ASSESSING THE SICK CHILD

Immediate assessment

Warning Signs of Possible Severe Illness

1. Check airway/ breathing

CHECK: breathing rate

Breathing effort

Oxygen saturations

Green - Low Risk

Is struggling to breathe

Is breathing very fast

Has noisy breathing

Has oxygen saturation less than 92%

Pallor reported by parent/carer

Activity

Responds normally to social

cues
Content/ smiles
Stays awake or awakens
quickly
Strong normal cry/ not crying

Not responding normally to social

cues
Wakes only with prolonged
stimulation
Decreased activity
No smile

No response to social cues

Appears ill to a healthcare
professional
Does not wake or if roused does not
stay awake
Weak, high-pitched or continous cry

Nasal flaring
Tachypnoea:
RR > 50 breath/minute,
age 6-12 months
RR > 40 breaths/minutes, age >
12 months
Oxygen saturation < 95% in air
Crackles

Grunting
Tachypnoea:
RR > 60 breaths/minute
Moderate or severe chest indrawing

Respiratory

Put on oxygen by face mask at 10l/minute

2. Check circulation
CHECK: heart rate
Temperature
Feel hands and feet - If child has:

Very cool skin

Slow or very fast heart rate

Ring paediatrician or doctor straight away.

3. If child is:

Floppy or drowsy

Check blood sugar level.

Hydration

Other

Normal skin and eyes

Moist mucous membranes

None of the amber or red

signs

Reduced skin turgor

Fever for > 5 days

Age 0-3 months, temperature 38

Age 3-6 months, temperature 39

Swelling of a limb or joint

Non weight bearing/ not using an
extremity

Emergency phone numbers

On call doctor:..........................................as per local roster

Kimberley Paediatrician on call:... Derby Hospital 9193 3333
RFDS..............................................................1800 625 800
Princess Margaret Hospital:.9340 2222 - ask for Emergency
Department doctor.
Poisons information:.................................................131126

Pale/mottled/ashen/blue

Dry musous membranes

Poor feeding in infants
CRT > 3 seconds
Reduced urine output

Ring paediatrician or doctor straight away.

First Line

Red - high risk

Normal colour of skin, lips and

tongue

If child

Amber - intermediate risk

Colour

A new lump > 2 cm

Other warning signs of children at high risk of severe illness include:

less than half normal fluid intake in last 24 hours

no urine output for 6 hours or more (ie less than 4 wet nappies in 24
hours)

underlying chronic conditions eg heart disease, lung disease, diabetes,
disabilities

poor socio-economic circumstances (children at risk)

not fully immunised

Non-blanching rash
Bulging fontanelle
Neck Stiffness
Status epilepticus
Focal neurological signs
Focal Seizing
Bile-stained vomiting

If any suspicion of severe illness or shock, discuss immediately with senior

colleague/ doctor/ paediatrician. Get essential information, obtain vital
signs, THEN CALL PAEDIATRICIAN OR DOCTOR. Dont delay in order to
complete detailed assessment.

Kimberley Aboriginal Medical Services Council (KAMSC) and WA Country Health Service (WACHS) Kimberley

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ASSESSING THE SICK CHILD

Normal Observations
AGE

RESP RATE

HEART RATE
(beats/min)

SYSTOLIC
BP (mmHg)

< 1 year

30-40

110-160

70-90

1-2 years

25-35

100-150

80-95

2-5 years

25-30

95-140

80-100

5-12 years

20-25

80-120

90-110

> 12 years

15-20

60-100

100-120

(breaths/min)

how worried are the parents?

Disability

immunization history

Normal <2.0 sec

Prolonged 2.0-4.0 sec
Markedly prolonged >4.0

Full assessment

General:

posture

pupils

behaviour/activitynormal/ lively /irritable/ lethargic/

very sleepy

colour, rashes (to check if a rash blanches, press on it

with a glass slide, or eyeglasses, or gently press it to
see if it fades whilst under pressure). Non-blanching
rashes (ones that dont fade under pressure) are more
worrying

Ear, nose and throat examination

fontanelle if open (soft part of top of head in small

babies may be normal, bulging, or sunken)

tone normal, floppy, stiff

Should be measured by axillary method until 6 months

of age. Beyond 6 months, tympanic measurements are
considered reliable.

