Understanding Traffic Lights - The Unwell Child and What to Do Next

When I am driving and see a traffic light ahead the first thought is, "Am I supposed to stop or go?" My next thought is, "what might it change to and what do I do then?"  Assessing the unwell child is like that.  It's not just about the snapshot.  Guidelines look a moment in time but the unwell child is in constant flux making that approach problematic.

The traffic light system for unwell children has been around for a very long time.  It is used across Primary and Secondary care to aid clinicians in their attempts to risk assess febrile and unwell children with all of the non-specific signs and symptoms with which they present.  

I am often asked if I use the traffic light system in my own practice.  The answer is yes and no.  Yes - the system is a useful hierarchy of signs and symptoms.  No - because most childhood illnesses are too dynamic for a snapshot to be completely valid.  Things change constantly.  A risk assessment based on a moment in time is far too simplistic.

That doesn't mean that observation of the child is necessary for decision making.  In most cases it's simply a question of asking how the lights are changing and what I'm going to do with that.

Amber turning green

A 2 year old child presents with a cough, runny nose and a fever.  The parent reports that a couple of hours ago they looked pale and lethargic.  They were shivering, felt hot centrally but had cold hands and feet.  Now they have none of those things happening.  They are walking, talking and cheerfully interactive.

This is a very common scenario.  Parents and carers will often express a certain paradoxical frustration with the apparent wellness of the child.  The child appeared seriously unwell a couple of hours ago and the parent is now feeling that you will think that they have over-reacted.  It is a good thing to acknowledge how unwell the child was and use that as an opportunity to explain why you as a clinician are happy with the child despite how concerning the child's appearance was.  

Giving or signposting to something written is also important.

Green turning amber

A 2 year old child presents with a cough, runny nose and a fever.  When you see them they are miserable but alert and interactive.  They have a temperature of 39.5, heart rate of 160 and are refusing to drink.  They last had any symptomatic treatment 6 hours ago.  The parent reports (you have to ask about this - it won't usually be volunteered) that 2 hrs ago they looked much better and were drinking a bit.

Unlike actual traffic lights, unwell children swing from green to amber and back to green quite normally during uncomplicated self-limiting infections.  There is a reason that we mostly see unwell children between the age of 6 months and six years.  It's not because they are high risk for dangerous infections.  In fact quite the opposite - it is a stage of life characterised by extreme response to simple infections.  The normal physiological response can look bad but usually resolves to reveal a reassuring baseline.  In many ways, a febrile unwell 2 week old is easier from a decision making point of view - that is a very high risk presentation.  A febrile unwell 2 year old is low risk but that presents a different problem - how to recognise the small number that do have a serious illness.

What can be terribly inconvenient is the above situation.  The snapshot we are given is not green but also not red.  Red is also easier from a decision making point of view.  Amber presentations make us have to decide what to do next.  Here are your options:

Every clinician will have a preferred option.  Many working in Primary Care do not feel the need to have a face to face reassessment if the child improves in behaviour and activity.  That is completely valid as such improvement is a good demonstration of physiological change and evidence that the baseline state of the child (active, interactive, good oral intake and no increased work of breathing) is not consistent with sepsis or meningitis for example.

Really good safety-netting advice empowers the parent to make that assessment in a way that is dynamic and continuous.  A reassessment in whatever form (face to face or remote) facilitates documentation of improvement and adds value to the safety-netting advice by giving the opportunity for the parent to further discuss the illness, what to expect and when to worry.

Amber children are a fair bit of work but they are a great opportunity to do what we should consider core business.  We can take a group of children who are reasonably low risk and look for signs (e.g. increased work of breathing, meningism or unexplained tachycardia) that this one is the one with something that needs immediate intervention.  For those that are within what is expected of an uncomplicated infection we can make sure that they have symptomatic treatment in the assumption that they will demonstrate a baseline state of reasonable wellness that effectively rules out serious illness.  Finally we can equip the person caring for that child with the ability to recognise signs of serious illness should those develop later.  That is a lot of great care.

Edward Snelson
Paediatric off-roader
@sailordoctor

Disclaimer - drive on the road when you can, off the road when you have to but always get home safely.  If you need help, call.

COVID question number 6 - What is hyperinflammatory syndrome and how do I recognise it?

At the same time that we are seeing increasing evidence that COVID-19 is less common, less severe and less infectious in children (1), evidence is emerging of a new phenomenon that seems to be related to COVID-19 infection in children: hyperinflammatory syndrome (2).

In a time when people are being encouraged to self-manage febrile illness at home, and primary care has moved to do more remote assessments, the emergence of such a serious clinical entity is worrying.  Although the number of cases remains relatively small, it represents a significant number of seriously unwell children.  Considering how much we focus on the recognition of sepsis in children, current cases of hyperinflammatory syndrome are being reported in numbers comparable to and possibly greater than numbers of children with severe sepsis.

This does not mean that all febrile children should now have a face to face assessment or that all febrile children should be referred to secondary care.  Like sepsis, it is impossible to recognise an entity like hyperinflammatory syndrome before it is clinically apparent.  There is no predictive test.

Like sepsis, we need to be aware of hyperinflammatory syndrome and recognise it where it is manifest, rather than over-diagnose it to the detriment of children with uncomplicated viral illnesses.  So how do we get that balance right?  The answer lies in recognising what is unusual about the illness rather than focusing on the most common features, since these are not necessarily good discriminators.

First, a few FAQs about hyperinflammatory syndrome in children:

What is hyperinflammatory syndrome?
Like sepsis, definitions of hyperinflammation vary and reflect the fact that it is a clinical diagnosis without a binary test or decision tool.  The published literature reflects an uncertainty about pathophysiology but describes a significant number of cases (20 in North London in less than a month) of children with a similar clinical presentation.  The features have been described as most similar to Kawasaki Disease Shock Syndrome (3), a thing so rare that most of us had never heard of it before this recent surge of cases.

Is it caused by COVID-19 infection?
When the initial reports of cases were being circulated without details, it was unclear as to whether this was simply a case of something happening during the COVID-19 pandemic or because of it.  While no official source has yet declared that COVID-19 is definitely the cause, there is plenty of evidence that this is the case.  First, the numbers are highly unusual (4) and there is a pandemic at the moment.  Secondly, many of the children have tested positive for SARS-CoV-2/COVID-19.  While a small proportion testing positive could be explained by the background rate of COVID-19 in the community, the positive test rate in these cases seems too high.  At the moment the sample size is too small to be conclusisve.  Finally, the demographic of affected children mirrors that of severe COVID-19 in adults, with a predilection for males and BAME children.  It therefore seems most likely that these cases are related to the COVID-19 pandemic.

