What is the initial management of a paediatric illness?

Initial Management of Pediatric Illness

The initial management of pediatric illness should focus on assessment of airway, breathing, and circulation, with early recognition and aggressive treatment of respiratory or cardiac insufficiency to prevent deterioration and improve outcomes. 1

Initial Assessment

Rapid Assessment of Severity

• Assess responsiveness by gently shaking or pinching the child; if unresponsive, shout for help 1
• Evaluate airway patency and breathing by looking for chest movement, listening for breath sounds, and feeling for expired air 1
• Check circulation by assessing pulse, skin color, and capillary refill time 1
• Measure oxygen saturation using pulse oximetry; oxygen saturation <90% in room air (at sea level) indicates need for hospitalization 1
• Assess for signs of respiratory distress: tachypnea, retractions (intercostal, suprasternal, subcostal), nasal flaring, grunting, and cyanosis 1, 2

Danger Signs Requiring Immediate Intervention

• Impaired consciousness or abnormal mental status 1, 3
• Severe respiratory distress with retractions, stridor, or grunting 1, 2
• Central cyanosis or oxygen saturation <92% despite supplemental oxygen 1, 3
• Inability to drink or feed 1, 3
• Persistent vomiting 1, 3
• Convulsions or seizure activity 3

Management Algorithm

Step 1: Airway Management

• Position the child appropriately with head tilt-chin lift or jaw thrust to maintain airway patency 1
• Remove visible foreign bodies that can be easily grasped; avoid blind finger sweeps 1
• Consider airway adjuncts (oropharyngeal airway) if needed 4
• For severe upper airway obstruction, consult anesthesia or ENT for potential intubation or surgical airway 1, 5

Step 2: Breathing Support

• Administer oxygen therapy for hypoxemia (SpO2 <92%) 1
• For mild-moderate respiratory distress: provide supplemental oxygen via nasal cannula or face mask 2
• For severe respiratory distress: consider high-flow oxygen, CPAP, or mechanical ventilation 1, 4
• For suspected pneumonia: initiate appropriate antibiotics after obtaining cultures 1
• For bronchospasm: administer bronchodilators (e.g., albuterol) 6

Step 3: Circulatory Support

• Establish intravenous or intraosseous access if needed 1
• For signs of shock: administer fluid bolus (10-20 mL/kg) of isotonic crystalloid 1
• For persistent hypotension: consider vasopressors 1
• Monitor vital signs continuously in unstable patients 1

Step 4: Specific Disease Management

• For influenza-like illness: consider oseltamivir for children over 1 year of age 1, 2
• For suspected bacterial infection: obtain appropriate cultures and start empiric antibiotics 1
• For status asthmaticus: administer systemic corticosteroids and consider magnesium sulfate 6

Criteria for Hospital Admission

Indications for General Ward Admission

• Hypoxemia (SpO2 <90% on room air) 1
• Moderate to severe respiratory distress 1, 2
• Inability to maintain adequate oral hydration 1
• Age <6 months with suspected bacterial infection 1
• Significant comorbidities increasing risk of deterioration 1

Indications for ICU Admission

• Impending respiratory failure or need for mechanical ventilation 1, 7
• Oxygen requirement of FiO2 ≥0.50 to maintain SpO2 >92% 1
• Sustained tachycardia, inadequate blood pressure, or need for vasopressor support 1
• Altered mental status due to hypoxemia or hypercarbia 1, 7
• Recurrent apnea or irregular breathing 1

Monitoring and Follow-up

Ongoing Assessment

• Monitor vital signs, including respiratory rate, heart rate, blood pressure, and oxygen saturation 1, 4
• Reassess work of breathing and mental status frequently 2, 4
• Monitor fluid intake and output 1
• Perform serial clinical assessments to evaluate response to therapy 4, 3

Laboratory and Diagnostic Considerations

• Complete blood count with differential 1
• Blood cultures for suspected sepsis 1, 8
• Chest radiography for respiratory symptoms 1
• Consider additional testing based on clinical presentation (e.g., lumbar puncture if meningitis suspected) 8, 2

Common Pitfalls and Caveats

• Young infants (<3 months) may present with subtle signs of serious illness; maintain a low threshold for hospitalization 1, 2
• Tachypnea may be the earliest and sometimes only sign of respiratory distress in infants 2, 3
• Children can compensate well until sudden decompensation; close monitoring is essential even if initially stable 4, 7
• Fever may be absent in young infants with serious bacterial infections 8, 2
• Respiratory distress may be a manifestation of non-pulmonary conditions (e.g., metabolic acidosis, cardiac disease) 4, 7