1. Recognizing the Seriously Ill Child Chiropractic Pediatrics, Ch. 4 N. Davies

2. Fever Definition: Elevation in body temperature It is not a disease… though it may indicate the presence of disease It is helpful…defense mechanism

3. Possible Risks 1. >101 in a newborn (2-3 months old) 2. >105 for a prolonged period of time may lead to dehydration brain injury (rare)

4. “Red Flags” Core body temperature elevated State of arousal Breathing effort State of peripheral circulation Dehydration  fluids taken in and excreted (24 hrs)  acute weight loss

5. Arousal Observe the child for:  signs of drowsiness  hypotonia  response to stimulation If the baby cries, note characteristics of the cry  weak, whimpering, appears to require undue effort

6. Dyspnea Recession of the sternum and chest wall Nasal flaring Respiratory grunting Central cyanosis NOTE: tachypnea alone is not indicative of serious illness

7. Peripheral Circulation Generalized pallor Cold lower legs (knee down) NOTE: cold hands & feet and mottling of the skin have little or no relationship to serious illness

8. Estimation of Fluid Intake/Loss Serious signs: Ingesting <50% of the normal fluid intake <4 wet diapers in a 24 hr period

9. Estimation of Acute Weight Loss Compare current weight to expected weight  look at the anthropometric chart (percentile) to determine their expected weight expected weight - current weight X 100 expected weight Weight loss of >7.5%... Dehydration  Refer to the hospital

10. Signs of Dehydration Dry mucous membranes and skin Rapid, weak pulse Pallor or ashen/grey discoloration of the skin Soft, sunken eyeballs Depressed fontanel Poor tissue turgor (tenting) Lethargy Seizures

11. Uncommon High-risk Signs Bile-staining vomit Convulsions (especially 1 st time) Lump >2 cm in diameter (abdomen)  except hydrocele or umbilical hernia Petechial rash Fecal blood without visible cause

12. The following criteria are designed to recognize acute life-threatening illnesses  They are conservative referral criteria with a wide margin of error…

13. Assessing the Febrile Child 1. Quality of cry 2. Reaction to parent stimulation 3. State variation 4. Color 5. Hydration 6. Response to social overtures A score >12 should be referred for evaluation 10… 2.7% serious illness 16… 92.3% serious illness

14. Quality of cry 1-strong with normal tone; content and not crying 3-whimpering or sobbing 5-weak or moaning or high pitched

15. Reaction to parent stimulation 1-cries briefly then stops; content and not crying 3-cries off and on 5-continuous cry or hardly responds

16. State variation 1-if awake, stays awake; wakes up quickly if stimulated 3-eyes close briefly, awake; awakes with prolonged stimulation 5-falls to sleep; will not rouse

17. Color 1-pink 3-pale extremities; acrocyanosis 5-pale, cyanotic, or ashen

18. Hydration 1-skin and eyes normal, mucous membranes moist 3-skin and eyes normal and mouth slightly dry 5-skin doughy or tented and dry mucous membranes +/- sunken eyes

19. Response to social overtures 1-smiles or alerts (<2 months) 3-brief smile or alerts briefly (<2 months) 5-no smile; face anxious, dull, or no alerting (<2 months)

20. In practice… Watch the child during the consultation Assign the number that best describes the case and enter it in the record  Add up the 6 scores

21. Summary of Referral Criteria Observational items score >12 Any combination of poor arousal, circulation or dyspnea Acute body weight loss >7.5% Decreased fluid intake or excretion Persistent bile-stained vomiting A first convulsion Periods of apnea Respiratory grunting or central cyanosis A lump >2 cm diameter (abdomen) A petechial rash Blood evident in the feces Fever of >3 days’ duration in a child who is on antibiotics