The hyperinflammation syndrome that is being reposted is thought to be a post-infection phenomenon, rather than a complication of acute infection.  The exact mechanism for this is unclear.  Clinically, it has features similar to Kawasaki Disease (for which the mechanism is unknown) and some overlap with toxic shock syndrome (which is seen in bacterial infection) so we're on the back foot when it comes to working out pathophysiology.

How do I recognise hyperinflammation in a febrile child?
The reported features of the children presenting with hyperinflammation are a mixture of non-specific signs and symptoms with a few more unusual elements that may help the front-line clinician.
While gastroenterological symptoms were common, I would suggest that this information is of little help to a clinician who sees acutely unwell children.  Diarrhoea, abdominal pain and painful swallowing were all common features in children who later developed hyperinflammation but are also frequently found in other viral illnesses.

In the case series reported in the Lancet, tachycardia was sometimes present and sometimes heart rate was unremarkable.  This is somewhat surprising since this hyperinflammatory syndrome seems to affect the cardiovascular system most severely.  It is also consistent with other serious paediatric presentations, where heart rate is one of the least specific clinical signs, being both falsely concerning and falsely reassuring on many occasions.

Tachypnoea, also a common feature occurring when the child presented with hyperinflammation is a more specific feature.  Uncomplicated viral illnesses in children do not tend to affect breathing other than in the form of a transient tachypnoea while febrile.  Unexplained, consistently fast breathing should therefore be considered clinically significant.  This was reflected in the Lancet case series, the majority of whom had tachypnoea.  Note that the cases reported did not tend to have pneumonia, thus the qualifier of "unexplained".  Other explanations for fever and abnormal breathing remain more likely.

The other feature that was most consistent and helpful in discriminating from uncomplicated viral illness was an unrelenting fever.  In children with an uncomplicated viral illness, pyrexia can be dramatic and associated with alarming features such as shivering, cold peripheries, blue lips and mottled skin.  Typically, this is followed by a dramatic improvement, often with the aid of antipyretic medication.

In the cases reported with suspected hyperinflammation secondary to COVID-19 infection, the fever was noted to have been persistently high (38-40 C/ 100.4-104 F) which is much less commonly seen in uncomplicated viral illness.  This may therefore be one of the more useful ways of telling the two apart.

Other features reported include a "variable rash" and painful extremities.  Rashes and pains are common features of uncomplicated viral infection but in combination with the more specific features may help clinicians recognise the syndrome early.

Recognising hyperinflammation (presumed to be related to COVID-19 infection in children) early may therefore be a case of recognising the unusual, looking for alternative explanations such as pneumonia and if no other pathology explains how unwell the child is, looking at how many of the less specific symptoms are present.  If that sounds familiar, that's because it is a similar approach to recognising Kawasaki disease.

The disease then tends to progress to a phase with more significant cardiac involvement, with a profound effect on circulation in many cases.  Shock refractory to fluid boluses is a commonly reported feature.

If signs of shock develop, this will make it more straightforward to recognise that the child does not have an uncomplicated viral illness.  Distinguishing hyperinflammatory shock syndrome from sepsis and other similar presentations brings its own challenges for emergency medicine and acute paediatrics.

Edward Snelson
@sailordoctor

References

1. Munro APS, Faust SN, Children are not COVID-19 super spreaders: time to go back to school Archives of Disease in Childhood Published Online First: 05 May 2020. doi: 10.1136/archdischild-2020-319474
2. Riphagen S., Gomez X., Gonzalez-Martinez C., Wilkinson N., Theocharis P., Hyperinflammatory shock in children during COVID-19 pandemic, Lancet, May 07, 2020 doi:https://doi.org/10.1016/S0140-6736(20)31094-1
3. Kanegaye JT, Wilder MS, Molkara D, et al. Recognition of a Kawasaki disease shock syndrome. Pediatrics. 2009;123(5):e783‐e789. doi:10.1542/peds.2008-1871
4. HEALTH ADVISORY: PEDIATRIC MULTI-SYSTEM INFLAMMATORY SYNDROME POTENTIALLY ASSOCIATED WITH CORONAVIRUS DISEASE (COVID-19) IN CHILDREN, 06 May 2020, New York State Department of Health (NYS DOH) Bureau of Communicable Disease Control (BCDC)

Rashes in children: What is the diagnosis? - Probably a virus

A rash is a very common feature of a paediatric presentation and is often the primary reason for seeking medical advice.

I think that clinicians also sometimes feel a bit of anxiety about rashes.  What does the rash mean?  Should I be able to diagnose the illness based on the rash?

The rash can be diagnostic but often it is not.  Even when the rash gives a specific diagnosis, that diagnosis is usually a virus and treatment remains symptomatic and supportive.

These are some important questions to have answers to when assessing a child with a rash.

• Is the child well? If not, how unwell are we talking about and for how long?
• Is the child febrile?
• How did the rash start?
• How has the rash changed since it started?
• Is the rash itchy?

When examining the child, it is important to avoid the temptation to focus excessively on the rash.  The child should have a systemic examination that will identify any cardio-respiratory, abdominal or neurological abnormality.

The rash itself is then in context of an assessment that has determined whether the child is significantly unwell or has any significant abnormal findings.  What this tells us is whether the rash is of importance because the child is quite unwell, or more of interest since the child is well.  In the well child with no significant abnormal findings, a diagnostic rash can still give useful information in terms of prognostication and the ability to give specific advice about what to do from a infection control point of view.

Let’s look at some specific rash related diagnoses that are accompanied by non-specific symptoms such as pyrexia-

Roseola Infantum

What does it look like?

This infection is most commonly seen between the ages of 6 months and 3 years.  The classical presentation is of a significant fever but a surprisingly well child with non-specific symptoms such as coryza and pharyngitis.  Essentially, the child has all the signs of a viral upper respiratory tract infection (URTI) but with an impressive fever.

A macular patchy erythematous rash often appears as the fever starts to resolve.  Typically the rash is more prominent on the trunk than limbs.

What causes it?

Human herpes virus 6

What specific advice is there for this diagnosis?

None.  Treatment is symptomatic.

Chickenpox

What does it look like?

Chickenpox is a vesicular (small fluid filled lesions) rash which is usually found all over the body.  Children are usually either mildly febrile and unwell in the first few days, or not unwell at all.  The rash is often itchy.

