Recognizing the Seriously Ill Child

Chiropractic Pediatrics, Ch. 4

N. Davies

Fever

Definition: Elevation in body temperature

It is not a disease… though it may indicate the presence of disease

It is helpful…defense mechanism

Possible Risks

1. >101 in a newborn (2-3 months old)

2. >105 for a prolonged period of time may lead to dehydration brain injury (rare)

“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

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

Dyspnea

Recession of the sternum and chest wall Nasal flaring Respiratory grunting Central cyanosis

NOTE: tachypnea alone is not indicative of serious illness

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

Estimation of Fluid Intake/Loss

Serious signs: Ingesting <50% of the normal fluid intake <4 wet diapers in a 24 hr period

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

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

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

The following criteria are designed to recognize acute life-threatening illnessesThey are conservative referral criteria with a

wide margin of error…

Assessing the Febrile Child

1. Quality of cry2. Reaction to parent stimulation3. State variation4. Color5. Hydration6. Response to social overtures

A score >12 should be referred for evaluation10… 2.7% serious illness16… 92.3% serious illness

Quality of cry

1 - strong with normal tone; content and not crying

3 - whimpering or sobbing

5 - weak or moaning or high pitched

Reaction to parent stimulation

1 - cries briefly then stops; content and not crying

3 - cries off and on

5 - continuous cry or hardly responds

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

Color

1 - pink

3 - pale extremities; acrocyanosis

5 - pale, cyanotic, or ashen

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

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)

In practice…

Watch the child during the consultation

Assign the number that best describes the case and enter it in the recordAdd up the 6 scores

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