Paediatric month: treating the unwell child

Almost every clinician experiences the same worry, doubt and cautiousness when dealing with paediatric patients – especially with the additional challenges this group of patients present.

Children are obviously smaller, often have less communication skills to accurately describe what is happening to them and there is the added pressure of a parent, teacher or carer’s concern, who is also looking for reassurance.

What we need to remember is that although there are differences in the anatomy and physiology of the various age ranges of a child, the approach to our assessment doesn’t change. Taking a thorough history and using ABCD are still the best ways to establish what is going on and decide a course of action.

When you first come into contact with a child, visual aids and the use of the paediatric assessment triangle (PAT) will give you a measure of how unwell they may be. Although the components of the PAT, work of breathing, appearance and circulation to skin, are formalised in the ABCD assessment, they can quickly be used to give a general impression as to where and what your priorities should be.

For younger children a useful mnemonic for your initial communication and assessment of the child’s appearance is TICLS:

• T – tone
• I – interactiveness
• C – consolability
• L – look (or gaze)
• S – speech (or cry)

After your approach, introduction and consent, and having formed an impression in your mind as to whether this child is unwell, proceed to the formal ABCD assessment:

A – Is it clear? Is the child talking, crying or making any noises suggestive of a blockage? Wheeze, stridor, coughing a lot? Children, as any parent will tell you, like to put things in their mouth so a scan of the airway is important.

B – Respiration assessment can tell you a lot about what is going on and is often one of the most vital assessment tools to getting a good idea of whether there is a compromised physiology. An increase in respiratory rate is often the body’s first reaction to an abnormality, whether medical or trauma related. Normal rate is age-dependant, but we must take into account pain, being anxious and scared as these factors may also raise respiration rate. The visual clues on any breathing assessment will be the same.

• Look at the effort of breathing; is it laboured, tired, is there the use of accessory muscles? How is the child’s colour? Is it mottled? Signs of cyanosis in the extremities or lips? Is there a new rash or any bruising?
• Listen – on auscultation is there a wheeze/creps/crackles? Is there any audible sounds from the mouth during respiration to indicate a blockage?
• Feel - is there equal rise and fall or any pain around the chest during palpation? Any obvious crackles or areas of vibration during the inspiration phase that you can feel? How is the skin? Does it feel hot, clammy or indeed very cold?

C – Pulse range, as with respirations, must be assessed within the normal limits for the age of the patient but again, can be altered in a number of ways including being anxious and scared. With circulation there can be other clues that a child is unwell, such as being diaphoretic, cold, peripherally shut down, pale. Thready pulses and abnormal blood pressures are a sign of compromise in physiology. A tachycardia in the below age ranges should be considered as an intermediate risk group for serious illness and further specialist paediatric care should be sought as soon as practical.

Age	Heart rate (bpm)
<12 months	>160
12–24 months	>150
2–5 years	>140

 

D – As well as a pupil, temperature and a BM check, the best form of check in an unwell child is their interaction with family and friends. Those that know them best will be your primary source of establishing how things are different in terms of conscious level, energy levels, interactions and sharpness.

The most commonly reported illness in children is that of an unexplained fever. Temperature either above or below a normal range of 36-37°C is a very good prognostic indicator of the body fighting something (for children under 6 months specific focus should be given to high temperatures as this is dangerous). A New NICE quality standard has been created to help clinicians with the feverish child and can be viewed at: http://www.nice.org.uk/guidance/QS64. This site also contains a list of red flags that can be associated with a seriously unwell child, who should be transported immediately to hospital, as well as identifying markers and algorithms for leaving at home with referral and worsening advice.

http://www.nice.org.uk/guidance/cg160/resources/cg160-feverish-illness-in-children-support-for-education-and-learning-educational-resource-traffic-light-table2

If you decide to leave a patient at home, you should leave a copy of possible red flags to be aware of or a copy of the PCR showing exactly what advice and symptoms to look out for. There should always then be advice or an active referral to another primary care clinician, e.g. GP for a review and further assessment within the next 24 hours.

Published 18th July 2015