History

A thorough history is paramount to arriving at the correct diagnosis. In younger patients, parents must interpret how their child is “feeling.” Older children may not be able to completely define or localize their symptoms. On the basis of the chief complaint, the pediatrician must ask questions that help distinguish between common and potentially life-threatening entities. Common complaints leading to acute care visits include altered mental status, vomiting, respiratory distress, fever, and abdominal pain.

For patients presenting with altered mental status, the pediatrician should inquire about the presence of other symptoms such as fever or headache. Screening questions regarding feeding changes, medications in the household, or the possibility of trauma should be asked. Parents will often describe a febrile child as “lethargic,” but further questioning will reveal a tired appearing child who interacts appropriately when he or she has defervesced. Febrile patients need to be differentiated from the lethargic child who presents with sepsis or meningitis. Infants with meningitis or sepsis may have a history of irritability and/or inconsolability, not waking up for feedings, poor feeding, grunting respirations, seizures, and decreased urine output. Patients with poisonings or inborn errors of metabolism can also present with lethargy, poor feeding, seizures, and vomiting. Nonaccidental trauma should always be considered in a lethargic infant. Older children may present with altered mental status due to meningitis/encephalitis, trauma, or ingestions. Children with meningitis may have a history of fever and complaints of neck pain; other associated symptoms can include photophobia and vomiting. Children with ingestions can present with other abnormal neurologic symptoms such as ataxia, slurred speech, seizures, or characteristic constellations of vital sign changes and other physical findings (toxidromes).

Vomiting is a very common complaint of intestinal, abdominal (pancreas, liver) or non-gastrointestinal (hyperammonemia, increased intracranial pressure) origin. Care should be taken to determine whether the emesis is bilious, which is suggestive of intestinal obstruction. Other historical data to be gathered include the presence of abdominal distention, weight changes, presence of diarrhea, obstipation or hematochezia, history of trauma, and presence of headache. Although common causes of vomiting are gastroesophageal reflux and viral gastroenteritis, the pediatrician needs to be aware of other serious causes. In the infant, bilious emesis and abdominal distention and/or pain are worrisome for obstruction, as may be seen with malrotation with midgut volvulus or Hirschsprung disease. It is important to consider extra-abdominal causes of vomiting in the neonate, including hydrocephalus, incarcerated hernia, inborn errors of metabolism, and nonaccidental trauma. Markedly increasing head circumference or a bulging fontanel can be the result of congenital hydrocephalus or can signal the presence of subdural hematomas from nonaccidental trauma. In an older child, the differential diagnosis includes intussusception, incarcerated hernia, diabetic ketoacidosis, appendicitis, poisonings, and trauma. Patients with intussusception may present with vomiting and colicky abdominal pain. A history of increased urination in the presence of vomiting may herald the diagnosis of diabetes mellitus. Patients with headache and vomiting raise a concern for increased intracranial pressure and should be questioned about neurologic changes, meningismus, and fever. Vomiting may be also a nonspecific symptom of a systemic illness (otitis media, sinusitis).

Parents can interpret different symptoms as respiratory distress. Tachypnea secondary to fever is quite concerning. Parents of newborn infants are sometimes alarmed by the presence of periodic breathing. Normal variations in respiratory patterns must be distinguished from true respiratory distress. Parents need to be questioned regarding associated symptoms such as fever, limitation of neck movement, drooling, choking, and the presence of stridor or wheezing. A history of apnea or cyanosis warrants further investigation. Although wheezing is often secondary to bronchospasm, it can also be caused by cardiac disease or congenital anomalies such as vascular rings. Infants with congenital heart defects may be tachypneic but may lack any signs of respiratory distress as a compensatory mechanism for shock or metabolic acidosis. Older children who present with wheezing after a coughing or choking episode should be evaluated for a foreign body aspiration. Stridor is most commonly due to croup. However, anatomic abnormalities such as laryngeal webs, laryngomalacia, subglottic stenosis, and paralyzed vocal cords also cause stridor. In toxic-appearing children with respiratory distress, the pediatrician should entertain the possibilities of epiglottitis, bacterial tracheitis, or a rapidly expanding retropharyngeal abscess. The incidence of epiglottitis has markedly declined with the advent of the Haemophilus influenzae type b (Hib) vaccine, but remains a possibility in the unimmunized or partially immunized patient. Children with retropharyngeal abscesses may present with drooling and limitation of neck movement, especially hyperextension.

