Children &

Young People
Acute Care
Pathways
Dr Tim Fooks, GP and Clinical Lead
SEC SCN Children and Young People

UK Mortality Rate

If the UK health system performed as well as that of

Sweden, as many as 1500 children might not die each
year.

Children & Young

People Strategic
Clinical Network

CYP Work
Programme

This Whole
System
approach
applies
across all
CYP areas
with
collaborati
on key

Right place, right time ....?

High Volume
Conditions
Admission Data

Admissions with No LOS for children <5yr

2013/4
2500
2000
1500
CWS
B&H
Crawley

1000
500
Crawley
0

B&H
CWS

In most
CCGs, up to
50% are the
target group

Keeping Sick
Kids Safe
Role of the Clinician

Role of the Clinician for parents

Recognition of serious
illness
Reassurance
Resilience promotion

Accessing Care - Parents with Sick

Children
Factors affecting parents seeking help
from medical services:
Sense of responsibility + fear of failure
Felt or enacted criticism by professional
Failure to be reassured:
Viral explanation seen as sign of medical
uncertainty
Inconsistent approach by Clinicians

The Goldilocks Zone

Acute Care
Pathways

60 Second Practice Survey

>80% response
91% aware of pathways
Usage sometimes
Advice sheets sometimes
82% Pulse sat monitor suitable for
children <5yr

16

GP Quotes
Personally I found them very useful
providing a clear concise and reassuring
checklist
I feel much safer handling bronchiolitis
patients than I have done in the last 25
years

17

e-learning module (HEKSS)

Fever, D&V and Bronchiolitis
Dr Nelly Ninis, Consultant Paediatrician,
St Marys, Paddington.
Expert in diagnosis of
septicaemia
Member of NICE guideline panel
Available NOW at e-LfH

Fever
Acute Care Pathways

Fever

normal part of childhood illness,

~ 70% of preschool children yearly.
~ taken to health professional
Probably important component of immune response
Use of antipyretics is widespread.
reasons for treating fever are contested and not
necessarily evidence based but include minimising
discomfort, controlling the fever, and preventing
febrile convulsions.
May be a component of early serious disease

Fever Literacy and Phobia

Definition of threshold for fever

81%
0%
19%

<38.0C, (100.5F)
between 38.0C and 38.3C,
>38.3C. (101F)

20% children brought to clinic for a chief complaint of fever were

never truly febrile.
93% participants believed that high fever can cause brain damage.
For a comfortable-appearing child with fever,

89% of caregivers would give antipyretics

86% would schedule a clinic visit.

Pre-hospital Recognition of Serious

Illness
Consideration of sepsis associated with
faster onset of treatment
Delay in antimicrobial Rx associated with
hour by hour worsening of outcome
Only 50% of neonatal cases of meningitis
(<3m) present with fever, but do have
other features of serious illness
(poor feeding, lethargy and poor overall state)

Recognition of Meningococcal Disease

448 children and young people ,16yr

103 fatal, 345 non-fatal
Micro confirmation 373 cases

Recognition of Meningococcal Disease

4-6hr - non-specific symptoms
8hr (median time) 72% signs of early sepsis
(leg pains, cold hands and feet, abnormal skin colour)

24hr most close to death

50% admitted after first consultation
19hr median time to hospital admission
13-22hr median onset of classic features
(haemorrhagic rash, meninigism, impaired consciousness)

Parent Advice Sheets

NICE CG 160 Fever key messages

A. Thermometers and the detection of fever
In children aged 4 weeks to 5 years, measure body temperature by
one of the following methods:
1. electronic thermometer in the axilla
2. chemical dot thermometer in the axilla
3. infra-red tympanic thermometer. [2007]
B. Reported parental perception of a fever should be considered
valid and taken seriously by healthcare professionals. [2007]

NICE CG 160 Fever key messages

C. Clinical assessment of the child with fever

Assess children with feverish illness for the presence or absence of

symptoms and signs that can be used to predict the risk of serious illness
using the traffic light system [2013]

Measure and record temperature, heart rate, respiratory rate and capillary
refill time as part of the routine assessment of a child with fever. [2007]

NICE CG 160 Fever key messages

D. Recognise that children with tachycardia are in at least an intermediate-risk
group for serious illness. Use the Advanced Paediatric Life Support (APLS)[1]
criteria below to define tachycardia: [new 2013]
Age
<12 months
1224 months
25 years

Heart rate (bpm)

>160
>150
>140

E. Management by remote assessment

Children with any 'red' features but who are not considered to have an immediately
life-threatening illness should be urgently assessed by a healthcare professional
in a face-to-face setting within 2 hours. [2007]