What causes it?

Varicella zoster virus

What specific advice is there for this diagnosis? 

There is no specific treatment.  If the child seems unwell then paracetamol (acetaminophen) is the preferred treatment for systemic symptoms.  While there is some concern about using ibuprofen, the evidence strongly suggests that this concern is unfounded.  However, most children do not become significantly unwell with chickenpox and it is unusual for symptoms to require more than paracetamol.  If a child with chickenpox is very unwell, that is a clinical situation that mandates a careful assessment to consider the possibility of sepsis, usually in the form of invasive streptococcal infection.

Itching can be treated with antihistamines.  In the UK, it is usual practice to ask that the child is kept out of school or nursery until day 7 of the rash, at which point new lesions are not forming and the existing spots are crusting.

Hand, foot and mouth disease

What does it look like?

Vesicles on the face around the mouth, ulcers inside the mouth, vesicles on the hands and feet and perianal vesicles or ulceration.  (Somehow the perianal bit got left out when naming this childhood infection)  The child is usually systemically well but when the rash is appearing may be a little miserable and pyrexial.

What causes it?

Coxackie virus

What specific advice is there for this diagnosis?

Treatment is symptomatic.  This is a good opportunity to practice the philosophy of “treat the child, not the fever.  Many children with hand, foot and mouth disease are not febrile but may be in significant discomfort from the oral lesions.  The importance of analgesia to help the child be comfortable enough to drink should be emphasised.

The UK public health advice for hand, foot and mouth disease is that in itself, it does not mandate and absence from school or nursery.

Pityriasis rosea

What does it look like?

The classical pityriasis rosea rash starts with a herald patch in the form of a well localised erythematous area somewhere, usually on the trunk.  This may go unnoticed and if seen rarely causes alarm.  The generalised rash that follows is what usually leads to the seeking of a medical opinion.  This rash is an impressive patchy pink rash with the pattern of the patches following the lines of the dermatomes of the skin on the trunk, forming what is described as a “Christmas tree” distribution.

What causes it?

Human herpes virus

What specific advice is there for this diagnosis?

The child is usually well at the time of the Christmas tree-like rash appearing so no specific treatment is needed.  It should be explained that the rash may last for a few weeks.  There is no need for the child to be excluded from school or nursery.

Slapped Cheek Syndrome (Fifth Disease)

What does it look like?

Most of the features are non-specific: Fever, coryza, sore throat.  The name comes from the typical bright red rash which appears (usually) on both cheeks.  The redness is both more impressive and more consistent than the flushed cheeks seen in febrile children.  This is often followed by a more non-specific, patchy, popular, blanching erythematous rash on the rest of the body.

What causes it?

Parvovirus

What specific advice is there for this diagnosis?

For the purposes of managing the child, treatment is symptomatic.  Most cases of slapped cheek resolve without complications.

A rare but significant complication of parvovirus is an aplastic crisis secondary to the effect of the virus on the bone marrow.   A history of recent parvovirus infection followed shortly afterwards by significant or atypical illness or pallor should prompt the testing of a full blood count.

Parvovirus infection in pregnancy carries a risk of miscarriage or hydrops fetalis (due to the same aplastic crisis).  Parvovirus is not treatable and most pregnant women are immune.  In most places, the advice for pregnant women who come in contact with parvovirus is to seek medical assessment if they subsequently become ill, especially if they develop a rash of any kind.  If serology confirms parvovirus infection then the pregnant woman should be referred to the fetomaternal team.  Through the marvels of modern medicine, it is now possible to transfuse a baby in utero and potentially keep them well long enough to reach a gestation where it delivery is an option.

Measles 
What does it look like?
Typically the child is febrile, coryzal and coughing for a couple of days before the rash appears.  The rash itself is an erthematous maculopapular rash which usually starts on the head before spreading to the rest of the body.
Kopliks spots are diagnostic but rarely seen as they don't hang around for long.  These are small white spots that appear on the inside of the cheeks, opposite the molars.
Measles should be suspected when a child has significant non-purulent conjunctivitis or is particularly miserable despite analgesia.  Unlike uncomplicated viral illnesses, the child is usually quite unwell several days into the illness when the rash appears. (Consider a differential diagnosis of Kawasaki Disease in the child who has had fever for five days as many of the features overlap.  Unlike Measles, early specific treatment for Kawasaki Disease is essential)

What causes it?

Measles virus

What specific advice is there for this diagnosis?
Measles infection requires specific infection control measures and in the UK is a notifiable disease.  There is no specific treatment for Measles and at presentation, the key decision is about how unwell the patient is.  If well enough to be managed at home, it is very important to avoid unnecessary admission to hospital as this might lead to infection of those most at risk.  However if the child is showing signs of significant infection (mainly encephalitis) then admission is probably necessary.  If referring to secondary care it is essential that the accepting team are aware that Measles is suspected so that the child can be kept away from others from the moment of arrival to hospital.

Viral Urticaria

What does it look like?

It looks like an allergic reaction or nettle sting.  The itchy, raised red and white rash can be seen in any part of the body and can be quite alarming.  Typically this rash appears as the illness is getting better.  Lesions appear and disappear several times a day.  If the onset of the rash is accompanied by other symptoms appearing (such as wheeze, oral swelling or vomiting) then acute IgE mediated allergy should be suspected.  Viral urticarial should not be accompanied by the appearance of these symptoms.

What causes it?

One of many possible viruses

What specific advice is there for this diagnosis?

It should be explained that the rash is caused by the virus and the child’s immune system.  The rash doesn’t tell us anything specific about the infection and doesn’t mean anything bad about the illness or the child.   While anthistamines may reduce the itching, they do not seem to make the rash go away any faster.  The rash will usually resolve spontaneously over the space of several days.

It is notable that children who develop viral urticaria are sometimes taking antibiotics when the rash appears.  This can cause concern regarding possible drug allergy.  The evidence suggests that a large number of children developing rashes while taking antibiotics are simply manifesting a viral rash (including urticaria).  This association is contributing to the overdiagnosis of antibiotic allergy.  Many specialists are now advising that a label of antibiotic allergy is not given to a child if they have an acute illness that could be viral, the only symptom is a rash and it is the first time the child has had a rash while taking antibiotics.

Non-specific Viral Rash

What does it look like?

