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The Unwell Child EdMedSocTo Cover: - Approach to the unwell child - Traffic Light System - ABCDE assessment - Lethargic and febrile child - Child with a rash - The wheezing/noisily breathing child - SummaryNICE Traffic light system ● Tool for risk stratification ● Can be a lot to remember ● Each section can be linked to ABCDE ● Green ○ Discharge home w/ advice ● Amber ○ Refer for specialist paediatric assessment ○ Discharge with specific safety netting ● Red ○ 999 if immediately life threatening ○ Refer for immediate specialist assessment if not life-threateningAirway and Breathing Nasal flaring = Amber Grunting = Red Chest indrawing = Red RR >60 = Red Wheeze = suggests airway obstructionCirculation Reduced turgor = always Red Prolonged CRT = at most Amber Tachycardia = at most AmberDisability - Activity Appears ill to healthcare professional = RED Weak/high-pitched/continuous cry = RED ● Responds normally ● Stays awake/Awakens quickly ○ Green ○ Green ● Responds abnormally ● Wakes only after a while ○ Amber ○ Amber ● Doesn’t respond ● Doesn’t wake or stay awake ○ Red ○ RedExposure - Appearance, Fever and Other Reported pallor = Amber Visible pallor (or mottled) = Red All signs of meningitis/meningococcal sepsis = Red Fever <3 months = Red High fever 3-6 months = Amber Prolonged fever >=5 days = Amber Rigors = Amber Neurological signs = RedLethargic and febrile child A 2-month old baby girl is brought into your GP by her parents. Her parents are concerned that she has been very sleepy over the past 24 hours and is not feeding well. On examination she seems quite pale and wakes briefly when stimulated but goes back to sleep immediately. HR 180, Temperature 39.3C What questions might you like to ask in the history? What is your next step? What investigations might you like to do?Investigation and differentials - lethargic and febrile child Investigations: Differentials FBC Infectious: CRP UTI/Pyelonephritis Blood cultures Pneumonia Urine dipstick +/- culture Meningitis Consider: Meningococcal disease Lumbar puncture HSV encephalitis CXR Stool culture Non-infectious: Kawasaki disease Perform a lumbar puncture if: less than 1 moJuvenile Idiopathic Arthritis (JIA) if they meet these criteria they should also get IV antibioticsChild with a rash A 3 year-old boy is brought into GP by his dad. Dad says he has been a little bit feverish and has had a runny nose for the past 3 days. He reports that a rash has also developed which started on his face but now has spread to his chest. Temperature 37.8C What questions might you like to ask in the history? How would you manage this?Child with a rash A 3 year-old boy is brought into GP by his dad. Dad says he has been quite lethargic and feverish over the past 24 hours. He reports that a rash has also developed on his legs. Temperature 38.5C What questions might you like to ask in the history? How would you manage this?Child with a rash Most cases - mild viral exanthems (rashes associated with a viral illness) Disease Differentiator Chickenpox (VZV/HHV-3) Fever first, Face -> Trunk Macular -> Papular -> Vesicular Hand, foot and mouth disease (Coxsackie Affects hands, feet and mouth, vesicular A16, Enterovirus 71) Slapped cheek (Parvovirus B19) Bright red rash predominantly affecting cheeks Roseola infantum (HHV-6) High fever, followed by rash Febrile convulsions may occurChild with a rash However - some are serious Measles Starts behind ears, Koplik spots in mouth Prodrome - fever, conjunctivitis, irritability Rubella Starts on face, spreads to trunk and arms then disappears in same order Eczema herpeticum More commonly seen in children with history of eczema Rapidly progressing and painful rash ‘Punched-out’ lesionsChild with a rash Non-viral exanthems Kawasaki disease High-grade fever lasting over 5 days Strawberry tongue Palms and soles become bright red and skin can peel Scarlet fever Sore throat + inflamed oropharynx High fever for 1-2 days Fine erythematous sandpaper rash, torso first Petechial rash Does not blanch with pressure Can be ITP, HSP, HUS, meningococcal sepsisThe wheezy child A 3 year old boy presents to your GP practice. He has been coughing profusely for the past couple of nights. After a bout of coughing, he makes a sharp high-pitched noise on inhalation. List your differential diagnosis How would you treat your top differential?The wheezy/noisily breathing child Disease Differentiator Management Croup ‘Barking’ cough, 6mo - 3y Oral dexamethasone Acute epiglottitis Tripod position, high fever, Urgent admission/ENT ref unvaccinated Antibiotics + airway support Bronchiolitis <1 year old, off food, dry Supportive care, Humidified cough O2 via head box if sats <92 Inhaled foreign body Sudden onset stridor Laryngoscopic removal Acute asthma exacerbation Atopic child, wheeze Nebulised salbutamol Anaphylaxis Skin reaction, angioedema 150-500 mcg 1:1000 Adr Pneumonia Bronchial breathing, fever Antibiotics, bed rest, fluidsConclusion Many paediatric conditions can present similarly - need to be aware of key differentiators to rule-out/rule-in certain diagnoses Have a high degree of suspicion for something serious - use NICE traffic light criteria to identify when something may be more severe than it seemsQuestions Any questions?