Recognising the Sick Child

Children (from 0 - 18 y) constitute about 25% of the population and account for about a quarter of all visits to the Emergency Department. Pre-school children typically see their GP up to 6 times a year, while older children often attend twice a year. The age group 0 - 4 is the one which is brought to the doctor more than any other, bar the very elderly.

Sickness in a child makes both parents and doctors anxious, for good reason.

The good news is that the vast majority of illness in children is self-limiting and minor; the bad news is that children = especially the very young - can "go off" (become very ill) very unexpectedly.

The basic problem is that the minor illnesses are often indistinguishable from those which turn out to be more serious in the early stages; in addition, society has changed: there are fewer grandmother figures, more migrants with few family or friends to call upon, and many more single parents, sometimes struggling on their own to cope - even with children who are well.

One of the solutions has been observation, e.g. for a period of up to 24 hours in hospitals or at home: the is because probably the greatest diagnostic test of all is time, and the way a child's appearance or complaints can crystallise or dematerialise with simple care. Another solution is a checklist.

I suppose for the purpose of simplicity, it is best to think of two main groups of children when thinking about how to spot a sick child:

(1) The acutely unwell child who is most likely to present with
Fever, difficulty in breathing, vomiting, diarrhoea, rash, seizure or worsening pain

In such cases, the doctor is likely to follow a so-called ABCD -ENT -T approach and to check the

Airway: is there a lot of drooling, noise or obvious blockage coming from the mouth
Breathing: is the child struggling to breathe with really rapid breaths and all the chest wall muscles in action with a grey / bluish tinge to the skin
Circulation: is the child cool and grey and when you press on his / her breastbone for 5 seconds, does it take a couple of second or more from the white-ish "blanching" of the skin to disappear, suggesting really poor circulation, for whatever reason
Disability: is the child fully alert or (not) responding to voice, pain or not at all
ENT: is there inflammation of the tonsils or ear-drums, for instance
Temperature: is there a fever, using electronic thermometer at the eardrum or armpit

The doctor will also try to remember that the commonest missed acute illnesses in children are diabetes, meningitis, appendicitis or testicular torsion

The doctor will also realise that there are some particularly high-risk patients: particularly those younger than 2 when the body's immune system etc is still relatively immature and the patient may be at risk from infection, kidney or lung disease, congenital disorders or genetic issues

Most minor illness will be "up and down": so the child can be very ill and feverish one minute, and then a half hour after giving him some Paracetamol or Ibuprofen, he might be leaping around the waiting room of the doctor's surgery or the Emergency Department, causing no little exasperation for the parents. Nonetheless, this is actually a perfectly acceptable kind of diagnostic test which is part of the same process of observation which happens when a child is actually admitted to hospital.

Basically, getting rid of pain and fever, which is what Paracetamol or Ibuprofen do, removes one or two of the so-called "confounding factors" in assessing child: clearly it is harder to assess a child who is hot and bothers or writhing in pain, than one who is not.

The doctor of course will also measure certain physiological parameters like heart and respiratory (or breathing) rate and temperature and urine output: no parent can be reasonably expected to do the same but it is worth bearing in mind that that heart rate should never be over 160 beats per minutes, nor should the respiratory rate be greater than 40 per minute: similarly, the number of breaths per minute should seldom be under 20 in a young child or the heart rate less than 60; indeed if the rates are anything like these, the patient should already be with the doctor. Or ambulance crew.

The other group of children here are those who are (2) the slowly sick.

A simple rule of thumb is that children are rarely unwell for longer than a week, unless they have "back-to-back" infections when they are infants. So any fever that last more than 5 days is suspicious for a significant illness. Other issues which should cause enough concern to warrant a visit to the family doctor include

. weight loss that is hot quickly restored (e.g. after gastroenteritis),
. persistent limb pain or limp (e.g. hip disorders or bone problems),
. pallor, persistent fatigue / exhaustion, bleeding gums,
. rashes that don't "blanch" (i.e. turn white when pressed with a glass or parental thumb) or
. constant headache.

What I would like to talk about is the way doctors think when trying to assess a sick child and the sort of factors they take into account.

I would also like to mention that the fears and concerns of parents are "medically" recognised as vitally important when doctors take a history.

I want to reassure viewers that serious illness in children is unusual but that with a partnership approach, between the parents and healthcare providers, the right diagnosis and treatment is much more likely.

The most important message today would be that all parents of small children in particular, should think about making a plan of what to do if their child becomes ill.

For instance, who to turn to (like a good neighbour or member of the family or the local chemist or the nursing help-lines, provided by some insurance companies).

For instance, what to do at home if the child becomes ill (e.g. to keep the child cool if they are feverish with tepid sponging or Paracetamol or Ibuprofen by mouth or suppository)

For instance, when to take the child to the doctor (obviously, if you are very concerned)

When to take the child to the Emergency Department: if you are extremely concerned about the child: for instance they are unconscious, in great distress or have an obvious and new abnormality like a rapidly developing rash, a seizure, profound difficulty in breathing and so on. A parent might make the decision that it would be quicker for them to take the child directly to the hospital rather than to the family doctor or calling an ambulance and it would be very hard to quibble with such a decision (except, of course, in hindsight if the chid is back to normal by the time they get seen in the hospital).

For instance, how to get hold of an ambulance: dialling 999 or 112, and how to convey a clear message to the operator; to stay on the line, identify the source of the call and the person making it, the nature of the patient and condition (for instance, my son John, who is 3 and is very drowsy and hot and has a rash). Stay on the line and the operator may be able to give advice on what to do while the ambulance is coming.

Other key messages: don't rely on strip thermometers, don't give Aspirin to young children, keep little children cool by tepid sponging and taking off an excess of clothes, don't be afraid to give Paracetamol or Ibuprofen for fear of "masking" signs (they don't!), call an ambulance if a child is unresponsive, and watch out for foreign bodies or granny's medicines not being swallowed, and boiling water not being splashed. And don't smoke around children!!!

Dr C Luke

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