The Unwell Baby

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:

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

 

Rapid Assesment

Airway and Breathing:

  • Airway obstruction?
  • Increased work of breathing ... grunting, nasal flaring, recession, indrawing?
  • Respiratory rate and rhythm
  • Auscultation
  • Cyanosis?

Circulation:

  • Heart rate
  • Pulse volume
  • Capillary refill time
  • Skin temperature

Disability:

  • Posture and tone
  • Pupils
  • 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.

The Unwell infant  ( <1 year old)

Background

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

The following is a guide only on an approach to the assessssment of these children.

Assessment

Document

If the answer to any of these is No then Beware!

Diagnosis

  • 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

Investigation

  • Urine examination and culture for all
  • Bag specimen, clean catch or SPA if trained.
  • FBC
    • 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.

Management

Resuscitation

  • Initial observations: Pulse, resp, BP, temp, oxygen sats, blood glucose, weight
  • Initial investigations
  • Secondary assessment
  • Emergency treatment
  • Definitive care