These rashes can appear during the acute infection or recovery phase of the illness.  Typically the rash is a diffuse, patchy erythema.  It may be macular or papular.  In the majority of cases, all of the rash blanches.  Occasionally, a few petechiae can be found.  In a population vaccinated against most strains of meningococcus, a small number of petechiae is most likely to be part of a viral rash.  Indeed, finding one or two petechiae is within normal for a well child at any point. (1)

What causes it?
Any virus that is on the rash B-team could be responsible.  If it's not a diagnostic rash, you can't make a specific diagnosis.

What specific advice is there for this diagnosis?
It's important to explain that the rash doesn't have any specific meaning. For example, a child with this rash does not need to be kept out of school, for infection control reasons at least. Safety-netting advice should mainly centre around the illness, not the rash.  The rash may well persist after the child's illness has resolved.

Many specific rashes start of as non-specific so if the rash changes significantly they may need to be reassessed.  In particular they should know how to assess for non-blanching rash.

Erythema Multiforme

What does it look like?

As the name (What, no Latin?) suggests, it is a rash with multiple forms.  The rash varies from place to place rather than being uniform in appearance.  The rash varies in appearance and texture.  The typical target lesions that also help make the diagnosis are circular and have a dark red centre.

What causes it?
The rash is in many ways very similar to urticaria in children.  It may be a drug reaction but is more commonly triggered by a virus.  That virus is not usually specifically identified.  Atypical bacterial infection, most commonly mycoplasma, may also trigger erythema multiforme.

What specific advice is there for this diagnosis?
Essentially the same applies to Erythema Multiforme as applies to viral urticaria and non-specific viral rashes.  If there is no obvious specific cause, safety-netting for the illness is most important.

Because Erythema Multiforme can rarely progress to Stevens-Johnson Syndrome, it is worth advising the family to seek reassessment if the child develops an inflamed mouth.

Henoch-Schonlein Purpura (HSP)
What does it look like?The typical HSP rash is a purpuric rash on the lower limbs, predominantly on the buttocks and extensor surfaces.  This is often fully apparent at presentation but sometimes the initial rash is not purpuric.  In some cases other symptoms precede the rash.

Typical symptoms of HSP include leg pains and abdominal pains, though in some cases HSP is asymptomatic.

What causes it?
The cause is unknown, however it is presumed that this vasculitic process is triggered by infection.  In that sense, it can be considered a viral rash.

What specific advice is there for this diagnosis?
Most cases of HSP are suitable for outpatient management and in many cases this is well within the remit of the General Practitioner.  A full explanation of the condition, possible complications and how to manage/ followup can be found here.

Bringing it all together
So there you have it - a reasonably comprehensive list of common rashes seen in childhood infections.  In most cases, the rash will not give a specific cause.  In every case, the clinical condition of the child is by far the more important part of the assessment.  After all, it's probably a virus and you probably can't treat that.

Edward Snelson
Rash decision maker
@sailordoctor

Disclaimer - it might not be.

References

1. Downes AJ, Crossland DS, Mellon AF Prevalence and distribution of petechiae in well babies Archives of Disease in Childhood 2002;86:291-292.

How do we diagnose sepsis in children? The Sepsis Jigsaw

Sepsis in children is something that we all fear.  It is difficult to define and  difficult to diagnose early.  This millennium has seen a huge rise in the presence of sepsis in education, campaigns and guidelines.  I believe that one of the reasons that we're talking about it so much is that we're still trying to understand what we mean.  Within that, we are trying to find ways to explain some of the things that we know.  That is because a lot of what we know about recognising sepsis is tied up in tacit knowledge.

Tacit knowledge refers to the things that we know but are not easily explained.  For example, it is  difficult to explain all the elements involved in driving a car.  Much of what we do in our lives relies on tacit knowledge.  How do you find things?  How do you figure things out?  These are far easier to do than to explain.

The very nature of the recognition of sepsis makes it something that needs completely taking apart and putting back together.

Sepsis is not easily definable in the first place.  2016 saw the Third International Consensus Definitions for Sepsis and Septic Shock (1).  This came from a process that involved two previous attempts to find consensus definitions, a recognition that none of the previous definitions were perfect, and a third brave attempt to find a definition for something that is somewhat amorphous.

The resulting definition:  "life-threatening organ dysfunction caused by a dysregulated host response to infection" is a good one and I would agree with it.  However, it does little to help us diagnose sepsis in children.  Recognising severe sepsis is not a great challenge.  Recognising early sepsis in children is very difficult because of the way that children respond to illness.

There is a bit of a misunderstanding that could result from many of the recent guidelines and publications about recognising sepsis in children: that fever plus tachycardia equals sepsis.  Since febrile children are routinely tachycardic, this does not make sense.  The misunderstanding comes from a retrospective approach to guideline definitions of sepsis.  If you look at all the children who were diagnosed as septic, what were the common features at presentation?  Abnormal temperature (high or low) and tachycardia come up a lot.

There are two sides to this coin.  Sepsis in children is not simple.  It is difficult to recognise and thwarted by many biases.  Yet it is deadly and anything that we can do to improve our recognition of sepsis is going to save lives. So complexity is no reason for complacency.

Since we don’t have a retrospectoscope when we see our next patient, we need to have a good way of recognising possible sepsis and serious bacterial infection (SBI) amongst the large numbers of children with uncomplicated illnesses.  If fever and tachycardia are not specific, what can we rely on?  Despite hopes to the contrary, routine near patient testing (e.g. CRP) in a primary care or emergency department setting will not give us the answer.

If neither numbers nor tests can sort the few out from the many, what is left?  Simply put, a global assessment made by an experienced clinician is what really brings the magic to the decision making.  So what is it that helps them to make a decision?  The answer is complicated but essentially, they put together a jigsaw of features and come up with enough of a picture so that the puzzle makes sense.  Some of the jigsaw pieces are fairly obvious but some of them are less well known or involve that tacit element of the process.  It is worth being aware of the various factors that influence this crucial decision.

The pieces of a sepsis jigsaw puzzle:

Temperature

Abnormally low or high, infection will affect temperature in some way.  This is an oversimplification which fails to address some of the subtleties of temperature and its relationship to bacterial infection and sepsis.

Factors to consider are:

• Low temperature in the context of an unwell child is more indicative of sepsis
• The relationship between height of temperature and sepsis/SBI is loose.  Although there is a correlation between very high temperatures and SBI, it is a weak one.  Children with viral infections may well get temperatures over 40˚C.
• Temperatures that are more persistent or fail to come down with antipyretics are often seen as more concerning.  Again, this is a poor discriminator as this can be seen in viral illnesses.  However, it is also true that a child with a persistent temperature may not get the opportunity to demonstrate their wellness by having a little run around.
• A normal temperature at the time of assessment does not rule out sepsis.

