Assessing childhood illness

Published on 21/03/2015 by admin

Filed under Pediatrics

Last modified 22/04/2025

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1 Assessing childhood illness

Lisa Jackson, Nandu Thalange

Talking to children and their families

Talking to children and their families is the key to understanding any child’s health. It may be diagnostic. It can be therapeutic. It is extremely rewarding.

Working with sick children is challenging and difficult. A kind, thorough and systematic approach will give the child and parents confidence.

Taking a history is important for the development of the relationship between the doctor and child. It is an opportunity to put the family at ease. The history should naturally flow into, and overlap with, the examination.

What do families want?

Children are taken to see a doctor for many reasons. The parents’ concerns might be quite different from those of the doctor:

Parents’ thoughts	Doctor’s thoughts
‘Sam coughs at night’	‘Sam coughs at night’
‘It keeps all of us awake’	‘His brother has asthma’
‘He’s had chest infections before’	‘It’s probably viral-induced wheeze’
‘He needs antibiotics’	‘Maybe he needs an inhaler’
‘The doctor will give me a prescription’	‘I need to make a diagnosis’

It is important to think about the ideas, concerns and expectations that parents have about their child’s symptoms. If these are not established early on, they will feel dissatisfied or frustrated. Asking a family about their concerns focuses the consultation and helps to manage the problem.

The paediatric history

The traditional, structured history is important, but the order in which things are done in the consultation should be flexible.

The consultation needs to be interactive – try and involve children so that they feel a part of the process.

Be prepared

Read the referral letter

Look at the previous notes

Where appropriate, speak to other professionals who have had contact with the child

Record observations – temperature, pulse, respiratory rate

Plot the height and weight on a growth chart – do not forget to look at the Personal Child Health Record.

Environment

An appropriate environment is needed. Think about:

The consultation room – position the furniture appropriately

Safety in the room – are plug sockets, sharps bins and other medical paraphernalia safe?

Suitable toys – these need not be expensive or numerous; drawing paper and pens have magical properties.

General principles

Child protection

It is important to recognize that, in some circumstances, we may have concerns about a child’s welfare. Some children may be suffering, or at risk of suffering, significant harm, either as a result of a deliberate act, or a failure on the part of a parent or carer to act or to provide proper care, or both. These children need to be made safe from harm, alongside meeting their own needs.

Teaching to assess childhood illness rightly stresses the importance of listening to and believing what parents and carers tell us. Child protection training shows that in order to safeguard this group of children we must also be prepared to think the unthinkable. Any professional in contact with children must receive appropriate child protection training. It is vital to pick up the warning signs from the history or examination.

Examining children

First impressions

Does the child look sick or well, and why?

The well child	The sick child
1. Plays	1. Quiet
2. Feeds	2. Still
3. Interacts	3. Pale
4. Smiles	4. Drowsy
5. Responds	5. Unresponsive

Recognizing whether a child is ill or well is the single most important aspect of the examination. These signs correlate very well with the severity of illness. For example, Babycheck™ is a scoring system – devised for infants under 6 months for use by parents and professionals – that uses these principles to help them judge illness.

During the history, observe the interaction of the parents and the child. Look for physical signs such as a limp or cough, which might not be forthcoming during the examination.

Making friends

This is about trust. Children trust friendly doctors. Parents trust friendly, competent doctors. Of course, the practicalities of modern medicine do not always allow the time to develop such a relationship. Other strategies that help:

Examine the child while the child is sitting on the parent’s lap

Play games – incorporate examinations into games

Rehearse examinations on yourself, a parent or a cuddly toy

Flexibility – examine available systems first

Leave unpleasant examinations until last, e.g. throat examination

Lots of eye contact, smiling and praise will work wonders.

Adolescents

It is important to respect the need for privacy and dignity of adolescents and older children. Appropriate explanations help. Some teenagers will prefer to be seen on their own, particularly for the examination. A chaperone will be needed if the patient is to be examined without family members present.

A practical approach

The detail of how to examine each system is important. Conventionally, we examine patients using a systems-based approach. However, the reality of examining children demands a more practical approach. Improvisation is needed, e.g. it is sensible to listen to a sleeping baby’s heart at the start of an examination, rather than when the baby wakes up.

A practical approach to the examination of a child is shown in Box 1.2.

Box 1.2

Use your senses

1. LOOK	Observations: Sick or not? Bright and alert?
	Distressed?
	Appearance: colour, rashes, eyes
	Chest movement, respiratory effort
	Gait, coordination
2. FEEL	Fever, hands, pulse, perfusion
	Vocal fremitus, cardiac apex, abdomen
3. LISTEN	Cry, cough, stridor
	Heart sounds, breath sounds, bowel sounds
4. MOVE	Joints, coordination, neck stiffness
5. CHECK	Ears, nose then throat
6. LAST OF ALL	Plot the child’s height and weight (and, for young children, head circumference) on the growth chart