Assessing the condition of an unwell child, whether on the phone or in the surgery, isone of the most important and satisfying, but at the same time nerve-racking parts of a GPs work. Just like the parents, the doctor is on tenterhooks, alert for any sign of serious illness, and conscious of the huge responsibility to make accurate diagnoses and management decisions. And yet, at the same time, treating sick children, for most GPs, is one of our favourite parts of the job.
How does a GPs approach compare with a parent’s? Naturally there is a huge overlap, and the GP esteems highly the parent’s deep knowledge of their own child; however, the GP can be a great help too, since by dint of comparable experience he or she is extra adept at recognising patterns, both reassuring and worrying. Furthermore, we have the tools to see, listen and measure, which help us to gain a fuller picture of the situation.
At the outset, the GP will always dig carefully for information. The symptoms of childhood feverish illness can be very non-specifi c; fever, vomiting, cough,grizzliness, sore throat etc come in countless permutations, often with mild illness. But the doctor is looking always for anything more worrying, whether individual signs such as neck stiffness, bad colour or poor rouseability, or more general hints of trouble – are the parents particularly worried this time, or does the child seem more unwell than ever before? If in a face to face consultation, the physical exam will then seek to build the picture further, arriving at a conclusion as to whether the illness is mild or serious.
Since 2007 this approach been codifi ed nicely in guidance on assessment of the feverish child under fi ve from the National Institute of Clinical Excellence, which developed a ‘traffi c light’ model of symptoms and signs to help clinicians correctly stratify patients into a ‘green’ group who could safely be given telephone advice, an ‘amber’ group with features of moderate concern who should be seen by a GP or Nurse Practitioner, and the most serious ‘red’ group who should be assessed most urgently, generally with immediate Paediatric referral. The guidelines are too comprehensive to be fully detailed here (view in full at http://guidance.nice.org.uk/CG47 ) but they do describe quite elegantly the ‘well’ and the ‘sick’ groups that the clinician strives to distinguish.
The ‘green group’ (or only mildly unwell) child should be alert and responsive, (even if perhaps grumpy and miserable!) Colour should be normal or, at most, flushed. If crying, cry should be normal. Mouth and tongue should be moist, and urine output should be near normal. Breathing should not be fast or laboured. A squeezed finger should regain its colour within three seconds. Fever should not have persisted longer than five days.
The ‘amber’ and ‘red’ groups will be, by degrees, further from normality, with the child having one or more of the following features; Activity and responsiveness may be signifi cantly lessened, cry weak or high pitched; Colour may be pale, or more seriously blue or mottled; mouth or eyes may look dry, or even skin itself feel loose. Urine output may be poor; a squeezed finger may take longer than 3 seconds to return to colour. Breathing may be quickened, possibly with nostril fl aring, grunting or indrawing of the chest.
There may be specific features too, such as a non-blanching rash, neck stiffness, seizure, bile-stained vomiting, or, in babies, a bulging fontanelle (the gap between the skull bones near the crown of the baby’s head). In babies under 3 months, fever of over 38.0 degrees C, and, in between 3 and 6 months, over 39.0 degrees are also signs of concern.
Hopefully the above will give a little look into how clinicians approach the sick child – with common sense rather than rocket science! My fi nal ‘take home’ message, though, would be this: if you are worried, or feel in new territory with a child’s illness,
please don’t be shy of making contact with health services, day or night. It might be crucial – and besides, we like it!
Just call or E-mail for a discussion without obligation
Dr Moray Grigor Mb ChB (Edinburgh 1991) MRCGP DCCH
0750 316 6750