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FEVER AND COUGH IN CHILDREN – WHEN TO CALL THE DOCTOR

15 Dec

FEVERISH illness in children. – when to seek further advice.
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I shall always remember a cold, foggy autumn Sunday evening as a GP > 30 years ago. I was sitting by the fire, reading a good book listening to my favourite album at the time ‘Black Magic Woman’ and the phone rang as I was on call. It was a young, first time father who was a senior executive for Sony and he wanted advice as to what to give his 3 month old baby for a cough. He wondered if Benylin would be alright. No,he did not want me to come out on such a dreadful evening to their home which was in an out of the way village and not easy to find. The majority of the patients lived within 2 mile radius of the practise and I knew most of them well but this was a new family who lived the furthest distance away from the practise. The baby was sleeping well but had not been feeding so well but he shrugged that off as probably being due to the cough.
I thought to myself, ” Did I really want to leave my warm, cosy cottage or leave the book when it was just getting to the crux of the plot and after all he wasn’t demanding that I ventured out .”
However, that gut feeling told me something was not right and I needed to set eyes on this baby and it must be sooner rather than later.
It was a grim, pea-soup of an evening and I drove cautiously to the visit, following the father’s instructions to the letter and somehow managed to find the house with very little problem. The mother greeted me at the door wearing a face-mask and the father and extended family all came to the door similarly clad. I was then shown to the nursery through a house which was something out of ‘House Beautiful’ no clutter, everything perfect, decor impeccable, carpets like walking on soft foam and a bijoux nursery. As I approached the cot I viewed the baby, ashen in colour, shallow rapid breathing and barely rousable. The family looked at me expectantly in silence. How could I tell this family that their baby was life-threatill as they seemed so unaware? I spoke firmly and gently telling them of my findings. The father’s reaction was simply, “Can we go privately?”

At that time in Wales that was not an option and even getting an ambulance to take them to the local hospital was not quick and easy.

Shortly we came to a compromise that I would take the baby and mother in my Ford Popular to the nearest hospital nearly 20 miles away followed by the father in his Mercedes.
We arrived at the Hospital having prewarned them of the arrival and the baby was admitted with a diagnosis of bronchiolitis with heart failure. when I had worked as a junior paediatric doctor I had worked under the watchful eye of Sister Williams, who was always a force to be reckoned with despite being not much bigger than most of the paediatric patients.  I greeted her like a lost friend and she immediately took charge and when the parents saw our relationship it was clear that they were instantly reassured their precious child would be in good hands under the NHS.
The baby thankfully made a full recovery but what remains indelible in my mind are several aspects of this case:-

  • my momentary hesitation to visit,
  • the parents not wanting to appear over anxious,
  • these caring parents who were unable to understand the severity of their baby’s illness
  • there anxiety about their local hospital.

These factors still apply today but a combination such as this could have result in a tradegy.

A retrospective study recently carried out looked at children admitted to hospital with serious respiratory tract infections. The parents of these children were sent questionnaires after the admission and, from their replies, the authors identified factors which may have delayed earlier medical intervention and one of the reasons included ‘Problems assessing the severity of the illness’ and my other observations aswell as:-

    • The belief that their child would not be prescribed antibiotics or would be prescribed antibiotics too readily
    • The belief that their concerns would not be taken seriously
    • Feeling powerless to challenge clinical authority.

Organisational factors:

    • Perceived problems accessing healthcare services
    • Inadequate primary care triage
    • Barriers to accessing timely consultations
    • Past experience of problems accessing healthcare, leading to failure to consult
    • Perceived poor quality clinical encounter
    • Inadequate assessment and communication

It is for this reason I felt it was important to write this blog.

If you have any concerns about your child’s medical condition bring the child to the surgery and if the child is < 5years or an older child which has significant concerns they will be seen as soon as possible. If it is Out of Hours call 111 in order that your child can be seen as soon as possible at the nearest Urgent Care Centre (UCC).

