Spotting the sick child
As a paediatrician, how can I provide a 20 minute guide for GPs on spotting the sick child?
This task seemed impossible until I teamed up with the GPs themselves.
HEAT (Hounslow Education and Training)
Hounslow CCG have organised an impressive training series for their GPs. Every six months, every practice in Hounslow closes for the afternoon for HEAT (Hounslow Education and Training). A few trusted locums staff the district while 150 GPs gather at Twickenham Stadium.
Mandy, Hounslow CCG’s Child Health Lead, buzzes with energy. She asked me to attend a HEAT event in March this year to talk on Spotting the Sick Child.
Mandy sent me links to superb videos that actually did most of the work for me. The Spotting the Sick Child site is a treasure trove of teaching materials with many excellent short videos.
Measuring vital signs gives some of the best clues as to the seriousness of an illness. Key messages from a previous HEAT event (taken from the NICE Guidance) were:
A parent’s report that their child has a temperature should be taken seriously
Under three months, a child with a temperature greater than 38ºC should be seen within 2 hours
Capillary refill of over three seconds indicates an intermediate risk of serious illness
Here are the commonly measured vital signs:
Capillary refill time
The oxygen saturations provide a simple addition to this. You can read elsewhere how Hounslow CCG acquired children’s Saturation Monitors for all its GPs.
Spotting the sick child early
A child with a trivial viral infection can appear very similar to a child who is at the early stages of a serious infection, which health professionals all want to spot quickly. We know that mortality rates for children in the UK compare unfavourably with those of our European neighbours. A pilot study in 2006 to assess why children die found some potentially avoidable deaths: 9 per cent of these were due to infection. So if we can spot serious bacterial infection early, and start antibiotics early for those infections, we can make a difference.
What is normal?
If a child with a fever has abnormal vital signs, this should alert the clinician. But what is normal? The normal range for vital signs changes at different ages. Various learned bodies publish different normal ranges for different ranges. So which to use? The NICE traffic light system is commonly applied. For increased accuracy, my colleague in Paediatric A&E pointed me in the direction of this paper in the Lancet.
Keep it simple
In the end, any of these normal ranges (as long as it is one of the reputable sources) may be used. The trick is to have them easily accessible for quick reference. In the hospital the normal ranges are up on the walls and on the bedside charts. Mandy, ever-thoughtful, is arranging for these normal ranges to be available on the GP screens in their consultation rooms.
That much-feared killer infection, meningococcal septicaemia, is thankfully much rarer these days. A GP is likely to see only one or two cases in a lifetime. Spotting that case among the myriad simple infections that GPs see is a challenge. But by sticking to the very basic assessment, measuring those vital signs and listening to parents, spotting the sick child really can become a lot easier.
Postscript from Mandy Baum
It was so very generous of Mando to find time in her hectic schedule to come all the way out to Twickenham to educate Hounslow GPs. Her enthusiasm and presentation skills shone through despite the IT glitches thrown at her. There was a lively discussion about how reassured one can be if a fever responds to antipyretics. Thank you on behalf of all Hounslow GPs.