotherapyGreat Ormond Street Hospital for Children NHS Foundation TrustLondon, UK(Chapter 26)

Teresa Durack RN (Adult), RM, DipN, PGDip, MScModern Matron, Corporate FacilitiesGreat Ormond Street Hospital for Children NHS Foundation TrustLondon, UK(Chapters 2, 23)

Netty Fabian RN (Child)Formerly Senior Staff Nurse, Transitional Care UnitGreat Ormond Street Hospital for Children NHS Foundation TrustLondon, UK(Chapter 19)

Róisín Fitzsimons RN (Child), BSc (Hons), Dip HEClinical Nurse SpecialistThe Children’s Allergy ServiceSt Thomas’ HospitalLondon, UK(Chapter 2)

Sheryl Gettings MSc, BSc (Hons), RN (Child)Senior LecturerLondon South Bank UniversityLondon, UK(Chapter 19)

Faith Gibson PhD, MSc, RN (Child), RN (Adult), ONC Cert, Cert Ed, RNT, FRCNClinical Professor of Children and Young People’s Cancer Care, Great Ormond Street Hospital for Children NHS Foundation Trust and London South Bank UniversityLondon, UK(Chapters 10, 15, Editor)

Claire Gilbert BSc (Hons) (Children’s Nursing), Diploma (Child Health), RN (Adult), RN (Child)Clinical Nurse Specialist, HypoglycaemiaGreat Ormond Street Hospital for Children NHS Foundation TrustLondon, UK(Chapter 14)

Ambrose Gullet RN (Adult), RN (Child), BScClinical Research Nurse, Nephro-urologyInstitute of Child HealthUniversity College LondonLondon, UK(Chapter 29)

Julia Hannan RN (Adult), RN (Child), Adv Dip Child Development, BSc Child Health, MA Death and SocietyClinical Nurse Specialist, Paediatric Oncology Outreach and Palliative Care TeamGreat Ormond Street Hospital for Children NHS Foundation TrustLondon, UK(Chapter 22)

Juanita Harrison RN (Adult), RN (Child), BA HonsSpecialist Practitioner Children’s NursingAlder Hey Children’s NHS Foundation TrustWest Derby, Liverpool, UK(Chapter 6)

Joy Hayes RN (Child) BSc (Hons), MSc, Dip Nurse Ed,Matron for PaediatricsWhittington Health NHS TrustLondon, UK(Chapters 13, 14)

June Hemsley RN (Child), BSc Children’s NursingClinical Nurse Specialist, Paediatric Oncology Outreach and Palliative Care TeamGreat Ormond Street Hospital for Children NHS Foundation TrustLondon, UK(Chapter 22)

Sylvia J. Hennem MSc, CSci, FIBMSSpecialist Practitioner of TransfusionGreat Ormond Street Hospital for Children NHS Foundation TrustLondon, UK(Chapter 4)

Melanie Hiorns MBBS, MRCP, FRCRConsultant Paediatric RadiologistGreat Ormond Street Hospital for Children NHS Foundation TrustLondon, UK(Chapter 14)

Penny Howard RN (Adult), RN (Child)Clinical Nurse Specialist, OrthopaedicsGreat Ormond Street Hospital for Children NHS Foundation TrustLondon, UK(Chapter 20)