  • Red flagThe following symptoms should always be treated as serious:
      • a high-pitched, weak or continuous cry
      • a lack of responsiveness, reduction in activity or increased floppiness
      • in babies, a bulging fontanelle (the soft spot on a baby’s head)
      • neck stiffness (in a child)
      • not drinking for more than eight hours (taking solid food is not as important)
      • a temperature of over 38°C for a baby less than three months old, or over 39°C for a baby aged three to six months old
      • a high temperature, but cold feet and hands
      • a high temperature coupled with quietness and listlessness
        fits, convulsions or seizures
      • turning blue, very pale, mottled or ashen
      • difficulty breathing, fast breathing, grunting while breathing, or if your child is working hard to breathe, for example, sucking their stomach in under their ribs
      • your baby or child is unusually drowsy, hard to wake up or doesn’t seem to know you
      • your child is unable to stay awake even when you wake them
      • a spotty, purple-red rash anywhere on the body (this could be a sign of meningitis)
      • repeated vomiting or bile-stained (green) vomiting

    It can be difficult to know when to call an ambulance or go to phone 111 seek a doctors advise as to where you should go. This is very important at a time when A&E departments are being replaced by Urgent Care Centres and you may need to be directed to a specialist centre.

      • AmbulanceCall an ambulance for your child if they:
        • stop breathing
        • are struggling for breath (you may notice a sucking in under the ribcage)
        • are unconscious or seem unaware of what’s going on
        • won’t wake up
        • have a fit for the first time, even if they seem to recover

        imageCall 111 and a doctor will advice you where to take your child if they have any of the following:-

          • have a fever and are persistently lethargic despite taking paracetamol or ibuprofen
          • are having difficulty breathing (breathing fast or panting, or very wheezy)
          • have severe abdominal pain
          • have a cut that won’t stop bleeding or is gaping open
          • have a leg or arm injury that means they can’t use the limb
          • have swallowed a poison or tablets

        Above all, trust your instincts. You know better than anyone what your child is usually like, so you’ll know what’s different or worrying.

        When I worked as a junior paediatrician for a rather old fashioned consultant paediatrician I can hear his words echo, ” Remember , mam is always right”, and if I see any child that is always my first thought, until with the mother of father we have looked at the child together and reached the same conclusion of what the problem is and how best to manage it.

        FEVER
        Child with fever
        Fever, or pyrexia, is when the body temperature rises above normal. The average normal body temperature taken in the mouth is 37°C but anywhere between 36.5°C and 37.2°C is deemed as normal. When temperatures are measured in the axilla they can be 0.2°C to 0.3°C lower than this. Aural (tympanic) thermometers may measure the temperature as higher.

        Fever is one of the most common reasons for a child to be taken to see a doctor and is the second most common reason for a child to be admitted to hospital.

        The cause of the fever can sometimes be hard to elicit and this can be a worry for healthcare professionals. It is usually due to a viral infection that is self-limiting but it can also be a sign of serious bacterial infection, including meningitis. Early diagnosis of serious infections in general practice is difficult as incidence is low, the child may present early in the disease process and diagnostic tools are more or less limited to history and examination.

        When a child presents with a fever it is important for the health care professional to take an adequate history and for the parent or guardian to provide accurate information

        History should include asking:

      • How long has the fever been present?
      • Has the parent/carer been measuring temperature and, if so, by what method?
      • Is there a rash? If so, is it blanching or non-blanching?
      • Meningitis
      • Are there any respiratory symptoms – eg, cough, runny nose, wheeze?
      • Has the child been clutching at their ears?
      • Has there been excessive or abnormal crying?
      • Are there any new lumps or swellings?
      • Are there any limb or joint problems?
      • Is there any history of vomiting or diarrhoea? Is the vomiting bile-stained or is there any blood in the stool?
      • Has there been any recent travel abroad?
      • Has there been any contact with other people who have infective diseases?
      • Is the child feeding normally (fluids and solids as appropriate)?
      • What is the urine output? Have nappies been dry?
      • How is the child handling? Normal self/drowsy/clingy and so forth?
      • Have there been any convulsions or rigors?
      • Is there any significant past medical history/regular medication/allergy?
      • Other points to consider from the history:
      • Level of parental anxiety and instinct (they know their child best).
      • Social and family circumstances.
      • Other illnesses affecting the child or other family members. Has there been a previous serious illness or death due to febrile illness in the family?
      • Has the child been seen before in the same illness episode?

