Tuesday, 1 September 2015

How special is your patient? (recognising the unwell child with a difference)

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.

Fig 3 -  In the Star Trek universe, 'Red Shirts' were never special and had a tendency to be killed off each episode.

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

 Disclaimer: I am told I am a very, very special doctor.  All generalists are specialists but that is another blog.

 If you found this helpful, you might also like:  The TPR paradox - how do I know if a child might have sepsis?

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