Circulation: Heart rate, central capillary refill and peripheral perfusion

The normality of these factors is quite rightly reassuring.  If outside of a reference range, these features may or may not be significant.  Each of these factors can be affected by pain, fear, pyrexia and environment.  Again, the extremeness of the abnormality is a consideration as is the persistence of deranged markers of circulation.

Respiration: Respiratory rate and work of breathing

Abnormal respiration is more discriminatory for SBI and sepsis, assuming that there is no other reason for being unwell and breathing abnormally (e.g. viral wheeze).  The reason for this is that respiration is less prone to the physiological changes that affect circulation.  Abnormal breathing may be caused by acidosis or hypoxia but is less likely to be due to a simple illness.  This ties in nicely with the definition of sepsis that relates to organ dysfunction.  While circulation changes may be a reaction to an uncomplicated viral illness, respiratory changes are more likely to be due to organ dysfunction.

Significant episodes

Since we might only see the child for a few minutes, it is important to take seriously any significant events that have occurred recently.  Pale, floppy or blue episodes are all notable.  Shivering and shaking are also worth taking into account.  They are not in themselves proof of serious infection.  Any of these things can occur during a temperature spike in an uncomplicated viral illness.  Remember that each of these is only a piece of a jigsaw.  You need to look at the whole picture and if the child is now running around pretending to be Spiderman, they’re probably OK despite the thing that happened.

Fluid balance

A well hydrated child (wet mucosa etc) who is drinking well and has good urine output is what you are looking for here.  Where these things are not adequate, sometimes all that is required is analgesia and a fresh start.  It all depends on how the rest of the pieces of the jigsaw are coming together as to whether it is time to go down a particular path.  Dehydration and poor urine output combined with other features is more significant.

Activity, behaviour and interaction

Now we are truly into the area of tacit knowledge.  (I wondered when he was getting around to that...)   Very little is published about the relationship between a child’s ability to smile, play, run or do anything for that matter and their risk of having SBI or sepsis.  However, it is reasonably intuitive that a child who runs in, smiles and talks the hind leg off of you is less likely to have sepsis than a child who is carried in, interacts little and looks miserable.   These factors rarely feature meaningfully because they are impossible to quantify.  Each appraisal is as different as each child is unique.  I couldn’t tell you what my threshold for ‘active’ or ‘interactive’ is because it will be specific to the child and depends on factors that I could not explain easily.  That is tacit knowledge in a nutshell.  While no-one can tell you what you are looking for in this category, it is an important piece of the jigsaw and should be give the weight it deserves.  Your instinct here is vital.
If you use these things in your decision making then that is completely normal.  An article in Archives of Disease in Childhood this year (2) published a consensus of which behaviours are seen to indicate that a child does not have sepsis.

Parental anxiety

More tacit knowledge here folks.  We will ask about symptoms and are looking to get some fairly specific answers.  Much of what we want to know will feed into the features already mentioned.  However, there may be things going on that a parent will struggle to articulate.  It is our job to distinguish between unwarranted anxiety (“I saw that news story about the child who died of sepsis…”) and the anxiety that comes from  a parent knowing that something is deeply wrong and being unable to articulate the reason why they know that.  The latter is the parent’s own tacit knowledge being given to you in the form of a person who cannot be reassured.

The trajectory of the illness

I believe that this may be one of the most important yet least discussed pieces of the jigsaw.  No one has told me about it and it may be that no one has ever told you, but when I say it, your own tacit knowledge about assessing unwell children will hopefully agree with the following statement:  An illness that has extreme fluctuation in symptoms (i.e. very unwell followed by surprisingly well) is almost certainly an uncomplicated viral illness.  I am talking about the “you wouldn’t believe how unwell they looked” kind of illness.  Sepsis and SBI don’t give you time off.  Viral illnesses, it seems, do.  So much so that a child who was floppy and lethargic can within the hour be smiling, playing drinking and complaining that they don’t want to go home because they want to play with the toys that you have.  It’s not in the guidelines but it is very important because the opposite is also true.  Two children can have the same heart rate, temperature, hydration and appearance, but the one who hasn’t had a return to normal in the past few hours is the one to really worry about in my opinion.

Many of these jigsaw pieces are the more quantifiable and traditional features that guidelines rely heavily on.  The rest are more woolly and difficult to define, let alone describe.  These are the pieces of the jigsaw that only you, the experienced clinician, can piece together.  If you would like to do a bit more reading about decision making in paediatrics, here is an article published in ADC (open access) (3) which further explores that issue.

Interestingly, there is a paediatric decision tool that takes into account some of the tacit knowledge features described here.  The POPS (Paediatric Observation Priority Score) includes features such as gut feel alongside physiological values (4).  This scoring system is both simple and over-simple in equal measure.  While it is quick, easy to do and validated, it only gives you a number at the end, not an answer or a diagnosis.  That number tells you to look at the jigsaw and see what the numbers mean.  The higher the number, the harder and longer you need to look and the better the explanation you need in order to be happy.

The other thing about POPS is that it doesn’t include my much neglected feature: the trajectory of the illness.  I think I’ll make a modified version of POPS which includes this.  I’ll call it POPcycleS.

How do we disgnose sepsis in children?  It remains a clinical diagnosis, best made by someone who has all the pieces of the sepsis jigsaw.

Edward Snelson
Perpetually puzzled physician
@sailordoctor

Disclaimer - If there is a piece of the jigsaw missing, go back and reassess the child.  They have probably eaten it.

References

1. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801–810. doi:10.1001/jama.2016.0287
2. Snelson E, Ramlakhan S Which observed behaviours may reassure physicians that a child is not septic? An international Delphi study Archives of Disease in Childhood 2018;103:864-867
3. Roland D, Snelson E ‘So why didn’t you think this baby was ill?’ Decision-making in acute paediatrics Archives of Disease in Childhood - Education and Practice Published Online First: 01 March 2018. doi: 10.1136/archdischild-2017-313199
4. Roland D , Lewis G , Fielding P , et al . The paediatric observation priority score: a system to aid detection of serious illness and assist in safe discharge. Open J Emerg Med 2016;4:38–44.doi:10.4236/ojem.2016.42006

You Better Think! - A three dimensional guideline for recognising the unusual diagnosis in the ill child (including Kawasaki disease)

When assessing ill children, it is easy to presume that the problem is an uncomplicated viral infection.  Most of the time it is.  The odds are severely stacked against a more significant diagnosis to the extent that it is easy to become overly presumptive.  This, combined with the fact that a simple and benign illness will share many features with a rare or dangerous illness means that spotting the unusual or harmful diagnosis is very challenging indeed.

