Date: 19th October 2022
Winter Pressures
PAEDIATRICS
Advice to Primary care and Urgent Treatment Care Centre Professionals
Guidance to GPs re High Risk clinical situations for Sepsis/ serious health conditions/ health escalations that will need consideration to referral to hospital urgently
Fever in less than 3 month old infant
Fever with rapidly spreading non blanching rash especially in non SVC distribution
Fever, inconsolable irritability, vomiting, bulging fontanelle, parents report that child is stiff to handle, poor feeding
Fever, altered behaviour, irritability, neck pain, light hurting eyes
Fever, not in usual self, abnormal posture or movements
child with Complex medical needs with fever: especially with indwelling vascular line/ urinary catheter, tracheostomy, shunts (in heart/ brain)
Fever, unable to weight bear with or without joint swelling, not in their usual self
Fever in immunocompromised clinical situations (e.g. oncology)
Fever with unwell ness in non-vaccinated child
Febrile, grunting, cold extremities and pale- dusky, passing less urine, dry
Fever, flank pain, unwell, urinary symptoms
Fever, abdo pain, adbo distension, vomiting, refuses to mobilise, not letting touch tummy (Contact surgical team for children age > 5 years)
Child with viral wheeze or asthma exacerbation not responding to appropriate management steps in community
Vulnerable child with unreliable history (patient on child protection register/ local authority care)
Significant failing to thrive children with new symptoms of unwellness.
This is not an exclusive list but covers mostly encountered sepsis prone/ other high risk clinical situations. Important to remember that there could be cross over with different permutation combinations of above symptoms in given serious health condition in a child. Also disease process and symptomatology could be evolving over variable period of time during disease process.
The symptoms severity stratification is age dependent in children. Also, clear instructions to parents are needed to accurately decipher possible abnormal signs (e.g. fontanelle - is it bulging irrespective of Child crying or quiet? Questions to ask parents about assessment of dehydration etc)
There is no substitute to use a balanced combination of clinical acumen and common sense in making management decisions. Also if in doubt.....
Consult with colleague in surgery
Risk assess, safety-net and call after reasonable time to get a follow up info
You can contact paediatric hot week team (on call middle grade/ consultant) for advice.
Hot phone number to paediatric consultant on call is (LCH: 07464522064, PHB: 07464522112). Available 9AM to 5 PM Monday to Friday.
FOR UNWELL CHILD WITH CARDIORESPIRATORY COMPROMISE, HYPOXIA, HAEMODYNAMIC INSTABILITY, RAPIDLY SPREADING NON-BLANCHING RASH ESPECIALLY IN FEBRILE UNWELL CHILD, ACUTE ABNORMAL NEUROLOGY- PLEASE ADMINISTER BLS AS APPROPRIATE, CALL 999 AND AMBULANCE TRANSER PATIENT TO NEAREST ED URGENTLY.
IN ADDITION, RAPIDLY SPREADING NON-BLANCHING RASH ESPECIALLY IN FEBRILE UNWELL CHILD WILL NEED URGNT ADMINISTRATION OF IM ANTIBIOTIC WHEN WAITING FOR AMBULANCE TRANSFER.
It is important to remember that during busy winter pressures, we all will be working together towards providing best possible care to patients whilst minimising risk from unnecessary health care contacts.
Practical tips to assess respiratory status:
Assess for following specific things to do risk stratification:
1. Are they grunting?
2. Are they pink in colour? (Tongue colour)
3. Are they moist on tongue and have tears when cry? (Significant n long periods of respiratory distress will make them dry)
4. Are they feisty or limp? (Poor tone is a problem- tired due to breathing effort and may be hypoxia related)
5. Are they consolable? (Irritability - a problem - May be indication of hypoxia)
If you are reassured by gaining this information in otherwise previously well child (i.e. no past med problems/ comorbidities) then in vast majority of circumstances child is OK to stay in community with symptomatic treatment. Will need safety-netting with consideration for arrangement for follow on phone call to family.
One should keep in mind about Community Acquired Pneumonia and a low threshold for Amoxicillin if temp > 38.5 and also high for age respiratory rate despite temp controlled with antipyretic...
One should not hesitate to err on side of safety to give Amoxicillin in community for clinically suspected symptoms of LRTI in otherwise well child.
Advise re managing asthma exacerbation:
2 most IMPORTANT things are
1. Regularity of use of regular steroid preventer inhaler with good technique and with use of spacer
2. Salbutamol inhaler with spacer and good technique as per the action plan
For symptom exacerbation.....
A typical action plan would be...
A. Begin with 2-4 puffs 4 hourly regularly till symptoms come under control
B. If symptoms continue then increase the salbutamol to multitasking: 10 puffs 4 hourly
C. Symptoms not well managed or have worsened despite the above, I think one should escalate to PO short duration steroid course 3 days’ worth. Prednisolone Dose: 20 mg OD below 20 kg and 30-40 mg OD for child above 20 kg body weight (I think it is right thing to do in paeds asthma patients as their access to direct Management by medics can be very limited)
C. If symptoms exacerbate to red flags: pale, dusky, floppy, not able to speak, working hard: parents should call 999 and keep giving Salbutamol 2 puffs every 2 mins till the help arrives.
It is very likely that 999 will be overwhelmed and in this situation parents will need an ample supply of salbutamol inhaler via spacer. It is especially important for any asthmatic child who has had asthma hospitalisation in the past.
Almost all above management steps applies to frequent viral wheeze patients too who have exacerbated.
High Risk paediatric clinical situations:
1. Patients with Chronic Lung Disease of prematurity
2. Patients with Cystic Fibrosis
3. Patients on continuous/ daily home oxygen
4. Patients with tracheostomy
5. Patients on long term Home Ventilation
6. Patients with brittle/ difficult to treat asthma
7. Patients with bronchiectasis
8. Patients with clinical conditions causing immune deficiency
9. Patients with chronic neuromuscular conditions
10. Patients who are wheel chair bound, special educational needs and on regular community physiotherapy support
11. Patients at risk for febrile neutropenia
This high-risk conditions list is not exhaustive but encompasses large proportion of paediatric “at risk” patients. Most of these patients have direct access to paediatrics department.
At the hospital MDTs, their community health professionals and we relevant clinicians are ensuring that we advise parents and carers of these patients regarding early recognition of any ill-health escalations, thereby facilitating community management of these escalations early and effectively.
We are gearing up to use Children’s Community Nursing team and Rapid access community physiotherapy team (offering their community based services to CYP age 21 y and less) especially for high risk paediatric patients to help avoid their contact with hospital for elective or emergency health needs.
Dr Amol A Chingale
Consultant Paediatrician
Lincoln County Hospital
Clinical Lead Acute Paediatrics, ULHT
Telephone number (via switch) to access paediatric hot week team at LCH is 01522512512
My email: amol.chingale@ulh.nhs.uk
My secretary: 01522 573342