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Performance Matters - Unwell Children

The LMC is regularly involved in representing and supporting doctors who have been identified as having “performance” issues. The LMC has identified a number of themes which recur and this regular feature will highlight these, so that our members can avoid these pitfalls.

Unwell Children

Parents often bring their children to be clinically reviewed because they are concerned that the child is “unwell”. Clinicians’ understanding of what “unwell” is can be very different to that of a parent. Parents naturally worry about their children when they have clinically a relatively minor illness. Parents are also usually able to identify their child as “unwell” when they also have a significant illness. Clinicians, however, sometimes do not identify these more significantly unwell children as they present rarely, and may be hidden amongst a myriad of relatively well children.

When clinicians do not identify a significantly unwell child, this is very distressing for all involved. This distress is made even deeper when it leads to disciplinary or performance investigation. To avoid this happening, this “performance matters” will give advice how to best avoid missing the signs of an “unwell” child.

History

The causes of being “unwell” are too many to list, but the presentations for these are similar. Parents usually report a change in the child’s behaviour, such as; irritability, reduced feeding, increased sleepiness, being floppy, having altered breathing, or being a funny colour. It is important to identify if these are present, and to note their presence or absence in the medical record. The negative findings are as important as the positive ones, as the absence of positive findings is both reassuring and can prove that the child was not “unwell” when the patient presented.

The general history is also important. As we know, children usually get better spontaneously in a short time period from most minor illnesses. If a child is not improving, or has been seen by multiple clinicians, this should be taken as a sign that the child may be more “unwell” that at initial assessment. Other factors which should be taken into account are whether the child has other medical conditions, or is under three months old.

Examination

A thorough examination is always worth completing and recording. This examination should include assessment of-

  • General appearance- are they alert, happy, responsive?
  • Hydration- fontanelle, capillary refill time
  • Temperature- high (>38.5) or low (<36.0) temperature can be a sign of sepsis
  • Rashes
  • Pulse rate
  • Heart sounds
  • Respiratory effort and rate
  • Chest sounds
  • ENT
  • Abdominal examination

Computer templates are a useful way to record these findings, as they prompt what is missing, and also give a record of the examination findings now and previously recorded values.

Investigations

Realistically if a child has worrying history or examination no investigations should be carried out in the primary care setting. However, if a child has a fever without obvious cause, a urine sample should be tested to look for UTI.

What to do with the well “unwell” child

If you are able to reassure yourself that the child is not significantly unwell, then reassuring the parents, and providing treatment or safety netting is appropriate. The specific nature of your safety netting should be recorded in the medical record.

What to do with the significantly “unwell” child

help if you are concerned about an unwell child. The paediatricians prefer to see well children than miss seeing an unwell child. Refer the unwell child directly to paediatrician. Follow the advice given by the paediatrician about transport, if they feel that an ambulance should be called, this advice should be taken, even if the parents have their own transport.

If you believe the child has meningococcal sepsis, give IM antibiotics and call for an ambulance.

Avoiding the pitfalls

The main message is that most children are not significantly unwell, and that it is easy to miss the truly unwell child.

  • To avoid this take a good history and full examination
  • Making good notes is essential
  • Use computer templates to record values
  • If in doubt speak to a paediatrician

The NICE Traffic Light System, the Paediatric Sepsis: Crib and Paediatric Sepsis 6 Tool Kit Sheet are available in the links above.

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