Much of the work done on congitive and diagnostic error takes the errors and then works backwards.  For a long time there have been reports on the number of deaths in healthcare that are related to error. (1)  These are reverse-engineered and start from the point of the problem.  People died - what is the evidence that there was any flaws in the care/ diagnosis/ treatment?  This is very different from the alternative approach of:  People had a healthcare episode- what happened next?

Outcome based stats are dangerous in that respect.  If you have 10% more adverse events than your colleagues but see 50% more patients (because you're awesome at your job) then please come and work with me.  You might flag up as a dangerous clinician if someone looks purely at incidents rather than the big picture.

I think that the most effective clinicians are those capable of recognising well children and capable of changing gear when something is unusual.  This is sometimes referred to as type 1 and type 2 thinking as per the model descibed by Croskerry. (2)

Using this model, we are most efficient when we are thinking inuitively and making gut feel decisions (type 1 thinking) and most effective at making the more complex diagnoses and managing the most dangerous scenarios when we are more considered and thorough (type 2 thinking).

Let's use this example to consider a child with non specific symptoms such as fever, rash, lymphademopathy and pharyngitis.  The reasonable but also dangerous assumption is that the child has an uncomplicated viral illness.  The possibility of another outcome is small but the consequences of missing an alternative diagnosis are great.  So, we need to use type 1 thinking to be efficient and be prepared to go into type 2 thinking when needed.

The obvious questions are then, what am I looking for and when do I look for it?  Guidelines on the subjects of febrile children, URTI in children and recognising complications such as sepsis tend to be written as if the problem was one dimensional or that the same guideline could be used in every circumstance.  This is one of the reasons that guidelines can sometimes frustrate.  Clinicians don't think that way, so it jars when a "fits all sizes" guideline over-simplifies such a complex process.

Here's an example of something that is useful but fairly simplistic.

This tells us what normal and abnormal look like.  It does very little to tellus what it all means.  Stopping here would be fine if we are just going to tell people when to refer or not.  To do that safely, such guidance will invitably err on the side of caution.

What it fails to do is to address what may be causing the red flags or atypical findings.  While a diagnosis is not necessesary in order to make a decision to refer, having a suspected diagnosis helps us to get the right child to the right place at the right time.

Lets take two of the possible complex and dangerous diagnoses as examples.  A child has a febrile illness with conjunctivitis, phayngitis, swollen lymph nodes, a rash and is pretty miserable.  Good to know.  If I told you that the onset of symptoms was within the past 24hrs, would you consider Kawasaki disease? No.  If I told you that it was day 6 of the illness and that for the past 3 days the child was neither better nor worse would you think that the diagnosis was likely to be acute sepsis? No, but can we get a guideline to help us get there?

Since it is a factor in our decision making, we could add in the dimension of time and disease progression to our guideline.  If we did that I think that it could look something like this:

Even adding this dimension doesn't fulfil our need for something which maps to our way of thinking.  We now have the bit that focuses on the child in front of us and the bit that takes into account the real world where patients present in different ways, but many guidelines fail to take into account the fact that different diseases behave differently.  Worse than that, the differences can be subtle.

Guidelines often struggle to deal with the fact that medicine is a complicated subject.  Do you write a guideline for a clinical scenario (e.g. febrile child)?  If so, you need to include every possible cause and when to think of it.  Do you write your guideline about a specific disease (e.g. Kawasaki disease)?  If so, how will people know when to use the guideline?  If they have looked it up, they are 90% of the way there and the guideline is going to be more useful as confirmation and treament advice.

For these reasons, guidelines will never be a substitute for the need for clinical knowledge and understanding.  Our child with non-specific symptoms guideline needs to have another layer - specific diagnoses, what they look like and when to consider them.

We need guidelines to be both simple in order to be practical and complex because nothing is simple.  We need them to be based on real-world clinical practice and to be honest about the uncertainties inherrent to that.

The short answer to the child with non-specific symptoms?  Anything is possible, including Kawasaki disease.  Early recognition of Kawasaki disease is important as treatment will reduce complications.  So, you better think.  In fact, because type 1 thinking will do very nicely most of the time, but not all of the time, you better think think.

Edward Snelson
Occasional overthinker
@sailordoctor

Disclaimer: Over and under-thinking are both perfectly acceptable in the right circumstances.

References

1. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system.National Academies Press, 1999.
2. Croskerry P. A universal model of diagnostic reasoning, Acad Med. 2009 Aug

Paediatric Sepsis - the Facts, the Myths, How We Got Here and Where We Need to Go Next

You may be wondering if you're the only one confused about what's happening with paediatric sepsis.  You're not.  I work in paediatric emergency medicine and I just about get it.  Just.

I am frequently asked questions about what people (in both Primary and Secondary Care) should be doing now with regards to sepsis.  Everything seems to be changing so quickly that it is difficult to keep up.  As intelligent clinicians, we like to understand the reasons for change as well as what changes are occurring.  In the case of sepsis, research evidence is only part of the explanation for the changes that are happening.  That doesn't seem very reasonable but there are valid reasons.  As you're the one having to change your practice, it's probably time that you received a full and honest explanation for why you should do this in the absence of robust evidence.

Sepsis has always been with us.  We might have changed but sepsis has always been the same - a dysfunctional response to infection, manifesting as an exaggerated response to the illness or as organ dysfunction.

Some things have changed in our understanding of sepsis, while other aspects remain frustratingly beyond comprehension.  What we know and what we don't know are key elements to understanding the evolving approach to paediatric sepsis.

What we know:

• Sepsis carries a high morbidity and mortality
• Early treatment with antibiotics reduces morbidity and mortality
• Undertreatment of sepsis increases morbidity and mortality

That's about it for what we know.  It's a short list.

