RCGP: When is a sick child seriously ill?

Adapted from RCGP, Acutely ill children by Ann Van den Bruel and Matthew Thompson June 14

A feverish child is very common and many of them consult the GP or go to the A and E department. Emergency admissions to hospital with febrile illness are increasing even though admissions for serious causes of infections are relatively rare at less than one percent of febrile children seen in primary care. These serious illnesses are mainly caused by pneumonia, urinary tract infection and many fewer by sepsis, meningitis and osteomyelitis. The trick is to be able to recognise the very few children with serious illnesses as soon as possible.  This is where it becomes so difficult as the early stages of illness are non specific.  Up to half of children with meningococcal disease, for example, are not recognised as such at first contact.

Parents often correctly realise that their child has a much more serious illness than usual, indeed this indicates 14 times the likelihood that there is a serious illness,  but other times their description of catastrophe bears little resemblance to what the doctor or nurse sees.

Some clinical signs are more useful than others. For instance if the temperature is over 40 degrees, the risk of serious illness is raised from 1% to 5%. Other important signs are cyanosis (blue lips), poor peripheral circulation (mottled hands and feet), rapid breathing, crackles on listening to the lungs, reduced breath sounds, meningeal irritation (causing a high pitched cry or a stiff neck), petechial bruising, (non blanching bruised looking rash), and reduced level of consciousness, ( drowsy or incoherent).

Combinations of features can help sort out potentially serious from not serious causes.

The only prediction rule that has been tested is this.  If one of these is present then there is a 6% chance of a serious infection:

the clinician has a gut feeling something is wrong, the child is breathless, the temperature is over 39.5 degrees, and there is diarrhea in a child aged 1-2.5 years.

If NONE of these are present however there is a 0% chance of a serious infection. That is,  no concern from a doctor, no breathlessness, a fever under 39.5 and no diarrhea aged 1-2.5 or diarrhea but in a child out with this age range.

Symptoms and signs can change over time of course so vigilance from the parents is still needed.

Meningitis

Meningococcal disease may be lethal. The trouble is that in the first 8 hours of the illness, it presents with the usual flu like symptoms of fever, headache and sore throat.  Typical symptoms of meningitis only occur after 13 to 16 hours. These include neck stiffness, rash, fits or loss of consciousness. They also don’t occur in all children with the illness. Other symptoms that can help are leg pain and also the less distinguishing skin pallor or blueness and cold hands and feet.

Pneumonia

80% of all serious infections are due to pneumonia. This is obvious when you have an ill looking child, who is breathing fast and has a low oxygen saturation and on blood testing a raised CRP.

If a doctor has no concerns about the child AND there is no shortness of breath however, it is very unlikely that the child has pneumonia.

Heart rates and breathing rates can be raised in sick children but when this becomes abnormal is still a matter of debate.

If a doctor has concerns about a child, this raises the chances of serious illness from less than 1% to 11%.

Blood testing is rarely done in primary care but when done  perhaps in the A and E department, CRPs under 20 and procalcitonin levels under 0.5 ng/ml rule out serious infections.

Safety netting advice is particularly important if the diagnosis is not clear, there could be complications of a particular diagnosis or the child is at a higher risk of getting complications.

Although children are getting healthier, acute infections remain common, and parental concern leads to many presentations at the surgery or in A and E.  How to distinguish serious illness that needs quick intervention from non serious illness that can be managed at home remains a challenge.