Introduction to Illness

Illness is common in children. If you take your average 2-year-old who attends nursery, 5 or 6 episodes of viral illness a year is not unusual. However much we as healthcare professionals accept this, we have to understand that for a parent with a poorly child, each episode can be a source of great anxiety.

People are bombarded daily by healthcare horror stories and in many cases do not have the family network with experienced grandparents nearby to reassure them, so many will present to health care workers for advice. Most childhood illnesses are simple, self limiting viral illnesses or other minor problems that do not need intervention, but occasionally a child will present with a more serious infection. Our job is to be able to spot that more seriously unwell child. This is the basis of the concept of big sick/little sick which you will have heard referred to many times during the course. The term is pretty self explanatory and of course it’s the big sick we mustn’t miss.

So how do we ensure that we do this? In some ways dealing with kids can be a bit like being a vet; young children cannot tell you exactly what their symptoms are and you may have to rely on the parents interpretation (the toddler who is crying who the parents think may have ear pain).

Now parents and carers generally know their children best, but they will not always know to give you certain information. This is why it is important to take a detailed, focused history to get the important details about what has been happening, over what timeline and what has led them to call for help today. At the end of the history you should have a pretty good idea of the most likely diagnosis but then you need to do a thorough examination to confirm that diagnosis or, if necessary, change it. Remember, initial impressions are really important but things can change with time. The child with a high temp may look dreadful, miserable and lethargic until the temp comes down, at which point they look much more like their normal self. Similarly a child with a fever and non blanching rash may be talking to you and appear stable before rapidly deteriorating with their overwhelming sepsis. Attention to detail is all important; in that latter case, examination of the child with the fever and rash would have revealed a baseline tachycardia and tachypnoea that would alert you to the fact that they were more unwell than initial impressions would suggest.

So what do you need to know in order to manage children with potentially serious illness?

1) Understand normal parameters in a child. If the observations fall outside this, what is the reason? If you have an hypothesis (i.e. tachycardia could be due to high fever) then test it. If you make an intervention, see what effect that has. In this case if you feel the tachycardia may be due to fever, the heart rate should come down as the fever settles. If it doesn’t, think again.
2) A thorough ABCDE approach is likely to identify all children in the big sick category.
3) Remember the sort of illnesses children get, will vary with age. For example, bronchiolitis is an illness most commonly seen in infants under a year of age, whereas chicken pox is commonest in younger children.
4) Little sick, do they need to go to hospital? Big sick clearly do.

Main learning points:

• Understand normal observations and how they change with age If obs are not normal, don’t dismiss them because they can change over time. Reassess frequently
• A thorough ABCDE approach will avoid signs being missed Basic understanding of the common conditions that lead to children being seen in hospital

The 999 Call

“My 7-year-old grandson has been unwell for a week with a cough and sore throat. He now has a high fever and is very breathless. He looks like he is in pain when he’s breathing. I have tried to get in to see my GP but when they heard how unwell he sounded they suggested I call 999. I am really worried about him, could someone come quickly?!”

1. From the information from the 999 call, are you anticipating a child who is big sick or little sick?
2. What is the differential diagnosis going to be?
3. What are the priorities once they arrive?