Assessment and recognition of the unwell child
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Introduction and Physiology

The recognition and assessment of the unwell child is an important clinical skill in both general practice and hospital medicine. Children may clinically change much more quickly than adults. Children often compensate well in the earlier stages of an illness, before rapidly deteriorating.

Really well children are obvious – they smile and are playful. Really unwell children are also usually obvious – they are quiet, they might be floppy or unresponsive and may have other signs – like skin mottling, cyanosis, terrible rashes, or obviously abnormal breathing. It’s the children in the middle of this spectrum that are more difficult to assess – and typically the question to be answered is – is this child safe to go home?

It is important to remember that children are not just little adults – they have different physiology:

  • Higher respiratory rate due to increased metabolic demand
  • Horizontal ribs cause more of a reliance on the diaphragm
  • Have a small stroke volume but high heart rate resulting in a relatively higher (then adults) cardiac output
  • Lower systemic vascular resistance
  • Circulating volume is relatively higher than adults but in absolute terms is low
  • Much large relative surface area – resulting in much more rapid heat loss
  • Limited glycogen stores in the liver – higher risk of hypoglycaemia when unwell

Like when assessing any sick patient – start with the basics:

  • ABCDE – airway, breathing, circulation, disability
  • Progress to a more extensive secondary survey including a focussed history

In about 90% of cases of a sick child, the diagnosis can be made on the basis of a thorough assessment at the bedside.

  • In neonates (<28 days old) and infants under 3 months old infection is the most likely cause of an unwell baby. UTI is the most common infection.
  • Fever (>38.0 degrees C) in any child <3 months should prompt hospital assessment and typically empiric IV antibiotics
Crying Baby
This baby is upset but appears to have good skin colour and muscle tone, as well as likely having a strong cry – all (relatively) positive signs! The angry baby might be sick, or starting to get sick – but is not usually critically unwell.

The Initial Assessment

This typically involves the recording and assessment of vital signs, followed by a primary survey that involves ABCDE:

Airway & Breathing

  • Respiratory rate
  • Work of breathing. Signs of increased work of breathing include:
    • Nasal flaring
    • Tracheal tug (skin is “sucked in” around the trachea on inhalation)
    • Subcostal recession (skin “sucked in” below the rib cage on inhalation)
    • Intercostal recession (skin “sucked in” between ribs)
    • Suprasternal recession (skin “sucked in” above clavicle)
  • Stridor or wheeze
  • Foreign body
  • Grunting
  • Hypoxia
  • Auscultate the chest
Intercostal recession in a neonate
An example of intercostal recession – in this example seen in a neonate. This file is taken from wikimedia commons and is licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license.


  • Colour / mottling
  • Heart rate
  • Blood pressure
  • Capillary refil <3 seconds (central – usually assess around the area of the sternum)
  • Heart sounds (e..g murmur)
  • Obtain vascular access if this is indicated. In children receiving CPR, or those with difficult vascular access – d not delay – use the IO route. Typically this is 1-2cm below the tibial tuberosity.


  • GCS
  • Pupillary response
  • Posture (muscles tone – floppy?)
  • Palpate the abdomen

ENT, Extra factors Exposure

  • ENT examination
  • Type of cry – weak or hoarse?
  • Can the child be consoled?
  • Is the child interactive?
  • Eyes – glassy eyed or looking around the rom?
  • Rash, bruising or other skin changes – e.g. mottling, cyanosis, jaundice
  • Temperature
  • Blood glucose level

The secondary survey

This should include a focussed history including:

  • Irritability
  • Lethargy
  • Fever
  • Reduced feeding (<50% of normal volume in the last 24 hours)
  • Vomiting
  • Floppiness / decreased tone
  • Seizure like activity
  • Apnoea
  • Signs of dehydration
    • <4 wet nappies in 24 hours or >12 hours between wet nappies. Sunken fontanelle. Dry mouth or eyes. Sunken eyes.
  • PMHx:
    • Intrauterine history
    • Birth history – prematurity, PROM, GBS, maternal or neonatal resusciaiton

Important differentials

  • Sepsis
    • Temp >38.0 and age <3 months
    • Grunting or tachypnoea >60
    • Pale / mottled
    • Dry mucus membranes
    • Poor urine output
    • Bulging fontanelle
    • Seizures
    • Decreased GCS
  • Bronchiolitis
    • Increased WOB (work of breathing)
    • Reduced fluid intake (and possibly subsequent signs of dehydration)
    • Reduced interaction – due to exhaustion
    • Typically a child <12 months old
    • Preceding viral URTI type symptoms for 2-3 days
  • Cardiovascular casues
    • Cyanosis
    • Loud murmur
    • Chest pain
    • Syncope – especially on exertion
    • Myocarditis
  • GI causes
  • Oncological
  • Other


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Dr Tom Leach

Dr Tom Leach MBChB DCH EMCert(ACEM) FRACGP currently works as a GP and an Emergency Department CMO in Australia. He is also a Clinical Associate Lecturer at the Australian National University, and is studying for a Masters of Sports Medicine at the University of Queensland. After graduating from his medical degree at the University of Manchester in 2011, Tom completed his Foundation Training at Bolton Royal Hospital, before moving to Australia in 2013. He started almostadoctor whilst a third year medical student in 2009. Read full bio

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