Recognizing the Seriously Ill Child

1. Recognizing the Seriously Ill Child Chiropractic Pediatrics, Ch. 4 N. Davies

2. Fever Definition: Elevation in body temperature It is not a disease… though it may indicate the presence of disease It is helpful…defense mechanism

3. Possible Risks • >101 in a newborn (2-3 months old) • >105 for a prolonged period of time • may lead to dehydration • brain injury (rare)

4. “Red Flags” • Core body temperature elevated • State of arousal • Breathing effort • State of peripheral circulation • Dehydration • fluids taken in and excreted (24 hrs) • acute weight loss

5. Arousal • Observe the child for: • signs of drowsiness • hypotonia • response to stimulation • If the baby cries, note characteristics of the cry • weak, whimpering, appears to require undue effort

6. Dyspnea • Recession of the sternum and chest wall • Nasal flaring • Respiratory grunting • Central cyanosis NOTE: tachypnea alone is not indicative of serious illness

7. Peripheral Circulation • Generalized pallor • Cold lower legs (knee down) NOTE: cold hands & feet and mottling of the skin have little or no relationship to serious illness

8. Estimation of Fluid Intake/Loss Serious signs: • Ingesting <50% of the normal fluid intake • <4 wet diapers in a 24 hr period

9. Estimation of Acute Weight Loss • Compare current weight to expected weight • look at the anthropometric chart (percentile) to determine their expected weight expected weight - current weight X 100 expected weight Weight loss of >7.5%... Dehydration • Refer to the hospital

10. Signs of Dehydration • Dry mucous membranes and skin • Rapid, weak pulse • Pallor or ashen/grey discoloration of the skin • Soft, sunken eyeballs • Depressed fontanel • Poor tissue turgor (tenting) • Lethargy • Seizures

11. Uncommon High-risk Signs • Bile-staining vomit • Convulsions (especially 1st time) • Lump >2 cm in diameter (abdomen) • except hydrocele or umbilical hernia • Petechial rash • Fecal blood without visible cause

12. The following criteria are designed to recognize acute life-threatening illnesses • They are conservative referral criteria with a wide margin of error…

13. Assessing the Febrile Child • Quality of cry • Reaction to parent stimulation • State variation • Color • Hydration • Response to social overtures A score >12 should be referred for evaluation 10… 2.7% serious illness 16… 92.3% serious illness

14. Quality of cry 1 - strong with normal tone; content and not crying 3 - whimpering or sobbing 5 - weak or moaning or high pitched

15. Reaction to parent stimulation 1 - cries briefly then stops; content and not crying 3 - cries off and on 5 - continuous cry or hardly responds

16. State variation 1 - if awake, stays awake; wakes up quickly if stimulated 3 - eyes close briefly, awake; awakes with prolonged stimulation 5 - falls to sleep; will not rouse

17. Color 1 - pink 3 - pale extremities; acrocyanosis 5 - pale, cyanotic, or ashen

18. Hydration 1 - skin and eyes normal, mucous membranes moist 3 - skin and eyes normal and mouth slightly dry 5 - skin doughy or tented and dry mucous membranes +/- sunken eyes

19. Response to social overtures 1 - smiles or alerts (<2 months) 3 - brief smile or alerts briefly (<2 months) 5 - no smile; face anxious, dull, or no alerting (<2 months)

20. In practice… • Watch the child during the consultation • Assign the number that best describes the case and enter it in the record • Add up the 6 scores

21. Summary of Referral Criteria • Observational items score >12 • Any combination of poor arousal, circulation or dyspnea • Acute body weight loss >7.5% • Decreased fluid intake or excretion • Persistent bile-stained vomiting • A first convulsion • Periods of apnea • Respiratory grunting or central cyanosis • A lump >2 cm diameter (abdomen) • A petechial rash • Blood evident in the feces • Fever of >3 days’ duration in a child who is on antibiotics