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Your first... very sick child

A parent's intuition is often the best indicator of whether a child is seriously ill, says Dr Stefan Cembrowicz

A parent's intuition is often the best indicator of whether a child is seriously ill, says Dr Stefan Cembrowicz

If you haven't done a paediatrics job (and half of us haven't) you may not have had a seriously sick child presented to you.

At least 95 per cent of the feverish children we see in general practice do not have serious infections. How can you spot the one in 20 who does? This is the most vital thing about general practice paediatrics.

Beforehand

  • Many ill children are now triaged by phone. Having listened to the parents' narrative, the key question is 'How is he in himself?'
  • Parents intuiting something is wrong is a key signpost of serious illness
  • Parents will readily do the glass test while you are speaking to them on the phone. And check back that parents understand what to look out for in terms of deterioration; where to go, and who to ring

Clinical encounters

First look at ABC: airway, breathing, circulation.

• Airway, breathing: signs of respiratory distress include recession, grunting, accessory muscle use, flared nostrils. An infant's respiratory rate is 30-40 breaths per minute, that of a one to two-year-old is 25-35, and a two to five-year-old is 25-30.

• Circulation: an infant's pulse is 110-160 beats per minute, a one to two-year-old's is 100 to 150, a two to five-year-old's 95-140. Bradycardia or cyanosis are late (and preterminal) signs.

Capillary refill time after five seconds' pressure on a finger or the sternum should be two seconds. Blotchy, cold peripheral skin suggests circulatory failure. Next, check the child's disability or level of consciousness using AVPU:

• Alertness: look at eye contact – is he 'himself', agitated, drowsy?

• Response to voice

• Response to pain

• Unresponsive.

Practise recording basic signs in a one-minute examination (temperature, pulse, respiratory rate, hydration, alertness), on healthy children with URTIs, for the day when you do see a very ill child. A child who is playing and smiles back at you is less likely to be seriously ill.

If there is the slightest suspicion of meningococcal sepsis, immediately inject 600mg of benzylpenicillin IM and alert your local A&E department that you are rapidly en route.

Meningococcal sepsis has a 10-40 per cent mortality rate, yet only one-third of such children receive prehospital penicillin. If necessary transport the sick child immediately in your own car.

Three strikes and you're in

Severe infections are typically dramatic and fulminating, but there can be an insidious bacteraemic stage, when the blood-brain barrier has not yet been crossed.

I have seen serious infections present like this – one child was brought in three days running, with nonspecific febrile symptoms and 'not quite right'. Be very suspicious about the child seen three times with a temperature.

Systematic evaluation and checklists2 are helpful, but GPs also work by sixth sense. Learn to trust your intuition.

If you sense something is not quite right; if you feel uncomfortable and uncertain about your conclusion, step back and ask yourself why.

Stefan Cembrowicz is a GP trainer in Bristol

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