Assessment of the small sick child: 0-3 years

Question 1

What is the basic ABCFF of paediatric assessment?

Answer 1

A - alertness, arousal, activity
B - breathing
C - circulation
F - fluids in
F - fluids out

*if all these are ok, then child is unlikely to be severely ill at this time.

Question 2

Signs of an ‘unalert’ unwell child?

Answer 2

A: Not alert, not particularly responsive (e.g. to poking, pain, etc), not engaged with surroundings, listess, not moving, being passive

Question 3

Signs of an infant in respiratory distress (B: Breathing)

Answer 3

B: sometimes, not feeding well is an indicator of breathing difficulty (e.g. can ask mother if he’s staying on the breast well, etc). Noisy breathing (upper airway noise - croup). Increased RR. **Intercostal/subcostal recession -> indicates increased WOB.
** Grunting -> sign of serious respiratory distress

Question 4

Causes of distressed breathing:

Answer 4

Foreign Body
Upper Airways - croup
Respiratory Syncytial Virus (RSV)
Pneumonia
Bronchiolitis -> wheeze, not responding to bronchodilators
Asthma -> CANNOT make this diagnosis at e.g. Ventral septal defect -> cyanosed
Tracheomalacia -> floppy trachea, usually improves (make sure is eating and drinking well, that resp muscles are working and RR within normal range)

Question 5

Signs of poor circulation on infant (C: Circulation)

Answer 5

Check colour - may be cyanosed. Mottled is not good.
Coolness of peripheries - indicates poor perfusion
Capillary refill - thumb on sternum for a few seconds (more than 2 secs to refil = poor perfusion) -> remember this is generalized sign

Question 6

Causes of circulatory problems in infants?

Answer 6

Bleeding - hypovolaemia
Dehydration - hypovolaemia
Fluid loss - diarrhoea, vomiting
Septicaemia - Usually associated with viral infections with fever >40degrees

*Can assess anterior and psoterior fontanelles for dehydration if <18 months old. Sunken fontanelles = dehydration (mind you can be full/swollen if child screaming its head off)

Question 7

Normal Pulse Rate in 0-3 year olds?

Answer 7

90-160 bpm

Question 8

Assessing dehydrations - what questions to ask? (F, F)

Answer 8

Fluid in: Deviation from normal feeding? (also qualify ‘normal’)

Fluids out: infants dehydrate reeeally quickly

Question 9

Assessing dehydration - signs

Answer 9

Lethargy**
Dry mucous membranes (dry instead of shiny inside lip)
Sunken fontanelle
Sunken eyes
Reduced urine output
Decrease in bare weight -> weigh on sequential days. Drop of 50-100g can indicate issue

Question 10

What constitutes a serious fever in this age group?

Answer 10

> 38.5

Question 11

Describe management of septicaemia?

Answer 11

Rapid aggressive management:
Fluid Resusitation - IV access, nasogastric tubes
Abx - IV or IM

Question 12

Investigations and management for septicaemia vs meningitis

Answer 12

Investigations:

• Septic screen: FBC, M/C/S of sputum, Blood CUltures, Lumbar Puncture
• CXR
• LISTEN TO PARENTS

Observations:
- Alertness, Breathing, Circulationg, Fluids in/out

Clinical Decision:

1. Concerned that the child is very unwell, and requires referral to hospital straight away
2. Confident that the child is not seriously unwell, and is able to return home. However, if you notice any of the following things, then you will want to take the child to hospital straight away.

Discharging Doctor:

• Follow up on pain of child
• Check parent’s understanding of advice given
• Provide numbers to ring in case of emergency or worry

Question 13

Paracetamol dose for infants?

Ibuprofen dose?

Answer 13

15mg/kg

10mg/kg