Fever is the most common reason for a sick child visit. Most fevers are the result of self-limited viral infections. However, pediatricians need to be aware of the age-dependent potential for serious bacterial infections (urinary tract infections, sepsis, meningitis, dysentery, osteoarticular infection). During the first 3 mo of life, the neonate is at risk for sepsis due to pathogens that are uncommon in older children. These organisms include group B streptococcus, Escherichia coli, Listeria monocytogenes, and herpes simplex virus. In neonates, the history must include maternal obstetric information and the patient’s birth history. Risk factors for sepsis include maternal group B streptococcus colonization, prematurity, chorioamnionitis, and prolonged rupture of membranes. If there is a maternal history of sexually transmitted infections during the pregnancy, the differential diagnosis must be expanded to include those pathogens. Septic infants can present with lethargy, poor feeding, grunting respirations, and impaired perfusion, in addition to fever. Infants with fever, irritability, and a bulging fontanel should be evaluated for meningitis. As the infant matures beyond 3 mo of age, the bacterial pathogens that usually cause bacteremia, sepsis, and meningitis are Streptococcus pneumoniae, H. influenzae type b (if the child is unimmunized or only partially immunized), and Neisseria meningitidis. Immunization against some serotypes of S. pneumoniae appears to be reducing the occurrence of occult bacteremia and serious infections caused by that organism, as has immunization against H. influenzae type b. Other ailments that manifest with fever include septic arthritis and osteomyelitis, juvenile rheumatoid arthritis, and Kawasaki disease. Children with a septic joint generally present with only one joint that is painful and often have pseudoparalysis of that joint. In contrast, patients with juvenile rheumatoid arthritis may present with pain, stiffness, swelling, and warmth of several joints. The diagnosis of Kawasaki disease should be considered if the patient meets the diagnostic criteria for this illness (Chapter 160).

Abdominal pain is another frequent complaint. Often this symptom is due to a minor illness such as constipation, functional abdominal pain, urinary tract infection, or gastroenteritis. Parents should be questioned about associated symptoms including stooling patterns, abdominal distention, fever, urinary symptoms, and vomiting. In neonates, a tender abdomen is concerning for the presence of a small bowel obstruction; these infants tend to appear ill. There may be a history of vomiting and decreased or no stooling. Pediatricians also need to be wary of neonates with abdominal tenderness and bloody stools, as 10% of cases of necrotizing enterocolitis occur in term infants. Infants with milk protein intolerance can also present with bloody stools, but these infants are well appearing and do not have abdominal tenderness. In older patients, the differential diagnosis for abdominal pain expands to include intussusceptions and appendicitis. Patients with intussusception can present in a variety of ways, ranging from having episodes of colicky abdominal pain, but otherwise well in between episodes, to being in a shock-like state. The diagnosis of appendicitis in the child younger than 3 yr is extremely difficult because children in this age group do not localize their pain well. Often the diagnosis is made after the appendix has ruptured.

The child’s past medical history also needs to be obtained. It is important to be aware of any underlying chronic problems that might predispose the child to recurring infections or a serious acute illness. The child with sickle cell anemia is at increased risk for bacteremia as well as painful vasoocclusive crisis. A careful review of systems can help in identifying the nature of the acute illness, as well as any complications needing intervention, such as dehydration accompanying an otherwise minor viral illness.

