The seriously ill child

The rapid clinical assessment of the seriously ill child will identify if there is potential respiratory, circulatory or neurological failure. This should take less than 1 minute. Normal vital signs are shown in Figure 6.1 and how a rapid assessment is performed is shown in Figure 6.2.

Resuscitation is given immediately, if necessary, followed by secondary assessment and other emergency treatment.

The seriously ill child may present with shock, respiratory distress, as a drowsy/unconscious or fitting child or with a surgical emergency. Their causes are listed in Figure 6.4. In children, the key to successful outcome is the early recognition and active management of conditions that are life-threatening and potentially reversible.

 Capillary refill time is affected by body exposure to a cold environment.

Cardiopulmonary resuscitation

In adults, cardiopulmonary arrest is often cardiac in origin, secondary to ischaemic heart disease. In contrast, children usually have healthy hearts but experience hypoxia from respiratory or neurological failure or shock. If this occurs, irrespective of the cause, basic life support must be started immediately.

Basic life support

See Figure 6.5.

Advanced life support (Fig. 6.6)

Children who have been resuscitated successfully should be transferred to a paediatric high-dependency or intensive care unit.

The seriously injured child

Management of the seriously injured child must take account of potential injury to the cervical spine and other bones and internal injuries (Fig. 6.7).

Shock

Shock is present when the circulation is inadequate to meet the demands of the tissues. Critically ill children are often in shock, usually because of hypovolaemia due to fluid loss or maldistribution of fluid, as occurs in sepsis or intestinal obstruction.

Why are children so susceptible to fluid loss?

Children normally require a much higher fluid intake per kilogram of body weight than adults (Table 6.1). This is because they have a higher surface area to volume ratio and a higher basal metabolic rate. Children may therefore become dehydrated if:

Table 6.1

Fluid intake at different ages

Body weight	Fluid requirement/24 h	Volume/kg per hour (approximate)
First 10 kg	100 ml/kg	4 ml/kg
Second 10 kg	50 ml/kg	2 ml/kg
Subsequent kg	20 ml/kg	1 ml/kg
Examples of calculations
Infant (7 kg)	700 ml	28 ml/h
Child (18 kg)	1000 + 400 = 1400 ml	40 + 16 = 56 ml/h
Adolescent (42 kg)	1000 + 500 + 440 = 1940 ml	40 + 20 + 22 = 82 ml/h

• they are unable to take oral fluids

• there are additional fluid losses due to fever, diarrhoea or increased insensible losses (e.g. due to increased sweating or tachypnoea)

• there is loss of the normal fluid-retaining mechanisms, e.g. burns, the permeable skin of premature infants, increased urinary losses or capillary leak.

Clinical features

The clinical features of shock are manifestations of compensatory physiological mechanisms to maintain the circulation and the direct effects of poor perfusion of tissues and organs (Box 6.2).

Box 6.2   Clinical signs of shock

Early (compensated)	Late (decompensated)
Tachypnoea Tachycardia Decreased skin turgor Sunken eyes and fontanelle Delayed capillary refill (>2 s) Mottled, pale, cold skin Core–peripheral temperature gap (>4°C) Decreased urinary output

Acidotic (Kussmaul) breathing

Bradycardia

Confusion/depressed cerebral state

Blue peripheries

Absent urine output

Hypotension

Management priorities

Fluid resuscitation

Rapid restoration of the intravascular circulating volume is the priority (Fig. 6.8). This will usually be with 0.9% saline, or blood if following trauma.

Subsequent management

If there is no improvement following fluid resuscitation or there is progression of shock and respiratory failure, a paediatric intensive care unit should be involved and transfer arranged as the child may need:

Septicaemia

Bacteria may cause a focal infection or proliferate in the bloodstream, leading to septicaemia. In septicaemia, the host response includes the release of inflammatory cytokines and activation of endothelial cells, which may lead to septic shock. The commonest cause of septic shock in childhood is meningococcal infection, which may or may not be accompanied by meningitis. Fortunately, its incidence in the UK has fallen markedly since immunisation was introduced against meningococcal C, but other strains are still prevalent. Pneumococcus is the commonest organism causing bacteraemia, but it is unusual for it to cause septic shock. In neonates, the commonest causes of septicaemia are group B streptococcus or Gram-negative organisms acquired from the birth canal.

Clinical features

See Box 6.3

Box 6.3   Clinical features of septicaemia

History	Examination
Fever Poor feeding Miserable, irritable, lethargy History of focal infection, e.g. meningitis, osteomyelitis, gastroenteritis, cellulitis Predisposing conditions, e.g. sickle cell disease, immunodeficiency

Fever

Tachycardia, tachypnoea, low blood pressure

Purpuric rash (meningococcal septicaemia) (Fig. 6.9).