What we don't know:

• We don't have a good definition of sepsis in children.  The Third International Consensus Definitions for Sepsis and Septic Shock (1) gave a definition of "life-threatening organ dysfunction caused by a dysregulated host response to infection."  This is in many ways spot on but at the same time suitably subjective so as not to be specific when it comes to a clinical decision.  The other commonly used definition of SIRS (systemic inflammatory response syndrome) is very specific (if you have an abnormal temperature and tachycardia, you fulfil the SIRS criteria) and has the opposite problem.  It is very prescriptive and very often wrong.  Hot, tachycardic children are not hard to come by.  A few of these will have sepsis but most will not.
• We don't have a good way of deciding if a child has sepsis.  Various approaches have been tried.  Decision tools have always been hampered by poor sensitivity and specificity.  No blood test or combination of blood tests has been found to be reliable either in the ruling in or ruling out of sepsis in children.  If there was a reliable method we would all be using it. Telling the difference between a febrile viral child and a child with early sepsis is as much of a challenge now as it was in years past.
  

Image taken from http://rolobotrambles.com/ with kind permission from Damian Roland.

• We don't know the impact of the various paediatric decision tools that have been introduced in recent years.  In an attempt to improve the recognition of sepsis, there have been many campaigns, guidelines and decision tools landing in your inbox over the past few years.  Driven by the fact that sepsis is often diagnosed late and that the consequences can be fatal, these initiatives inevitably push for increased diagnosis, using a lower threshold. Increased diagnosis can only be through a lower threshold at the moment, since we have failed to find a way to improve sensitivity and specificity together.  What nobody knows is whether this move to a lower threshold is having a positive or a negative effect.  If for every case that is diagnosed earlier, 1000 have unnecessary treatment (totally made up numbers of course), is the overall effect good or bad?
• We don't know how many cases of sepsis can be diagnosed earlier.  The main problem of course is that retrospective analysis of cases of paediatric sepsis are inherently flawed.  The outcome is known, therefore all tachycardia becomes evidence of sepsis, despite the fact that other causes are possible.  Most children who present with sepsis will have had one or more contacts with a clinician in the days preceding their diagnosis of sepsis.  In some cases the symptoms will have been due to a viral infection which preceded the sepsis and in other cases the symptoms may have been due to the developing sepsis.  It is rarely possible to be certain which of these was the case.

It is therefore with a large number of uncertainties that we go forward.  There is no doubt that we are getting better at treating sepsis, but recognising it remains an area that we have a serious amount of work to do.

So why have we changed practice in the absence of evidence?  The answer is that, although we are all coming at the problem from a different point of view and with different agendas, we all want to do this better.  With the evidence pointing towards a benefit from early recognition and more aggressive treatment, changes are afoot to try to achieve these outcomes.  We need to alter our perspective and awareness of the problem of sepsis even if we do not yet have the answer to the question of how to better recognise it in children.

How should I change my practice?

Taking Damian Roland's sepsis spectrum and simplifying it, there are three clinical scenarios that I think are generally true by the end of consultation with an ill child.

Scenario 1 - the child with a febrile illness who has demonstrated their wellness to the point that sepsis is extremely unlikely

For these children, we should no longer be talking in terms of them having 'just a virus.'  They have a virus and they have no signs of sepsis, however, they are now in a group that is at risk of developing sepsis.  Worse still, if sepsis should develop, the signs might not be recognised as they will be attributed to the viral illness.

What should now be standard practice is a safety-netting conversation at the close of the consultation which makes clear what the red flags are and when to seek further assessment or advice.  Parents should feel that they are empowered to seek this without fear of being seen as over anxious people.

Scenario 3 - the child who appears to be seriously unwell

If you work outside of a centre which has acute paediatrics, get them there.  If you are the person at the other end, make sure that the child is seen quickly, a decision is made to treat ASAP and that there is no delay to treatment with a full Sepsis 6 bundle as appropriate.  These children might have had multiple cannulation attempts over a long period of time in the past, but now it's time to get out that drill.

Scenario 2 - all the children in between 1 and 3

In between those two set pieces is where we make the big decisions and make them very carefully.  As mentioned above, there is no good decision tool available, no test and no easy answer.  Decision making in these circumstances is complicated (2) and the explanation of how these decisions are made cannot be oversimplified.

What can be simplified are the guiding principle for assessing these children who occupy the uncertain zone.

• Gut feel is an important part of the decision making process.  This means that you should listen to your gut feel and to the anxieties of the parents and your colleagues.
• Persistence of abnormal signs is concerning.  While signs (heart rate, level of activity) fluctuate significantly during an uncomplicated viral illness, children with a significant infection tend to be persistently unwell.  Persistent tachycardia, tachypnoea, lethargy or other signs of illness should be taken very seriously.
• No one factor will give you the answer.  Making these decisions would be a lot easier if there was a solid rule.  Can you send someone home with a pyrexia? Often.  Can you send someone home with tachycardia? Sometimes.  
• You can only work with the information that you have.  What do I do if it is 2am, the child is asleep and is suitably grumpy when woken?  In this situation, the doctor-patient banter that I rely on to rule out sepsis is not available to me, so I am forced to look at all the other information that I have.   Admittedly, I look at it very carefully before making a decision.  I can only work with what I've got though and I'm not going to keep the child till morning just to tick the "I've seen them smile and run around" box.
• The sepsis assessment never ends.  If the initial assessment leaves uncertainty, there are several options including referral, observation and discharge, depending on the degree of suspicion.  In all of these cases, we need to be clear about the need to take persistent, worsening or new symptoms seriously. 

Early sepsis is difficult to detect, so we need to use every tool available to us to make sure that the diagnosis is made at the earliest possible opportunity.  Until we have something better, creating that opportunity means as many clinical assessments as needed depending on the scenario.

What has changed over the past few years?  Hopefully we have.  We now better recognise the importance of early recognition of and immediate treatment of sepsis.  What we shouldn't forget is that while we have set rules for ourselves that achieve the latter, we haven't yet found a way to consistently do the former.  So that leaves us with a need to do what we can to make the best clinical decision possible for each of our patients, while being patient with the academics who will hopefully one day come up with a magic test.

Edward Snelson
Medical Historian or Historical Medic?
@sailordoctor

Disclaimer - very little research into the actual history of sepsis went into this article.  By little, I may mean none.  Still, the leeches bit is probably true.

References

1. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), JAMA, February 23, 2016
2. Roland D, Snelson E ‘So why didn’t you think this baby was ill?’ Decision-making in acute paediatrics Archives of Disease in Childhood - Education and Practice Published Online First: 01 March 2018. doi: 10.1136/archdischild-2017-313199

A genuinely useful test - Blood sugar in acutely unwell children

When your patient is a child, the decision to do investigations is a complex one.  On one hand, it is often the case that at the end of history taking and examination there is some uncertainty which tempts the clinician to gather more information in the form of tests.  Parental anxiety might seem to be best managed through investigations either to demonstrate normality or to show that concerns have been taken seriously.