Physical Exam

Observation is important in the evaluation of the acutely ill child. Most observational data that the pediatrician gathers during an acute illness should focus on assessing the child’s response to stimuli. How does the crying child respond to the parents’ comforting? How quickly does the sleeping child awaken with a stimulus? Does the child smile when the examiner interacts with him or her? Assessing responses to stimuli requires knowledge of normal responses for different age groups, the manner in which those normal responses are elicited, and to what degree a response might be impaired. Thus, the pediatrician must be both clinically and developmentally oriented.

During the physical examination, the pediatrician seeks evidence of illness. The portions of the physical examination that require the child to be optimally cooperative are completed first. Initially, it is best to seat the child on the parent’s lap; the older child may be seated on the examination table. Vital signs are often overlooked but are valuable in assessing ill children. The degree of fever, the presence of tachycardia out of proportion to the fever, and the presence of tachypnea and hypotension all suggest a serious infection. The respiratory evaluation includes determining respiratory rate and noting any evidence of inspiratory stridor, expiratory wheezing, grunting, or coughing. Evidence of increased work of breathing—retraction, nasal flaring, and the use of abdominal musculature—is sought. Because acute infections in children are most often caused by viral infections, the presence of nasal discharge may be noted. It is possible at this time to assess the skin for rashes. Frequently, viral infections cause an exanthematous eruption, and many of these eruptions are diagnostic (the reticulated rash and “slapped-cheek” appearance caused by parvovirus infections or the typical appearance of hand-foot-and-mouth disease caused by coxsackieviruses). The skin examination may also yield evidence of more serious infections (bacterial cellulitis or petechiae and purpura associated with bacteremia). Cutaneous perfusion should be assessed by warmth and capillary refill time. When the child is seated and is least perturbed, an assessment of the fontanel can be completed; the examiner can determine whether the fontanel is depressed, flat, or bulging. It is also important to assess the child’s willingness to move and ease of movement. It is reassuring to see the child moving about on the parent’s lap with ease and without discomfort.

During this initial portion of the physical examination, when the child is most comfortable, the heart and lungs are auscultated. In the acutely febrile child, because of the relatively frequent occurrence of respiratory illnesses, it is important to assess adequacy of air entry into the lungs, equality of breath sounds, and evidence of adventitial breath sounds, especially wheezes, rales, and rhonchi. The coarse sound of air moving through a congested nasal passage is frequently transmitted to the lungs. The examiner can become attuned to these coarse sounds by placing the stethoscope near the child’s nose and then compensating for this sound as the chest is auscultated. The cardiac examination is next; findings such as pericardial friction rub, loud murmurs, and distant heart sounds may indicate an infectious process involving the heart. The eyes are examined to identify features that might indicate an infectious process. Often, viral infections result in a watery discharge or redness of the bulbar conjunctivae. Bacterial infection, if superficial, results in purulent drainage; if the infection is more deep-seated, tenderness, swelling, and redness of the tissues surrounding the eye are present, as well as proptosis, reduced visual acuity, and altered extraocular movement. The extremities may then be evaluated not only for ease of movement but also for the possibility of swelling, heat, or tenderness; such abnormalities may indicate focal infections.

The components of the physical examination that are more bothersome to the child are completed last. This is best done with the patient on the examination table. Initially, the neck is examined to assess for areas of swelling, redness, or tenderness, as may be seen in cervical adenitis. The neck is then flexed to evaluate suppleness; resistance to flexion is indicative of meningeal irritation. The Kernig and Brudzinski signs may be sought at this time. In children younger than 18 mo, meningeal signs may not always be present with meningitis; if they are present, the diagnostic implications are the same as for the older child. During examination of the abdomen, the diaper is removed. The abdomen is inspected for distention. Auscultation is performed to assess adequacy of bowel sounds, followed by palpation. The child often fusses as the abdomen is auscultated and palpated. Every attempt should be made to quiet the child; if this is not possible, increased fussing as the abdomen is palpated may indicate tenderness, especially if this finding is reproducible. In addition to focal tenderness, palpation may elicit involuntary guarding or rebound tenderness (including tenderness to percussion); these findings indicate peritoneal irritation, as is seen in appendicitis. The inguinal area and genitals are then sequentially examined. The child is then placed in the prone position, and abnormalities of the back are sought. The spine and costovertebral angle areas are percussed to elicit any tenderness; such a finding may be indicative of vertebral osteomyelitis or diskitis and pyelonephritis, respectively.

