The previous GPpaedsTips was all about deciding when a child does not have sepsis. The hierarchy of evidence was put forward as a model for determining what information is most helpful in this process. Those of you who take the time to read the terms and conditions will have noticed the "this rule does not always apply" clause.
Fig 1 - The hierarchy of evidence used in most cases to determine whether a child does not have a serious infection
The reason that the rules
do usually apply is that the majority of children are unlikely to have a
serious infection (one that has a reasonable chance of causing morbidity or
mortality). Also, they will usually have
some sort of red flag to alert the clinician to serious infection when they are
really unwell.
The reason that the rules do not always apply is that some
children are special. They might be
special because they are much more likely to have a serious infection. They might be special because they do not
readily alert the clinician when they are significantly unwell. If they are really special they will do both.
Fig 2 - Legolas from the Lord of the Rings
As explained to me by my daughter, a 'Special' in a book or film is a character that can only really be taken on by another 'Special'. Hundreds of unnamed characters might try to kill them without any hope of success.
Contrary to what parents think, most children are not
special, at least not in this context.
Most children are predictably ordinary.
They probably have a viral upper respiratory tract infection and if they
are developing a more significant infection they will have the courtesy to look
and behave as though they are unwell. Hopefully they will do so enough to convince a clinician
that this is the wrong time to assume that the red throat is all the
explanation that is needed for the fever.
So, how do you know when you have a special patient? You know because they come with labels such as:
- Neonate
- Immunosuppressed
- Immunodeficient
- Pre-existing neurological or muscular disorder
- The child with chickenpox
Neonates (or to
be honest, all sprogs under 3 months old) are the biggest group of specials in primary care. Due to their maternally donated immunity,
new-born babies tend to have a few months free of common viral infections. When infection does occur, the likelihood of
bacterial infection and sepsis is therefore much greater. In addition to this
they are to give clear signs of illness.
More often the indicators are vague and come in the form of a subtle
change in behaviour such as sleeping excessively or feeding poorly.
Children are rarely
immunosuppressed but it is increasingly common for a child to be treated
with immunosuppressant medication if they suffer from any chronic autoimmune
condition. Ideally these families have
direct access to specialist advice when their child becomes even slightly
unwell.
Thankfully and despite parental concerns, congenital immunodeficiency is very
rare in children. Having frequent
self-limiting viral illnesses is normal as long as the child is otherwise
thriving and developing normally. When a
child does have a congenital problem with their immune system they are usually
prone to rapid deterioration into serious infections. One of the best ways of establishing a
child’s tendency to do this is to ask what has previously happened in similar
circumstances.
If the child has a neurological
or muscular disorder they may not be able to look unwell in a way that you
will easily recognise. If in doubt, ask the
parents.
Which brings me onto my surprise witness: the child with chickenpox. Large numbers of children with varicella are
seen in primary care every minute of every day.
The vast majority have a self-limiting illness which causes more
annoyance than unwellness. A small
proportion of children with chickenpox get secondary infection. The danger is that someone will assume that
this is caused by the logical staph aureus and prescribe flucloxacillin. In fact Streptococcal infection is the
greater risk and infection may be invasive and severe. Any child who has chickenpox and goes onto be
unwell (especially when this occurs late in the usual 7 day course of the
illness) has to be presumed to have streptococcal sepsis.
The bottom line is that special children must be treated in
special ways. They are dangerous
patients for the unwary clinician. I
have listed the groups that I think might come your way but there will be others.
Fig 4 - Dumbledore could only be taken on by other special characters. Special children need special doctors when they are unwell.
What does special treatment look like? It does not comprise giving them all
amoxicillin “just to be on the safe side.”
It is useful to go into more detail about past illness in the history
and be extra thorough when examining. It
might involve a discussion with a specialist and often requires referral. Just like in the movies, a special character
needs another special character to take them on. I, like you, am a generalist. I don’t fancy my chances if I start to
free-style the management of a special patient so I phone a friend so that I survive another episode.
Edward Snelson
Fellow Red Shirt
