A remote nurse asked me this week during a clinic training session, how I recognised if a child was sick or not.
Here are my thoughts and some resources
When my own children get sick, a few things commonly happen:
- Stop eating and drinking. I dont care about the eating but lack of fluid intake worries me always
- Get irritable and altered behaviour. cant sleep or sleep too much. As a health care provider you must ask very carefully about this and BELIEVE the child’s carer.
- Breathe differently. Sick kids breathe harder. Really sick kids breathe shallower. Dead kids stop breathing. Shock affects breathing and is most earliest sign to look for in my opinion.
- The VOMITING child always worries me. This is a red flag for pathway to deterioration in the sick child.
- FEVER is a distractor from your assessment. You must look for 1-4 above first before considering FEVER. ABsence of 1-4 above with a fever, I dont get worried about usually (EXCEPT IN NEONATES)
Examination tips :
- Observe first. Most of my gestalt for sick kids comes from observation alone. Look at breathing and activity/behaviour
- I first listen to heart. Occasionally I get the diagnosis of Acute carditis from acute rheumatic fever ( a disturbingly common presentation in my region) from cardiac auscultation immediately. Also it helps before the child starts screaming
- Then listen to lungs. Same reason: before the kid starts screaming. Leave all possibly painful parts of the exam till last!
- Good look over for a rash
- Ears next. Its not easy and you just have to do your best. Get carer to help hold child as still as possible. Video-otoscopy with a USB device to your laptop is great and aids carer confidence and often the child if old enough.
- Nostrils next. Look for that pus coming out of a sinus ostia. Polyps can be seen in allergic conditions
- Oral exam last including dentition, tonsils, mucosa for enanthem signs.
- Urinalysis completes your workup .
Check out these useful free web resources
The video above is an advertorial but shows some useful footage of sick children to demonstrate the signs of critical illness. I am not sponsored by the company at all who makes that training course package!