Examining the ears and throat completes the physical examination. These are usually the most bothersome parts of the examination for the child, and parents frequently can be helpful in minimizing head movement. During the oropharyngeal examination, it is important to document the presence of enanthemas; these may be seen in many infectious processes, such as hand-foot-and-mouth disease caused by coxsackievirus. This portion of the examination is also important in documenting inflammation or exudates on the tonsils, which may be viral or bacterial.

Repeating portions of the assessment may be indicated. If the child cried continuously during the initial clinical evaluation, the examiner may not be certain whether the crying was caused by the high fever, stranger anxiety, or pain, or is indicative of a serious illness. Constant crying also makes portions of the physical examination, such as auscultation of the chest, more difficult. Before a repeat assessment is performed, efforts to make the child as comfortable as possible are indicated.

Febrile children can appear very ill. The elevated temperature is often accompanied by listlessness, tachycardia, and tachypnea. These patients should receive antipyretic medications and be reassessed once they have defervesced. In the majority of children with uncomplicated viral illnesses, the vital signs normalize. Persistence of abnormal vital signs should prompt the clinician to further investigate the source of fever. Continued tachycardia and poor perfusion may be secondary to myocarditis. Tachypnea may be the sole symptom in patients with pneumonia, especially in children whose chief complaint is abdominal pain due to lower lobe pneumonia. Persistent irritability suggests meningitis.

Risk Factors

The sensitivity of the carefully performed clinical assessment, observation, history, and physical examination for the presence of serious illness is approximately 90%. Careful data gathering is necessary in the observation, history, and physical examination, because each component of the evaluation is as effective as the others in identifying serious illness. Other data should be sought to improve this sensitivity level. In the child with an acute febrile illness, important supplemental data are age, body temperature, and the results of screening laboratory tests. Febrile children in the first 3 mo of life have yet to achieve immunologic maturity and therefore are more susceptible to severe infections. Thus, the febrile infant is at greater risk for serious bacterial infection than the child beyond 3 mo of age. In febrile children, the higher the fever is, the greater the risk of serious illness. The risk of bacteremia in infants increases as the magnitude of fever increases.

Screening laboratory tests may be helpful in identifying the febrile child at increased risk for selected serious illnesses. S. pneumoniae is a cause of occult bacteremia not associated with a focal soft tissue infection. A total white blood cell count of ≥15,000/mm³ and/or an absolute neutrophil count of ≥10,000/mm³, in addition to age 3-36 mo, higher grades of fever, and a more ill appearance, are indicators of increased risk for occult bacteremia caused by S. pneumoniae. The incidence of occult pneumococcal bacteremia in febrile children is declining because of the introduction of conjugated pneumococcal vaccine. Urinalysis and urine culture must always be considered when the source of fever is not apparent, especially in the highest-risk groups: females and uncircumcised males younger than 2 yr and all boys younger than 1 yr. The presence of leukocyte esterase, >5 white blood cells/high-power field on a spun urine specimen, or bacteria detected by Gram stain on an unspun urine specimen suggests urinary tract infection, but the sensitivity of these indicators is, on average, only 75-85% and urine culture is the definitive test. An elevated C-reactive protein value may also distinguish bacterial from viral infection.

