Finding a focus for infection in a child is one of those
things that we all know we ‘must do’.
That can be more difficult than it sounds. Often, no focus is easily found and then the
questions are, “Where do I look? What if I can't find a focus? I don’t know when to stop looking!”
How many children are seen with significant temperatures,
where the eardrum is not easily seen?
On probability alone, the focus is more likely to be a hidden upper
respiratory tract infection rather than something else. Is probability enough to go on?
Then there are the things that could be called a focus, but are
rather soft signs. Is a runny nose a
focus? If so, how high is the
temperature allowed to be? What about
vomiting and diarrhoea? Is that a focus
in its own right? You could throw that
question out to an audience of primary and secondary care clinicians and I
could guarantee that the conversation (if it continued in a way that could be
called that) would go on for quite some time.
The outcome would almost certainly be that many would agree to disagree.
If you ask me, the answer depends entirely on the
circumstances because the focus of infection is not nearly so important as the
global assessment and the specifics of the presentation. If a child presents early in an illness, is relatively well
and has just got a runny nose, then that might be enough to go on. Good symptom management and careful safety netting are probably the most important things in these cases.
Example 1
A 3 year old has a temperature of 38.2 at home. They have a runny nose and a cough but no
other symptoms. They have no convincing
focus of infection in their throat or ears.
Chest is clear and there is no respiratory distress. Heart and respiratory rate are normal. During the consultation, they are running
around and playing with the toys.
Example 2
A 3 year old has had a temperature of 38 to 39 on and off
for three days. They have a runny nose
and a cough but no other symptoms. They
have no convincing focus of infection in their throat or ears. Chest is clear and there is no respiratory
distress. Heart and respiratory rate are
normal. They are alert but neither
cheerful nor very active. They have just
returned from a three week trip to an area where malaria is endemic.
Who would like to accept the runny nose and cough as a focus
in child 2?
So when do I need to find a focus? Here are a few examples of circumstances in
which I would want to have something that is fairly definitive:
My two top tips for finding a focus are:
When deciding about how hard to look and how invasive the search should be, don't start at the beginning, start at the end. The child in front of you and the clinical scenario determine what the hunt will involve.
- Repeat the ENT examination unless you have already had really good views of tympanic membranes and pharynx
- Check a clean catch urine sample
When deciding about how hard to look and how invasive the search should be, don't start at the beginning, start at the end. The child in front of you and the clinical scenario determine what the hunt will involve.
Edward Snelson
Variable Venator
@sailordoctor