Shock

Multi-organ failure

Management priorities

Children with septic shock need to be rapidly stabilised and may require transfer to a paediatric intensive care unit.

Antibiotics

Choice depends on the child’s age and any predisposition to infection.

Fluids

Significant hypovolaemia is often present, owing to fluid maldistribution, which occurs due to the release of vasoactive mediators by host inflammatory and endothelial cells. There is loss of intravascular proteins and fluid which may occur due to the development of ‘capillary leak’ caused by endothelial cell dysfunction. Circulating plasma volume is lost into the interstitial fluid. Central venous pressure monitoring and urinary catheterisation may be required to guide the assessment of fluid balance. Capillary leak into the lungs causes pulmonary oedema, which may lead to respiratory failure, necessitating mechanical ventilation.

Circulatory support

Myocardial dysfunction occurs as inflammatory cytokines and circulating toxins depress myocardial contractility. Inotropic support may be required.

Disseminated intravascular coagulation (DIC)

Abnormal blood clotting causes widespread microvascular thrombosis and consumption of clotting factors. If bleeding occurs, clotting derangement should be corrected with fresh frozen plasma and platelet transfusions.

Steroids

There is no evidence that steroids are of benefit in septic shock.

Summary

Septicaemia

• The most common cause of septic shock in children is meningococcal disease

• May occur without meningitis

• Early antibiotic therapy and fluid resuscitation are life-saving

• May need admission to paediatric intensive care for multi-organ failure.

Coma

In coma, there is disturbance of the functioning of the cerebral hemispheres and/or the reticular activating system of the brainstem. The level of awareness may range from excessive drowsiness to unconsciousness. It is assessed rapidly by using AVPU (Alert, responds to Voice, responds to Pain, Unresponsive) or the Glasgow Coma Scale (Table 6.2).

The immediate assessment of a child in coma is shown in Figures 6.10 and 6.11. The causes, clinical features and investigations of coma are listed in Table 6.3. In contrast to adults, most children have a diffuse metabolic insult rather than a structural lesion.

Status epilepticus or post-ictal Trauma – accidental/non-accidental Radiological – plain X-rays or CT/MRI scans Intracranial tumour or haemorrhage/infarct/abscess Metabolic     1. Diabetes mellitus 2. Hypoglycaemia Low blood glucose 3. Inborn errors of metabolism 4. Hepatic failure 5. Acute renal failure Oliguria, hypertension Abnormal creatinine Poisoning Shock Hypertension Respiratory failure Respiratory failure

• the head positioned midline

• the head end of the bed tilted by 20–30°

• isotonic fluids at 60% maintenance

• intubation and ventilation if Glasgow Coma Score <9

• mannitol or 3% saline as osmotic diuretics

• maintaining normothermia and high normal blood pressure.

Status epilepticus

This is a seizure lasting 30 minutes or longer, or when successive seizures occur so frequently that the patient does not recover consciousness between them. After immediate primary assessment and resuscitation, the priority is to stop the seizure as quickly as possible (Fig. 6.12).

Anaphylaxis

Anaphylaxis is rapid in onset and may be fatal. It has an incidence of one episode every 20 000 person years, and about 1 in 1000 cases are fatal. In children, 85% of anaphylaxis is caused by food allergy; most are IgE-mediated reactions with significant respiratory or cardiovascular compromise. Other causes include insect stings, drugs, latex, exercise, inhalant allergens and idiopathic. While most paediatric anaphylaxis occurs in children <5 years, when food allergy is most prevalent, the majority of fatal paediatric anaphylaxis occurs in adolescents with allergy to nuts; asthma is an additional risk factor. The acute management of anaphylaxis relies on early administration of adrenaline (epinephrine) (Fig. 6.13). Long-term management involves detailed strategies and training for allergen avoidance, a written management plan with instructions for the treatment of allergic reactions and the provision of adrenaline (epinephrine) auto-injector(s). In some cases, such as insect sting anaphylaxis, allergen immunotherapy may be effective in preventing future episodes. The experience of an anaphylactic reaction can have a significant psychological impact on the child and family.

Apparent life-threatening events (ALTE)

These occur in infants and are a combination of apnoea, colour change, alteration in muscle tone, choking or gagging, which are frightening to the observer. They are most common in infants less than 10 weeks old and may occur on multiple occasions. They may be the presentation of a potentially serious disorder, although often no cause is identified.