Management

Most patients who present to the pediatrician’s office with an acute illness will not require resuscitation. The pediatrician needs to be prepared to evaluate and begin resuscitation for the seriously ill or unstable child. The pediatrician’s office should be stocked with appropriate equipment necessary to stabilize an acutely ill child. Maintenance of that equipment and ongoing training of the office staff in use of the equipment and procedures is required (Chapter 61). The evaluation must begin with assessment of the ABCs—airway, breathing, and circulation. When assessing the airway, chest rise should be evaluated, and evidence of increased work of breathing sought. The examiner should ensure that the trachea is midline. If the airway is patent and no signs of airway obstruction are present, the patient is allowed to assume a position of comfort. If the child shows signs of airway obstruction, repositioning of the head with the chin lift maneuver may alleviate the obstruction. An oral or nasal airway may be necessary in patients in whom airway patency cannot be maintained. These devices are not well tolerated in conscious patients and may induce gagging or vomiting. Once airway patency has been established, the adequacy of breathing should be evaluated. Auscultation of the lung fields should assess for air entry, symmetry of breath sounds, and presence of adventitious breath sounds such as crackles or wheezes. Pulse oximetry can be used to evaluate oxygenation. Bronchodilator therapy can be initiated to alleviate bronchospasm. Oxygen should be administered to all seriously ill children via nasal cannula or face mask. Cyanosis or slow respiratory rates may signal respiratory failure. If the airway is patent but the child’s respiratory effort is deemed inadequate, positive pressure ventilation via a bag-valve-mask device should be initiated. Once airway and breathing have been addressed, circulation must be evaluated. This involves assessment of cardiac output. Symptoms of shock include tachycardia, cool extremities, delayed capillary refill time, mottled or pale skin, and effortless tachypnea. Hypotension is a late finding in shock. Vascular access is necessary for volume resuscitation in patients with impaired circulation. Once an intervention is performed, the clinician must reassess the patient.

If the febrile child is older than 3 mo and appears well, if the history or physical examination does not suggest a serious illness, and if no age or temperature risk factors are present, the child may be followed expectantly. If otitis media is present, it should be treated. This profile applies to most children with acute febrile illnesses. If, on the other hand, the child appears ill or the history or physical examination suggests a serious infection, definitive laboratory tests appropriate for those findings are indicated (e.g., chest radiograph for a child with grunting). The area of greatest controversy is whether laboratory studies are needed in a febrile child who appears well and has no abnormalities on history and physical examination, but who is younger than 3 mo or whose temperature is high. Many would agree that a sepsis work-up is indicated in the febrile child younger than 1 mo and possibly younger than 3 mo. Obtaining blood and urine cultures in children older than 3 mo with higher grades of fever without a focus has also gained increased acceptance.

Disposition

The majority of children evaluated in the office for an acute illness can be managed on an outpatient basis. These patients should have reassuring physical examinations, stable vital signs, and adequate follow-up. A mildly dehydrated patient can be discharged to home for a trial of oral rehydration. Patients with a respiratory illness who are exhibiting signs of mild respiratory distress may be monitored at home with a repeat examination scheduled for the next day. Depending on the child’s status, the comfort of the parents, and the relationship of the family with the physician, telephone follow-up may be all that is necessary.

If the physician feels comfortable in following as an outpatient the child in whom no specific diagnosis has been established, a follow-up examination may yield the diagnosis. During the initial visit, or from one visit to the next during the acute illness, the change in symptoms or in the findings on physical examination over time may provide important diagnostic clues. For the child in whom a diagnosis has already been established and who does not require hospitalization, follow-up by telephone or an office visit should be used to monitor the course of the illness and to further educate and support the parents.

However, if it is deemed that the child needs a higher level of care, it is the pediatrician’s responsibility to decide what method of transfer is appropriate. Physicians may be reluctant to call for help because of a misperception that 911 services should be activated only for full-blown resuscitations. Emergency Medical Services (EMS) transport should be initiated for any child who is physiologically unstable (i.e., with severe respiratory distress, cyanosis, signs of shock, or altered mental status). If the family’s ability to comply promptly with recommendation for emergency department evaluation is in question, that patient should also be transported by EMS. Some physicians and families may defer calling EMS because of the perception that a parent can get to the hospital faster by private car. Although rapidity of transport should be considered, the need for further interventions during transport and the risk of clinical decompensation are other important factors in the decision to activate EMS. Ultimately, the legal responsibility for a patient lies with the referring physician, until responsibility of care is officially transferred to another medical provider.