Chapter 36. The sick child
Children tend to be treated with a greater sense of urgency than adults. This reflects both the instinct that most adults have to protect the young and the correctly held view that children can ‘go off’ quickly. While urgency is important, at no stage must a sense of panic prevail. The most important skill that comes with experience is recognising that a child is ill. Rapid and safe transport to hospital can be life-saving.
Recognition of serious illness
Health workers with a great deal of paediatric experience will intuitively recognise a very sick child. A systematic approach can be used following the familiar <C>ABC pattern, which is difficult to forget, even under pressure.
Assessment of the airway
• The airway may be patent or obstructed, protected or unprotected. Obstruction may be partial or complete and protection may be secure or insecure
• Any child who has anything other than an open and securely protected airway is seriously ill
• If the child is conscious, then a simple question such as ‘How are you?’ or ‘What’s wrong?’ should start the assessment and if you get a reply, then you have confirmed that the airway is patent, that they are breathing and that they have at least enough circulation to perfuse their brain
• In an unconscious child, an appropriate airway-opening manoeuvre should be performed and then breathing assessed.
The airway is at risk in any child who is not fully conscious
Assessment of breathing
The respiratory rate should be counted by exposing the chest. Exposure will also reveal recession. Recession is the appearance of indrawing of the chest wall that occurs while it is expanding during inspiration. It can be seen in a number of areas: intercostal (between the ribs), subcostal (below the ribs) and sternal.
| Age (years) | Respiratory rate (breaths/min) |
|---|---|
| <1 | 30–40 |
| 1–5 | 25–30 |
| 6–12 | 20–25 |
Wheezes (during both inspiration and expiration) indicate that respiratory work is raised because of the increased pressure associated with narrowing of the airways. Severe upper airway obstruction (such as that caused by a foreign body) can result in stridor. It is important to note that the loudness does not correspond to the severity of the problem. Silence in a previously noisy chest may indicate either exhaustion or total obstruction.
Hypoxia (reduction in oxygenation – <90% on air or <95% on oxygen) initially causes the heart rate to rise as the body attempts to deliver more blood to the tissues to make up for the lower concentration of oxygen. Eventually, however, the heart rate falls to below normal levels: this is a very serious sign and usually indicates imminent death. Hypoxia will also affect conscious level. First of all, the child becomes agitated but as the low oxygen delivery continues, drowsiness and then unconsciousness will ensue.
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