Management requires a detailed history and thorough examination to identify problems with the baby or in caregiving. The infant should be admitted to hospital. Causes and investigations to be considered are listed in Box 6.4. Multi-channel overnight monitoring is usually indicated.

In most, the episode is brief, with rapid recovery, and the baby is well clinically. Baseline investigations and overnight monitoring of oxygen saturation, respiration and ECG are found to be normal. The parents should be taught resuscitation and will find it helpful to receive follow-up from a specialist paediatric nurse and paediatrician.

Detailed specialist investigation and assessment will be required if clinical, biochemical or physiological abnormalities are identified.

The death of a child

The risk of death is four times greater during infancy than at any other age in childhood. In many, a serious condition will have been diagnosed before or after birth, such as a congenital abnormality or complications of prematurity. Deaths which occur suddenly and unexpectedly in infancy are known as sudden unexpected death in infancy (SUDI). In some, a previously undiagnosed congenital abnormality, e.g. congenital heart disease, will be found at autopsy. Rarely, an inherited metabolic disorder is identified, in particular the fatty acid oxidation defect medium-chain acyl-CoA dehydrogenase deficiency (MCAD), which can very rarely result in sudden death in infants, but is increasingly identified in the UK from routine biochemical screening (Guthrie test). After 1 month of age, in most instances of sudden death in a previously well infant, no cause is identified and the death is classified as sudden infant death syndrome (SIDS). The vast majority of such deaths, even when occurring more than once in the same family, are due to natural causes. Rarely, the death may be due to suffocation or other forms of non-accidental injury.

Sudden infant death syndrome

This is defined as the sudden and unexpected death of an infant or young child for which no adequate cause is found after a thorough postmortem examination. There is marked variation in the incidence of SIDS in different countries, suggesting that environmental factors are important (Box 6.5). SIDS occurs most commonly at 2–4 months of age (Fig. 6.14). The risk for subsequent children is slightly increased.

Box 6.5

Factors associated with SIDS

The infant

• Age 1–6 months, peak at 12 weeks

• Low birthweight and preterm (but 60% are normal birthweight term infants)

• Sex (boys 60%)

• Multiple births

The parents

• Low income^a

• Poor or overcrowded housing

• Maternal age (mother aged <20 years has three times the risk of a mother aged 25–29 years, but 80% of affected mothers are >20 years old)^a

• Single unsupported mother (twice the rate of supported mothers)

• High maternal parity^a

• Maternal smoking during pregnancy (1–9 cigarettes/day doubles the risk: >20/day increases the risk five-fold)^a

• Parental smoking after baby’s birth

The environment

• The infant sleeps lying prone

• The infant is overheated from high room temperature and too may clothes and covers, particularly when ill.

---

^aThree of these four factors are present in over 40% of SIDS but only 8% of control families.

Based on data from Fleming P, Blair P, Bacon C et al. 2000. Sudden Unexpected Deaths in Infancy. The Stationery Office, London.

In the UK, the incidence of SIDS has fallen dramatically during the last 20 years (Fig. 6.15), coinciding with a national ‘Back to Sleep’ campaign (Fig. 6.16). This advocates that:

• Infants should be put to sleep on their back (not their front or side)

• Overheating by heavy wrapping and high room temperature should be avoided

• Infants should be placed in the ‘feet to foot’ position

• Parents should not smoke near their infants

• Parents should seek medical advice promptly if their infant becomes unwell.

• Parents should have the baby in their bedroom for the first 6 months of life

• Parents should avoid bringing the baby into their bed when they are tired or have taken alcohol, sedative medicines or drugs

• Parents should avoid sleeping with their infant on a sofa, settee or armchair.

Summary

Sudden infant death syndrome (SIDS)

• SIDS is the commonest cause of death in children aged 1 month to 1 year.

• The peak age is 2–4 months.

• SIDS has been dramatically reduced by lying babies on their back to sleep.

Following the sudden death of a child

The sudden death of a child is one of the most distressing events that can happen to a family. If close family members are absent, arrangements should be made for them to come, if this is possible. The family should be spoken to sympathetically and in private (see Ch. 5). An outline of the recommended management after an infant has died suddenly and unexpectedly is shown in Figure 6.17.

Summary

Following an unexpected death

• The parents should be offered the opportunity to see and hold their child.

• The coroner must be informed and a postmortem performed.

• The parents should be informed about the postmortem, that investigations will be performed and that the police will be involved and they should be reassured that this is standard practice.

• Follow-up and bereavement counselling should be offered.