    Examination of the child
    Identify any immediately life-threatening signs on examination
    Rate of breathing:-
    Infants 60 breaths per minute at age 0-5 months
    >50 breaths per minute at age 6-12 months
    >40 breaths per minute at age older than 12 monthsLook for nasal flaring/grunting/chest indrawing.Measure the heart rate.
    More than 160 beats per minute in a child less than 12 months old
    More than 150 beats per minute in a child 12-24 months old
    More than 140 beats per minute in a child 2-4 years oldAssess the level of hydration:
    do the eyes and skin look normal? Is the mouth moist? What is the capillary refill time? Are the extremities warm or cool? Is the child feeding normally? Is the urine output reduced?
    Examine for other features:
    Rash: if there is a rash, is it blanching or non-blanching?

  • Capillary refill return
    The capillary nail refill test is a quick test done on the nail beds. It is used to monitor dehydration and the amount of blood flow to tissue.
    Pressure is applied to the nail bed until it turns white. This indicates that the blood has been forced from the tissue. It is called blanching. Once the tissue has blanched, pressure is removed.
    Normal result:If there is good blood flow to the nail bed, a pink color should return in less than 2 seconds after pressure is removed.

Assessment of the child using the National Institute for Health and Care Excellence traffic light system
NICE recommends that a traffic light system should be used to predict the risk of serious illness when the symptoms and signs have been elicited from the history and examination. Allowance should be made for individual disabilities when assessing learning-disabled children.
The following table summarises this system.
If the child has any of the symptoms or signs in the amber column, they are at intermediate risk of serious illness.
If they have any of the symptoms or signs in the red column they are at high risk of serious illness.
Children with symptoms or signs in the green column and none in the red or amber column are at low risk of serious illness.
Management of fever should be guided by the level of risk.Traffic light

Children with any red features not considered to have an immediate life-threatening illness should be seen within two hours by a healthcare professional.
Children with any amber features should be seen by a healthcare professional but the assessment of urgency of the appointment is left to the clinical judgement of the assessor.
Children with only green features can be managed at home with advice for parents and carers, including advice on when to seek further help.
Management by the non-paediatric practitioner
This includes professionals working in primary care and also those working in general accident and emergency departments.

Assessment using the traffic light system should be performed.
Children with any red features should be referred for urgent assessment by a paediatrician.
Children with any amber features in whom a specific diagnosis has not been made, should either be referred to urgent paediatric care or the carers of the child should be given a ‘safety net’, either detailing exactly when to seek further help (ie specific warning symptoms or signs) or arranging a further follow-up assessment.
Children with only green features can be managed at home with advice for parents and carers, including advice on when to seek further help.

Oral antibiotics should not be prescribed if there in no identifiable source of the fever.

Management of specific diseases:

If there is no obvious source of infection, urine should be tested in children presenting with fever.
If meningococcal disease is suspected, antibiotics should be given at the earliest opportunity.
Related blog posts
There’s no such thing as a touch of ‘flu!

Advice to parents or carers for home care of the child

Antipyretic(fever) treatment:

    • tepid sponging is not recommended.
    • Do not underdress or over-wrap children.
      Give alternating paracetamol or ibuprofen for discomfort or distress but not for the sole reason of reducing the temperature. If the child does not respond to one agent and the child’s distress persists or recurs before the next dose is due then give the child paracetamol alternating with ibuprofen at 4hourly intervals.
    • Give regular fluids: breast milk if the child is breast-fed.
    • Monitor for signs of dehydration: sunken fontanelle or eyes, dry mouth, absence of tears, poor appearance.
    • Monitor for appearance of rash: assess to ascertain if a rash is non-blanching.
    • Get up in the night to monitor the child.
    • Keep the child away from school or nursery while they have a fever and notify them.

IN SUMMARY
When to seek further help: if the child has a fit, develops a non-blanching rash, appears less well, the parent or carer is worried, the fever lasts >5 days, the parent or carer is distressed or feels they cannot look after the child.

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Posted by on December 15, 2013 in Training and Advice

 

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