Airway

If immediate assessment is reassuring, proceed to full

assessment (see page 2), but call early if anything changes.

stridor (harsh noise when breathing in)

noisy breathing

A child can appear quite well when first seen, but actually
be very sick. Do observations and a full physical examination.

drooling

History

A alert
V responds to voice
P responds to pain
U unresponsive

Examination

Capillary refill time:

AVPU scale to assess level of consciousness

Breathing

respiratory rate (count breathing for 1 minute)

Ask about

grunting when breathing out

what symptoms has he/she had?

nasal flaring (nostrils opening wide with breathing)

are they getting better or worse?

how long has the child been sick?

rib recession (indrawing)/ use of accessory muscles,

using abdomen to breath

any fever, rash, cough, breathing difficulty?

breath sounds/ air entry

any vomiting/ diarrhoea? (how much? What colour)

oxygen saturations

has she/he been eating and drinking normally? (if not,

how much?)

Circulation

has she/he had normal urine output/ normal number

wet nappies? (if not, how much?)

pulse/ heart rate

peripheral (hands and feet) temperature and colour

is the child still active and playing?

Has the child been to a clinic or hospital before with

this illness?

capillary refill (over sternum press on middle front

of chest for 5 seconds. Colour should return within 2
seconds after stopping pressure)

does the child have any other medical conditions?

blood pressure if unwell

(dont examine throat if child has stridor)

Temperature

Weight (and compare to previous)

Check naked weight on baby scales in children less than 2
years old

Blood sugar level

If unwell/ decreased level of consciousness

Urine
Check urine with dipstick if possible

Hydration status
Check for signs of dehydration (see below) sunken eyes,
sunken fontanelle, dry mouth

Kimberley Aboriginal Medical Services Council (KAMSC) and WA Country Health Service (WACHS) Kimberley

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ASSESSING THE SICK CHILD

SIGNS OF DEHYDRATION

Decreased urine output

Resources

SIGNS

MILD

MODERATE

SEVERE

Late/ uncompensated shock:

Weight loss

4-5%

6-9%

>10%

decreased blood pressure

NICE guidelines, Feverish Illness in children, 2007, accessed from http://

guidance.nice.org.uk/CG47

Pulse

Normal

Fast, weak

Fast, feeble

drowsy

All About Me, WA Department of Health Child Health Record, 2005

If any suspicion of shock or severe illness: discuss immediately

with senior colleague/ doctor/ paediatrician.

Resp rate

Normal

Fast

Fast,
laboured

Fontanelle

Normal

Sunken

Very sunken

Blood
pressure

Normal

Normal/low

Very low/
shocked

Eyes

Normal

Sunken

Deeply
sunken

Mouth

Normal

Dry

Parched

Mental state

Alert

Irritable

Drowsy,
comatose

Management

Fluid resuscitation, by intravenous or intraosseous

route (usually normal saline 10-20ml/kg bolus)

Shock is a physical state where body organs are not

receiving enough blood supply and oxygen to keep
functioning. If not recognized and treated, shock can lead to
worsening illness and death.

2.

Antibiotics IV or IM

3.

in babies less than 1 month old, discuss with the

on-call paediatrician. They will recommend amoxicillin
50mg/kg and gentamicin 5mg/kg

There are several causes, including:

4.

in children older than one month, IV or IM ceftriaxone

50mg/kg

5.

if meningitis or life threatening sepsis likely, add IV

vancomycin 10mg/kg stat (to cover MRSA)

6.

Partial septic screen, including CRP, FBC, blood cultures,

urine MCS (bag urines are not acceptable collect
in-out catheter or clean catch urine specimen. Refer to
UTIS IN CHILDREN PROTOCOL), throat swab, and any
other relevant organ-specific investigations.

blood loss

dehydration

anaphylaxis

severe heart or lung conditions

injuries including trauma and burns

poisoning

Treatment of febrile children under 5 years WACHS Kimberley Site

Instruction, 2011

Management may include:

1.

sepsis eg from meningitis

Advanced Paediatric Life Support, The Practical Approach, BMJ Books,

USA, 2005

Management of a shocked or severely ill child should be

guided by the on-call paediatrician. Refer to WA Country
Health Service (WACHS) site instruction Treatment of
febrile children under 5 years..

Shock

Dr Ffion Davies, Spotting the Sick Child, DVD, Leicester Royal Infirmary

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Early signs of shock may not be obvious in a child with a

severe illness but when signs of shock become evident the
child is mortally ill.
Early signs can be subtle and may include

increased heart rate

cold peripheries (hands and feet)

slow capillary refill time

BP may be normal or increased

Lethargy/ decreased activity

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Kimberley Aboriginal Medical Services Council (KAMSC) and WA Country Health Service (WACHS) Kimberley

VC - Last Modified: March 25, 2011 1:06 PM