NICE CG 160 Fever key messages

E. Management by the non-paediatric practitioner
If any 'amber' features are present and no diagnosis has been reached, provide
parents or carers with a 'safety net' or refer to specialist paediatric care for further
assessment. The safety net should be 1 or more of the following:
1. providing the parent or carer with verbal and/or written information on
warning symptoms and how further healthcare can be accessed (see section 1.7.2)
2. arranging further follow-up at a specified time and place
3. liaising with other healthcare professionals, including out-of-hours
providers, to ensure direct access for the child if further assessment is required.
[2007] 013]

NICE CG 160 Fever key messages

F. Management by the paediatric specialist
Perform the following investigations in infants younger than 3
months with fever:
full blood count
blood culture
C-reactive protein
urine testing for urinary tract infection[2]
chest X-ray only if respiratory signs are present
stool culture, if diarrhoea is present. [2013]

NICE CG 160 Fever key messages

G. Antipyretic interventions

Antipyretic agents do not prevent febrile convulsions and

should not be used specifically for this purpose. [2007]
No place for tepid sponging
Do not underdress or overwrap

H. When using paracetamol or ibuprofen in children with fever;

continue only as long as the child appears distressed
consider changing to the other agent if the child's distress is not alleviated
only consider alternating these agents if the distress persists or recurs before
the next dose is due. [new 2013]
do not give both agents simultaneously

Paracetamol or Ibuprofen or Both

Paracetamol or Ibuprofen or both?

4.5
4
3.5
3
2.5
2

ROR

1.5
1
0.5
0

Ibuprofen

Paracetamol

Both I+P

Reporting Odds Ratio - Acute Kidney Injury risk in <12yr

Yue Z1,et al 2014

Paracetamol or Ibuprofen or both?

Safety profiles when used alone similar but underlying health
issues need to be considered
Ibuprofen is more effective than paracetamol
has faster onset of action & lasts longer
relieving fever-associated discomfort,
providing symptom relief
improving general behaviour

Selecting the most suitable antipyretic for the individual child

may help to optimize the chance of treatment success first
time, thereby limiting the need to administer further treatment

Drugs R D. Jun 2014; 14(2): 4555. Published online Jun 12, 2014. doi: 10.1007/s40268-014-0052-x
Approach to the Treatment of Low-Risk Childhood Fever Dipak Kanabar

PMCID: PMC4070461 A Practical

When to use Paracetamol

Children under 3 months
Varicella zoster infection

(NSAIDs linked to increased risk of severe cutaneous complications in VZV

infection)

Known aspirin sensitivity

(2% asthmatic prone to exacerbation with ibuprofen, + another 2% have
drop in spirometry), but in those who are not NSAID sensitive, ibuprofen
reduces risk of asthma exacerbation more than paracetamol)

Pre-existing renal failure ie marked dehydration

Multi-organ failure
Risk of GI bleed

Ibuprofen dose?
30mg/kg in 24 hours in divided doses

3-6 months: 50 mg (2.5 ml) 3 times daily.

6-12 months: 50 mg (2.5 ml) 3 or 4 times daily.
1-4 years:
100 mg (5 ml) 3 times daily.
4-7 years:
150 mg (7.5 ml) 3 times daily.
7-10 years: 200 mg (10 ml) 3 times daily.
10-12 years: 300 mg (15ml) 3 times daily.

Paracetamol dose?
Single dose 1015 mg/kg
4 times daily regimen - max 60mg/kg/24hrs
Suspension (120mg/5ml) daily dose
No. of 5ml tspns in 24 hour period =

wt(kg) x 0.5

Paracetamol or Ibuprofen or Both

The PITCH Study Conclusion
Parents, nurses, pharmacists, and doctors
wanting to use medicines to supplement
physical measures to maximise the time
that children spend without fever should
use ibuprofen first and consider the relative
benefits and risks of using paracetamol
plus ibuprofen over 24 hours.
BMJ 2008;337:a1302

Role of the Clinician

Recognition of serious
illness
Reassurance and
Resilience promotion of
parents and carers
Respond in timely
fashion
Record clinical findings

Diarrhoea &
Vomiting
Acute Care Pathways

NICE CG 84 D&V key messages

Diagnosis
Perform stool microbiological investigations if:
you suspect septicaemia or
there is blood and/or mucus in the stool or
the child is immunocompromised.

NICE CG 84 D&V key messages

Fluid management
In children with gastroenteritis but without clinical
dehydration:
continue breastfeeding and other milk feeds
encourage fluid intake
discourage the drinking of fruit juices and carbonated
drinks, especially in those at increased risk of
dehydration (see 1.2.1.2)
offer oral rehydration salt (ORS) solution as
supplemental fluid to those at increased risk of
dehydration (see 1.2.1.2).

NICE CG 84 D&V key messages

Nutritional management
After rehydration:
give full-strength milk straight away
reintroduce the child's usual solid food
avoid giving fruit juices and carbonated
drinks until the diarrhoea has stopped.

