Acute assessment of unwell children under 5 years

A medical consult is recommended where there is no specific protocol for a condition

Always consider sepsis — signs and symptoms can include

High or low temperature
Fast breathing
Fast pulse
Low BP or dizziness
Confusion and/or agitation

Small babies can get sick very quickly
Behaviour and appearance are the best indicators of serious illness

Red Flags — Urgent Medical Consult
Acute weight loss over 5% Less than 3 months of age with fever (Temp more than 38°C) — mandates empirical antibiotic therapy Second presentation to hospital or clinic with same illness or within 72 hours Underlying medical condition Under immunised child History of prematurity and age less than 2 years Caregiver concern

Look

Appearance — TICLS

Tone — child active, moving around or listless
Interactivity/mental status — alert, interacting with care giver
Consolability — can child be comforted by caregiver
Look/gaze — is child fixing gaze on a face or is there a glassy-eyed stare
Speech/cry — child’s speech or cry weak, high pitched or hoarse

Work of breathing — see Table 1.3

Assess body position, visible movements of chest/abdomen and breathing pattern
Listen for abnormal airway sounds — snoring, hoarse speech, grunting, wheezing or gasping
Look for sniffing posture, tripod positioning, head bobbing, sternal or intercostal retractions, nasal flaring, tachypnoea
Shortness of breath

Circulation

Skin colour — pallor, mottling, cyanosis
Capillary refill time, warmth of peripheries
Non-blanching rash

Check

Calculate age-appropriate REWS

Adult — AVPU, RR, O₂ sats, pulse, BP, Temp
Child (less than 13 years) — AVPU, respiratory distress, RR, O₂ sats, pulse, central capillary refill time, Temp

Weight, BGL

If REWS score 3 or more or if any danger signs — urgent medical consult

If doctor not available within 30 minutes — contact paediatrician

If REWS score 2 or less see — Table 1.8 to assist with differential diagnosis

if unsure medical consult

If available POC Test — WBC, electrolytes
History and immunisation status
Head-to-toe exam

Table 1.8 Serious causes of fever in babies and children under 5 years

Sick child with fever *AND*	Possible cause
Reduced alertness OR floppiness OR poor feeding OR weak/high-pitched cry Seizures OR stiffening OR abnormal gaze Headache OR neck stiffness OR photophobia OR bulging fontanelle OR Non-blanching rash	Meningitis — medical consult
Increased work of breathing — fast or slow, gasping, grunting, stridor, nasal flaring, head bob, chest indrawing OR Apnoea OR Hypoxia — oxygen saturation less than 94% or not improving with oxygen	Chest infection OR Bronchiolitis — medical consult
Sore red throat OR enlarged tonsils OR enlarged lymph nodes	Sore throat
Arthritis (painful, swollen joint/s) OR impaired/reluctant weight bearing or use of a limb (+/- rash, +/- chorea (abnormal movements)	Acute rheumatic fever OR septic arthritis OR osteomyelitis — medical consult
Bulging ear drum OR pain, irritability	Acute otitis media
Redness OR mass OR discharge from skin	Skin infection Abscess or cellulitis
Soft stridor OR unable to eat OR drink or talk OR drooling saliva Reluctant to move neck/head	Epiglottitis — minimal handling — urgent medical consult
New bed wetting/incontinence (small child) OR dysuria and frequency (older child)	Urinary tract infection 2 months–12 years — medical consult
Blood in urine OR oedema OR raised BP	Post-streptococcal glomerulonephritis (PSGN)
Fever of unknown origin and REWS score 2 or less Wipe forehead with tepid cloth Maintain hydration If miserable provide one dose paracetamol, observe for 1 hour — if no improvement — medical consult