Chapter 6 Childhood illness – assessment and management of primary survey negative children
Introduction
This chapter describes the assessment and findings associated with illnesses that commonly affect children. It aims to be a guide to common presentations and treatment rather than a comprehensive review of all paediatric conditions. Chapter 5 describes the identification and initial management of potentially life-threatening problems. Box 6.1 describes the objectives for this chapter.
Secondary survey
A secondary survey will be required for all children who have not required transfer to hospital following the primary survey (see Chapter 5). Its aim is to fully assess the child so that decisions about their future management and disposal can be safely made. The SOAPC system (Box 6.2) can be used to undertake this survey but is modified to take account of the particular needs of children (see Chapter 5).
Subjective assessment
The parents of children with chronic illnesses (such as renal disease) or congenital problems are likely to have considerable expertise about assessment and management of the condition – as indeed may the children themselves. Practitioners should not be dismissive of information provided and suggestions made by ‘expert’ parents and children. It is important to remember, however, that although they be very knowledgeable about their field of expertise, they are likely to know no more than other people about other medical problems.
Objective examination
Before approaching a child directly, it is a good idea to observe their general behaviour (Fig. 6.1). Are they passive or active? Are they playing normally? Do they pay attention to their surroundings?
The content of the physical examination should be similar to that for an adult, although the order in which each system is assessed may be modified depending on the age and behaviour of the child (see Chapter 5). A cardiovascular, respiratory and abdominal examination should be undertaken as appropriate and opportunistically. There are some aspects, however, that are particularly important to the examination of the child.
Temperature
Taking the child’s temperature is of limited value in primary care as the presence or absence of a fever does not confirm or rule out serious disease. There are various confounding problems, such as whether or not the child has received an antipyretic and what part of the body is used to assess temperature. Indeed authorities still debate what the upper limit of normal is. It is, however, recognised that very young babies (for example, less than 6 months old) who have a significant fever (>38.5 °C) or who are hypothermic (<35 °C) are more likely to have serious disease. Young children may sometimes tolerate very high temperatures (>40 °C) with little apparent discomfort or serious pathology. Significant fever can usually be detected, if no thermometer is available, by touching the skin of the child’s trunk.
Analysis (differential diagnosis) and treatment and disposal (plan)
Common presentations
The irritable child
A common presentation that can be difficult to address is a baby who is reported to cry excessively. A truly irritable baby dislikes handling and must be assumed to have serious illness and be admitted urgently to hospital. More common is the baby who will not settle or settles only briefly, or the misery of the febrile toddler: these children can cause considerable concern to new parents and healthcare professionals alike but are not necessarily very ill. The cause may be due to a multitude of reasons from significant pathology to poor parenting skills. Even when the practitioner can confidently determine there is no significant clinical problem (difficult at the best of times) admission to hospital or referral for further support should be considered if parents remain anxious.
