Hello, my name’s Dr. Ffion Davies, and I’m a consultant in emergency medicine. What we’re
going to talk about today is how to identify a sick child. And that means a really sick
child, not just a child with minor illness. And I’m not also going to talk about chronically
sick children with serious diagnoses such as cystic fibrosis, and that sort of thing.
So every year in the UK, about 5 million children are brought to urgent and emergency care – that’s
walk-in centres, emergency departments – and then millions more are taken to the GP with
an acute illness. And in all of this, how can we work out which are the sick ones that
need admission to hospital, and of those admitted, who is going to actually deteriorate, and
even worse, die?
And that’s a little like a needle in a haystack. 25 years ago the world was a different place.
Parents would come much later in the presentation of disease. And it was actually quite a lot
more obvious that a child was very sick. Whereas now we have these millions of children in
a sort of ‘grey-zone’ and we’re trying to work out which are the really sick children.
And in the UK, of course, not many children are very sick. So it is a little like spotting
a needle in a haystack.
What I’m going to talk about in the next few minutes is how to tease out at the end
of your consultation which of those children are potentially going to deteriorate, and which ones can go
home quite safely. So, as any clinician, you’re going to take
a history and you’re going to do an examination, and what we’re going to do is put another
little step before history which I’m going to call risk stratification, and I’ll explain
that, and we’re going to talk a little bit about the history, and some things you need
to tease out from the history, and also, in terms of examination, what do we mean by examination?
And we’re going to talk about the power of observation – observing the child – and
the observations… in other words, the vital signs.
So what do I mean by risk stratification? Well, sometimes it helps to just stop and
think, is this child actually at an increased risk of dying? And there are certain things
that do make children at an increased risk of dying.
Those are: any child who hasn’t got a clean bill of health. Most children are healthy
children, but if a child’s been born prematurely, has some kind of syndrome, or is diabetic
– all of those things do actually increase the risk of that child getting into trouble.
And it’s worth just stepping back and remembering that.
And, age really matters. So, when you first start paediatrics, perhaps all children scare
you a little bit, and you’re a little bit under-confident, but actually most children
over the age of 2 have quite a good immune system. Those children under 2 should concern
us more, and particularly children under 6 months old, and particularly children under
6 weeks old. If you’re a little bit on the fence and you’re not sure whether to admit
a child or not, have a look at the age, because that should help you make your decision.
So that’s our risk stratification. Now we’re going to go on and take a normal history,
and examine the child. And in the history, you’ll find that a lot of things are very
common in paediatrics. In fact, when I first started paediatrics, I couldn’t understand
how so many children would come with either bit of a temperature or vomit or not quite
right. And within 24 hours, the paediatricians would have made diagnoses, such as brain tumours,
meningitis – and it seemed to be quite difficult to get to that stage from the starting point,
which was quite vague.
Imagine how many children get an upper respiratory tract infection every year – children under
the age of 1 may have 6 or 7 upper respiratory tract infections in that first year of life,
so be a little bit careful about that history, because it might not be the diagnosis this
time.
The other thing you might hear is, ‘he’s not keeping anything down’; we need to clarify
that. Is that one vomit, is that 20 vomits? Is it only for food, or is it also for drinks…?
You’ll also hear the word diarrhoea. Is that one loose stool, or is that 20 explosive
stools in the last 24 hours, so again we need to clarify that. You’ll also hear phrases
like ‘he’s not himself’; a lot of children, when they’re feeling unwell, will clearly
not be themselves. But in between episodes, most children like to play. So do we mean
that this child really hasn’t played or shown any interest in anything over the last
24 hours, or have they had their up and down periods? And that’s the most common way
of presenting – and parents will be apologetic and say, ‘oh I’m sorry, he didn’t look
like this an hour ago’, or ‘he’s much better since we gave him some paracetemol’,
and that up-and-down pattern is actually quite reassuring.
So let’s come on to examination. You’re going to do your normal examination, and you’re
going to look at this child, and if the child is 12 years old, and has a sore throat and
you have a look and you see tonsillitis, then you don’t have to do a full examination.
But actually, in emergency care, an awful lot of our patients are in the younger age
group. And there, a full examination really does matter. So, a proper top-to-toe, front
and back, ears, throat, etc. really does matter. But, I’d like you just to stop and think
a little bit about observation, and observations. Observing the child’s behaviour – as we
talked about when we’re taking a history of that behaviour – will also make quite
a difference. And the child’s that running around, eating crisps, is generally going
to be a well child. But in those drowsy children, which is quite common where a child is ill,
you need to work out, are they really drowsy, or can they be woken up and played with? And
that’s really important, not to just let a child sleep. Are they actually irritable?
