Intuition and the ill infant

Nowhere in medicine is the use of observation, instinct, and innate experience more important than in attempting to make a clinical diagnosis in an acutely ill infant. I like to refer to this as veterinary paediatrics, as sick animals and sick children share many attributes they refuse to eat; they lie down when they are sick; their language and communication skills are limited; they depend on others to sort out their problems; and when ill they prefer to be left alone.

Sir William Osler said, There is no more difficult art to acquire than the art of observation. This is well captured in the illustration of the sick child, a painting which used to hang on the wall of many doctors’ surgeries (fig 1). It shows the doctor carefully observing an ill child placed across the chairs in a poor household. His posture is pensive, his look inquiring, but the child’s position and that of the parents tell the viewer that the child is critically ill.

I like to quote to my students the saying of Auguste Bier (1861-1949): "A smart mother makes often a better diagnosis than a poor doctor." In reality, of course, any mother is likely to make a better diagnosis than a "poor" doctor. About 70 to 80% of paediatric diagnoses are basedlargely on history. It is essential that students ask the mother what her worries are. Figure 2 displays the fundamental problem the child or young infant being limited in his or her clinical vocabulary and yet needing to communicate to the mother or the attending doctor. Fortunately, most mothers are excellent barometers of their children’s wellbeing and are good communicators of their problems if doctors are attuned to listen.

It is important to look carefully

Look at the infant in figure 3. Is the infant sick or well? What can you learn simply by looking? You can see a well fed, pale, sleeping infant in the mother’s lap. Bellini’s portrayal of the infant Jesus shows eyes that are a little sunken. It is difficult to comment on hydration, and there is no rash. Such signs in your own patient might suggest that the infant is anaemic, perhaps dehydrated but well nourished, and needs further assessment. An example of a typical ill child is shown in figure 4 painted by Henry Jules Jean. It shows the greyness or muddiness which is typical if the ill child.

An observation unit is beneficial

We have in our children’s hospital anobservation ward in the accident and emergency department. Here our students and residents can allow children to be observed for several hours while attempting to make a decision about whether the child needs to be admitted or can be safely sent home. It is undeniably the most important ward in the hospital. The usefulness of a short stay observation unit in a hospital emergency department has been recently attested by a group from Bordeaux. ¹

The history should give important clues. Observation will add some further cues or pointers towards where we should look next. Is this an acute infection? Is the child septic? Could he or she have a major metabolic crisis? Is there any suggestion of neurological insult? The questions for any doctor attending an acutely ill infant are:
(1) How do I detect the early signs of serious impending illness?
(2) How do I decide who, what, when to refer to hospital?
(3) How do I ensure not to miss acute severe illness?

It is little short of disastrous for any doctor to see a child one day and to learn the next day that the infant died of a sudden unexpected infant death or of an overwhelming septicaemia in the subsequent 24 hours. Undoubtedly when this occurs many such infants will have had few or no alerting symptoms or signs. However, allowing ourselves more time to look, listen, and accumulate information can only improve our diagnostic acumen. A good instinct, innate suspicion, and deliberation will serve us all well. Boxes 1 and 2 list some of the mechanisms by which acute illness is signalled. A recent paper has proposed the ILL criteria for recognising significant bacterial sepsis in infants ILL being an anagram for irritability, lethargy, low capillary refill. ²

Experience and instinct will help

There are many rapid assessment schemes in paediatrics which attempt to give a score for the doctor to decide the degree of sickness. The Baby Check Score System was proposed by a Cambridge group in 1991. ^3-5 It consisted of 19 checks (seven symptom questions and 12 examination signs) each carrying a score. The higher the total score, the sicker the baby. It was evaluated in hospital, general practice, and by mothers. The authors concluded that the Baby Check Score should improve the detection of serious illness in infants and reduce the number admitted with minor illness. Others subscribe to subjective sickness scores, whereby you attempt to decide if a child is critically ill, seriously ill, mod-erately ill, or not too ill. Experience and instinct will make a major input to this decision.

Here are some vitals from a 10 week old infant who arrived at our hospital on a recent Friday morning. Pulse: 210 beats a minute; central temperature: 40 degres C; toe temperature: 30 degrees C; systolic blood pressure: 40 mmHg; capillary refill time: 8 seconds; respiratory rate: 70 a minute.

Clearly this infant is critically ill and requires immediate resuscitation with diagnosis taking secondary importance.The critically ill infant has mottled skin, a muddy or grey appearance, is centrally warm and peripherally cold, and usually lies quiet and immobile. I like the description of the ill child written in 1850 by Maunsell: "The child when ill is more or less peevish" dislikes being stirred or even cries when being handled; its hour of sleep is uncertain and rests ill or wakes startled and crying." This is a very nice description of alternating drowsiness and irritability"perhaps sepsis, perhaps meningitis. Scientifically this infant is shocked, shut down, and desaturated. Clinically still and silent, cold and cyanosed. The observations listed in table 1 may be alerting.

It can be surprisingly difficult to reach a rapid clinical diagnosis in an acutely ill infant. Intussusception, for example, may present as a pale, shocked, irritable infant. Galactosaemia may manifest as an apparent septic shock. Peritonitis or appendicitis are notoriously difficult diagnoses in infancy. Shaken baby syndrome may present with a convulsion or with respiratory difficulty. Table 2 lists some of the acute emergencies in infancy, all requiring rapid diagnosis and management.

Conclusion

Students should sit in the resuscitation room and observe events, especially ill infants. Stand beside intensive care unit incubators and look at sick infants. Linger in the observation ward looking and listening. Many centuries ago Leonardo Da Vinci advised "learn to see." Do so. Looking at infants breathing is by far themost instructive skill in assessing respiratory or cardiac problems. Rapid laboured breathing with grunting is almost synony-mous with pneumonia or cardiac failure. Ultimately, the good clinician is the good diagnostician. Intuition means immediate apprehension by the mind without reasoning. Immediate insight and instinct may instil innate impulsion. I’ve got a good nose for trouble, is how one general practitioner friend sums up this attribute. More likely he possesses good eyes and sharp wits.

1. Lamireau T, Llanas B, Fayon M. A short stay observation unit improves care in the paediatric emergency care setting. Arch Dis Child 2000;83:271.
2. Brogan PA, Raffles A. The management of fever and petechiae: making sense of rash decisions. Arch Dis Child 2000;83:506-7.
3. Thornton AJ, Morley CJ, Cole TJ, Green SJ, Walker KA, Rennie JM. Field trials of the Baby Check Score card in hsopital. Arch Dis Child 1991; 66:115-20.
4. Morley CJ, Thornton AJ, Green SJ, Cole TJ. Field trials of the Baby Check Score in general practice. Arch Dis Child 1991;66:111-4.
5. Thornton AJ, Morley CJ, Green SJ, Cole TJ, Walker KA, Bonnett JM. Field trials of the Baby Check Score card: mothers scoring their babies at home. Arch Dis Child 1991;66:106-10.