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									Recognizing the
Seriously Ill Child
Chiropractic Pediatrics, Ch. 4
N. Davies
Fever
Definition: Elevation in body temperature

 It is not a disease… though it may indicate
 the presence of disease

 It is helpful…defense mechanism
Possible Risks
1.   >101 in a newborn (2-3 months old)

2.   >105 for a prolonged period of time
       may lead to dehydration

       brain injury (rare)
“Red Flags”
 Core body temperature elevated
 State of arousal
 Breathing effort
 State of peripheral circulation
 Dehydration
     fluidstaken in and excreted (24 hrs)
     acute weight loss
Arousal

   Observe the child for:
     signsof drowsiness
     hypotonia
     response to stimulation


   If the baby cries, note characteristics of the cry
     weak,   whimpering, appears to require undue effort
Dyspnea

   Recession of the sternum and chest wall
   Nasal flaring
   Respiratory grunting
   Central cyanosis

    NOTE: tachypnea alone is not indicative of
    serious illness
Peripheral Circulation

   Generalized pallor
   Cold lower legs (knee down)

    NOTE: cold hands & feet and mottling of the skin
    have little or no relationship to serious illness
Estimation of Fluid Intake/Loss

Serious signs:
 Ingesting <50% of the normal fluid intake
 <4 wet diapers in a 24 hr period
Estimation of Acute Weight Loss

   Compare current weight to expected weight
     lookat the anthropometric chart (percentile) to
      determine their expected weight

        expected weight - current weight X 100
              expected weight

    Weight loss of >7.5%... Dehydration
     Refer to the hospital
Signs of Dehydration
   Dry mucous membranes and skin
   Rapid, weak pulse
   Pallor or ashen/grey discoloration of the skin
   Soft, sunken eyeballs
   Depressed fontanel
   Poor tissue turgor (tenting)
   Lethargy
   Seizures
Uncommon High-risk Signs
   Bile-staining vomit
   Convulsions (especially 1st time)
   Lump >2 cm in diameter (abdomen)
      except hydrocele or umbilical hernia
   Petechial rash
   Fecal blood without visible cause
   The following criteria are designed to
    recognize acute life-threatening illnesses
     They are conservative referral criteria with a
      wide margin of error…
Assessing the Febrile Child
1.    Quality of cry
2.    Reaction to parent stimulation
3.    State variation
4.    Color
5.    Hydration
6.    Response to social overtures

A score >12 should be referred for evaluation
     10… 2.7% serious illness
     16… 92.3% serious illness
Quality of cry

1-   strong with normal tone; content and
     not crying
3-   whimpering or sobbing
5-   weak or moaning or high pitched
Reaction to parent stimulation

1-   cries briefly then stops; content and not
     crying
3-   cries off and on
5-   continuous cry or hardly responds
State variation

1-   if awake, stays awake; wakes up
     quickly if stimulated
3-   eyes close briefly, awake; awakes with
     prolonged stimulation
5-   falls to sleep; will not rouse
Color

1-   pink
3-   pale extremities; acrocyanosis
5-   pale, cyanotic, or ashen
Hydration

1-   skin and eyes normal, mucous
     membranes moist
3-   skin and eyes normal and mouth
     slightly dry
5-   skin doughy or tented and dry mucous
     membranes +/- sunken eyes
Response to social overtures

1-   smiles or alerts (<2 months)
3-   brief smile or alerts briefly (<2 months)
5-   no smile; face anxious, dull, or no
     alerting (<2 months)
In practice…
   Watch the child during the consultation

   Assign the number that best describes the
    case and enter it in the record
     Add   up the 6 scores
Summary of Referral Criteria
   Observational items score >12
   Any combination of poor arousal, circulation or dyspnea
   Acute body weight loss >7.5%
   Decreased fluid intake or excretion
   Persistent bile-stained vomiting
   A first convulsion
   Periods of apnea
   Respiratory grunting or central cyanosis
   A lump >2 cm diameter (abdomen)
   A petechial rash
   Blood evident in the feces
   Fever of >3 days’ duration in a child who is on antibiotics

								
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