So, a lot of children cry when they’re being examined. But are they distractable, are they
consolable? Or are they truly irritable? Because true drowsiness and true irritability matter,
and should matter, but we need to make sure that it’s not just that the child needs
a bit of comforting.
And then, of course, observations means vital signs. You can actually do a full set of observations
as well as a full, top-to-toe front-to-back examination in under 3 minutes. So, it is
easy to do, and it’s worth it. For observations, we’re talking about the vital signs, so
we mean heart rate, respiratory rate and pulse oximetry for any child that may have difficulty
in breathing. These are important because it is quite hard to spot the needle in the
haystack for diseases such as meningitis, or other severe sepsis, and it’s the heart
rate that might jump out at you – if you know your normal ranges for that age of child
– and if not, use one of the PEW scores – and there’s a high heart rate, that
might be a sign of sepsis. In the same way that pneumonia is quite difficult to diagnose
in children, and perhaps the only sign for that might be a high respiratory rate, so
again, you need to know your normal values, and you need to think, ‘is this child compensating?
Is it abnormal, but it’s coping? Or is actually decompensating, and at severe risk of deterioration?
So we’ve talked about risk stratification, we’ve talked a bit about the history, and
we’ve talked about examination. We’ll just stop for a moment to talk about fever,
because it’s such a common presenting symptom. And there are 2 very common questions that
people ask. First is, ‘does the actual size of the temperature matter?’ Because it matters
a lot to parents – they’ll often come because he’s got such a high temperature,
and the second thing is, ‘what about antipyretics?’ What is the role of an antipyretic?
So does the actual temperature matter? Well the degree of fever does correlate to the
risk of serious bacterial infection, but not very well – there isn’t a great correlation,
and individual variation is quite wide. So some children throw a fever at the slightest
thing, and other children don’t. So for that child in front of you, really the degree
of fever doesn’t make very much difference. One point worth making is about babies under
the age of 4 weeks. For babies at this age, if they have sepsis, they may not have a fever;
in fact, they may be hypothermic, so anything under 37 degrees centigrade should be taken
quite seriously. And what about antipyretics; ibuprofen, paracetemol?
Well these are very, very useful drugs. They will reduce a fever but they will do that
because they’re a drug that reduces fever. What you musn’t do is take that to mean
that the source of the fever is less serious, because the drug will reduce the fever. But
in doing do, it’ll make the child feel better. So when we’re trying to see what the child’s
really like underneath, it’s important to see what the child is like with the fever
removed, and that’s when we can go back to assessing behaviour as we talked about
earlier. It also removes the effect of fever on those vital signs, so when we’re looking
at our observations, it’s very good to remove the fever, and now have another look at your
heart rate, and your respiratory rate, and see, if indeed, they are raised. What you
musn’t do is assume that we remove the fever and the fever comes down, because of the pharmacological
effect of these drugs, that the underlying cause is less serious.
So that’s a little bit about fever… but you might still be feeling a little bit under-confident
with children, and I think that’s natural for all of us. There are some useful resources
out there, and I’m going to point you in the direction of two. One of them is something
called the POPS score, which is the Paediatric Observation and Priority Score. This is a
PEWS type of score, and there are several around, but this one has been designed for
use in the emergency department, or other settings like urgent care settings. The advantage
of the POPS score is it not only identifies the very sick end of the spectrum, but it
can also help you confidently discharge children who are well with a low POPS score. And here’s
a web link to information and resources on the POPS score.
The other resource I’d like to highlight is a website, called ‘spottingthesickchild.com’.
This is a website that was first commissioned by the Deparment of Health, and has endorsement
from most of the major Royal Colleges. It has many hours of footage of real-life patients,
which, perhaps in a lifetime’s practice, you may not see so many sick children. So
I would highly recommend it – it’s available for free. You do need to request a password
but that will come straight back to you, and it has an awful lot of supportive material.
One of the advantages is it is real life footage, and you can see on this still of a child with
recession, that actually, if you haven’t got an experienced eye, you might not understand
what recession means, or whether it’s mild, moderate or severe, but the beauty of video
is that it teaches you on real-life cases. So, in summary, what are the top tips for
helping us get it right? Which children need to be in hospital and which children don’t?
So the first step is to stop and think before you start. What’s the age of this child,
and do they normally have a clean bill of health, or have they got underlying problems.
And in the history, it’s all about clarification – making sure we get to the bottom of what
the parents are trying to tell us. In examination, we’re going to do a top-to-toe, front-to-back,
and we’re going to remember observation – what is the child’s behaviour like – and
observations – what are the vital signs?
So that’s all from me – I hope you found this information useful. Thank you very much.