The reality is that these reasons for doing tests are all dubious and can achieve the opposite to the desired result.  There are few paediatric medical problems for which a test is more valid than clinical assessment.  For example, upper respiratory tract infections - If the symptoms are all well controlled by simple analgesia, what useful information could tests add?

Worse still, many tests are potentially misleading or might cause anxiety.  I like a full blood count as much as the next medic but goodness me don't they have a lot of information in them?  Does it mean something when the lymphocyte count is just below the reference range if the total white cell count is normal?  Sometimes the result can be alarming.  "Toxic lymphocytes" are a good example of something that you don't want to get on the lab report, especially when the child is climbing up the shelves in your consulting room while you try to work out how to answer the question, "Was the blood test result normal?"

But it's not all me, me, me.  The truly difficult part of all of this is that we should not use tests to reassure.  No matter how much another person wants a child to have a test for their own reassurance, we should only be doing tests which are in the best interest of the child.  Although a tough rule to live by, it is important to remember that the child is the patient, not the parent. 

The good news is that tests rarely tell you something of great value once a child has been clinically assessed.  Tests are most useful when they give you a number which has a clear clinical significance and where you could not have made a diagnosis without that test.  This criteria applies very nicely to testing blood sugar for an acutely unwell child, in certain curcumstances.  

Here are two cases where a simple skin prick glucose test has made all the difference:

Case 1

A three year old boy has been vomiting and febrile for 24 hours.  Clinically they are not dehydrated (they have wet mucous membranes, normal skin turgor, their eyes are not sunken and they are passing urine reasonably well) and they are neither septic nor meningitic.  In fact what is odd about them is that they seem subdued and grumpy despite having a normal heart rate and normal temperature.

Blood sugar is tested and found to be significantly low.

Why do unwell children get low blood sugar?  This happens for one of two reasons.  The most common reason is that the child has exhausted their available supplies of glucose.  The child's body has a limited reserve and if consumption exceeds supply then the child will eventually run out of glycogen, the most readily available way of mobilising energy in times of need.

The second possible reason is that the child has a metabolic problem.  Some children have a disorder in their metabolism which is normally masked by the almost constant supply of carbohydrate that they receive.  When this supply is interrupted, it unmasks the fact that one of the chemical pathways (needed in times of crisis) is faulty.  No plan B, no blood sugar.

How do children with low blood sugar look?  The brain is a complicated thing but it runs on two main things: oxygen and sugar (or backup substances but let's keep this simple).  If a child has a low blood glucose then the first signs are usually neurological.  Most commonly the child is not fully alert and is often unhappy.  I believe the term is hangry.  They will be less active but they may also be combative.

How should low blood sugar be treated?  The first thing to mention here is a pitfall.  Do not use glucagon to treat hypoglycaemia in children when the reason for their low blood sugar is that they have run out of reserves.  It simply won't work.

If the child is able to swallow safely, they can be given a sugary drink.  If not then what happens next depends on where you work.  If you are outside of a hospital setting, then a glucose gel rubbed into the oral mucosa will be a good plan.  In hospital, most places will give an intravenous bolus of dextrose 10%.  (ALSG recommends 2ml/kg) When the cannula goes in, there are usually some blood tests that need to be taken, depending on local guidelines.

The response to initial treatment should be assessed and further intervention given as needed.  If there is a good response, it is important to realise that this is not 'job done'.  To become hypoglycaemic, the child had to have exhausted their reserves, so a single bolus will have a very temporary effect.  It is essential to continue the carbohydrate supply, often in the form of maintenance intravenous fluids.


Case 2

A 5 year old girl presents with abdominal pain and vomiting.  They started being non-specifically unwell two days ago.  Yesterday they started having abdominal pains and overnight they started to vomit.  The child is drinking well and passing urine.

The child has no significant past medical history.  On examination the child is subdued and miserable.  The abdomen is soft.  The child is tachycardic but has a normal temperature.

When a blood glucose is checked, it reads three times the upper limit of normal.

Why do children get high blood sugar?  Although any significant illness can cause a moderately raised blood sugar level, hyperglycaemia of this magnitude always means diabetic ketoacidosis. (Well, that's not strictly true.  Occasionally it means that there is sugary residue from a drink or snack on the finger that was tested.  That's why you need to clean the finger first.)  Of course, it is possible (and preferable) to make the new diagnosis of type 1 diabetes before it gets as far as DKA.  If the blood sugar is high, type 1 diabetes should be the presumed diagnosis.

How does diabetic ketoacidosis (DKA) present?  DKA is a difficult diagnosis for all sorts of reasons:

• Symptoms are somewhat non-specific.  Abdominal pain and vomiting are good examples.
• DKA is rare and gastroenteritis is common
• Clinicians tend to check that a child is drinking and passing urine enough, but may not ask if oral intake and urine output is excessive
• The onset of symptoms can be surprisingly gradual.
• While less common, type 1 diabetes can occur at very young ages.  Unsurprisingly, it is not the first diagnosis that people think of when seeing an unwell young child.

Most commonly, the illness is initially mistaken for a viral URTI or gastroenteritis.  Polyuria and polydipsia are unusual symptoms in a child with a viral illness who is significantly unwell and should be major clues.  Abnormal breathing is a feature of the acidosis and should also prompt the clinician to think of DKA.  However there is one feature that rather tidily applies to both high and low blood sugar: the child will be subdued and lethargic.

How should DKA or newly diagnosed type 1 diabetes be treated?

This is fairly specialised stuff so these children will all need to be referred.  The acute management of DKA is rather complicated and requires careful fluid management to reduce the risk of developing cerebral oedema.  According to the NICE guidelines (1), fluids should be the priority for the first 1-2 hrs after which insulin can be started for DKA.

As tests go, blood glucose is much more useful that many, and the result and meaning are usually clear.  Blood glucose is a test to go for in children who have atypical symptoms or are significantly subdued.  High or low, an abnormal result is a game changer and early recognition of the problem will make a huge difference.

Edward Snelson
Tricorder trainer
@sailordoctor

Disclaimer: While it would be wrong to do an unnecessary test on a child, it is perfectly acceptable to Feng Shui them. They then need careful monitoring to see the effect of the intervention.

Reference

1. NICE guideline [NG18], Diabetes (type 1 and type 2) in children and young people: diagnosis and management