Occasionally a infant presents to the ED who is described as "unwell" without any specific symptoms to guide the doctor. A judicious period of observation in the department will often be helpful (e.g.. the development of a pyrexia). We do not use a "baby check" scoring system for the assessment of such children (they may themselves be falsely reassuring). However, certain basic principles can be applied to the assessment of such children, and should be part of a routine examination:
- Is the infant smiling?
- Does the infant play and reach for objects?
- Does the child follow parents eyes/fixes on objects etc?
- Is the child feeding normally?
- Has the child been wetting nappies normally?
If you, the nurses, (or the parents occasionally), assess that the answers to those questions are "yes", then the likelihood of a serious illness is small. However, this is not a substitute for full clinical assessment and investigations (where needed), and if there is any doubt the child should be admitted for observation.
The next section contains a guideline on how to approach the assessment of an "unwell" baby/infant:
Drugs: Always give doses as guided by AlderHey Book of Children's doses
The Unwell infant ( <1 year old)
This is one of the most difficult paediatric problems to deal with in the ED. You have to differentiate the basically well infant with a viral infection from the unwell with a more serious infection such as
- Urinary tract infection
- Lower respiratory tract infection
The following is a guide only on an approach to the assessssment of these children.
- Why has the parent brought the child into the ED?
- Evaluate the presenting symptoms, duration, what treatment has already been given
- Has the child has its HIB vacination in particular?
- Is the child smiling?
- Alert or listless?
- Miserable and irritable?
- Can they be easily consoled by the parent?
- Drinking well?
- Keeping down fluids?
- Normal number of wet nappies (4 a day rough minimum)?
If the answer to any of these is No then Beware!
Airway and Breathing:
- Airway obstruction?
- Increased work of breathing ... grunting, nasal flaring, recession, indrawing?
- Respiratory rate and rhythm
- Heart rate
- Pulse volume
- Capillary refill time
- Skin temperature
- Posture and tone
- Mental status - the AVPU scale
It should be possible to perform this assessment with the first minute. If the child is very sick Call for help early. You can then go on to: Diagnossis nad Investigations.
- Head to toe exam - Does the child look well?
- Pyrexial? (some infants apyrexial even in septicaemia)
- Look for shin rashes - ? viral
- Petechial rash of meningococcal septicaemia
- Note - Measles is very uncommon in the infants
- Dehydration ?
- Sunken eyes, skin turgor, dry mucous membranes
- Peripheral circulation - well perfused?, Capillary refill time prolonged (>2 sec)?
- Fontanelle - is it bulging or depressed
- Respiratory rate and pattern?
- Normal infant is 30 - 40 breaths per minute
- The ratio of pulse rate to respiratory rate is 4:1
- Raised in respiratory tract infection
- Urine examination and culture for all
- Bag specimen, clean catch or SPA if trained
- WBC unreliable in severe infection (often low)
- CRP unreliable in infants
- Check blood sugar - it may be low in sepsis. (DEFG)
Indications for admission
According to diagnosis and assessment (as above) but admit any in whom you are unsure of the diagnosis.
Pyrexial, irritable but well:
- Paracetamol & observation in ED - home if well
- Paediatric/senior opinion
Very unwell with peripheral circulatory failure
- Call for help
- ABC resuscitation (Don't Ever Forget Glucose)
- ceftriaxone and penicillin before transfer
- Dextrose if hypoglycaemic
- Initial observations: Pulse, resp, BP, temp, oxygen sats, blood glucose, weight
- Initial investigations
- Secondary assessment
- Emergency treatment
- Definitive care