NICE CG 84 D&V key messages

Information and advice for parents and carers
Advise parents, carers and children that[4]:
washing hands with soap (liquid if possible) in warm
running water and careful drying is the most important
factor in preventing the spread of gastroenteritis
hands should be washed after going to the toilet
(children) or changing nappies (parents/carers) and
before preparing, serving or eating food
towels used by infected children should not be shared

NICE CG 84 D&V key messages

Information and advice for parents and carers
children should not attend any school or other
childcare facility while they have diarrhoea or
vomiting caused by gastroenteritis
children should not go back to their school or
other childcare facility until at least 48 hours
after the last episode of diarrhoea or vomiting
children should not swim in swimming pools for
2 weeks after the last episode of diarrhoea.

Bronchiolitis
Acute Care Pathways

SIGN 91 - Diagnosis of Bronchiolitis

Consider in an infant with
nasal discharge
wheezy cough
fine inspiratory crackles and/or
high pitched expiratory wheeze
apnoea may be a presenting feature

Seasonality

Significant Co-Morbidities

Prematurity (<35 weeks)

Congenital Heart Disease
Chronic Lung Disease of Prematurity
Parental Smoking
(Social Deprivation)

Protective factor Breast feeding

Treatment options

Antivirals not recommended

Antibiotics not recommended
Beta-2 agonists not recommended
Anti-cholingerics not recommended
Nebulised ephedrine not recommended
Inhaled corticosteroids not recommended
Oral corticosteroids not recommended
LTRA - not recommended
Chest physio not recommended (unless on PICU)
NG suction, Oxygen therapy, Ventilation should be
considered

Head Injury
Acute Care Pathways

NICE CG 16 Head Injury

Take head injuries seriously, says NICE
1.4 million people attend A&E in England and Wales each
year with a recent head injury. Up to 700,000 of them will
be children under the age of 15.
Head injury is the most common cause of death and
disability in people up to the age of 40.
Early detection and prompt treatment is vital to save lives
and minimise risk of disability, says updated guidance
from the National Institute for Health and Care Excellence
(NICE).

PAEDIATRIC HEAD INJURIES

Dr Helen Milne
Emergency Medicine Consultant
Worthing Hospital

Head injury data 2011

Head Injury
Presentations

Total Paeds
Attendances

% Total ED
Attendances

% Paeds
ED Attendances

Worthing

2157
<16 years

16,033
<19 years

23%

10-15%

SRH

1703

~14,930

~25%

~11-12%

Age of patients

Outcome

Data Review
< 5 years

Admissions

CT

Abnormal
CT

Neurosurgical

Worthing

56.5%

4.5%

0.8%

0.2%

?1 patient

SRH

55.7%

8.1%

1.5%

0.2%

1 patient

CHALICE
(22,772)

56%

6.4%

3.3%

1.2%

0.6%

Key Points
Most head injuries seen in the ED

Could be managed with observation at home

Few need admitted

Rare to need a CT scan

Even more rare to need neurosurgery

Likelihood of brain injury increased by

LOC

Mechanism of injury

GCS

Childrens brain injuries

Most non surgical treatment

CT scan radiation

100-200 chest x-rays

NICE CG 176: Head Injury when to go to hospital

As soon after event as possible [1]

Unconsciousness or lack of full consciousness, even if
the person has now recovered.
Any clear fluid running from the ears or nose.
Bleeding from one or both ears.
Bruising behind one or both ears.
Any signs of skull damage or a penetrating head injury.
The injury was caused by a forceful blow to the head at
speed (for example, a pedestrian hit by a car, a car or
bicycle crash, a diving accident, a fall of 1 metre or
more, or a fall down more than 5 stairs).

NICE CG 176: Head Injury when to go to hospital

As soon after event as possible [2]

The person has had previous brain surgery.
The person has had previous problems with
uncontrollable bleeding or a blood clotting disorder, or is
taking a drug that may cause bleeding problems (for
example, warfarin).
The person is intoxicated by drugs or alcohol.
There are safeguarding concerns, for example about
possible non-accidental injury or because a vulnerable
person is affected

NICE CG 176: Head Injury When to go to hospital

If any of the following develop subsequently

Problems understanding, speaking, reading or writing.
Loss of feeling in part of the body or problems with balancing or
walking.
General weakness.
Changes in eyesight.
A seizure (also known as a convulsion or fit).
Problems with memory of events before or after the injury.
A headache that won't go away.
Any vomiting.
Irritability or altered behaviour such as being easily distracted, not
themselves, no concentration, or no interest in things around them.
This is particularly important in babies and children under 5.

Acute Asthma
Acute Care Pathways

National Review of Asthma Deaths

Confidential Enquiry reported 2014
Review of all deaths from Feb 2012 to January
2013 where asthma was listed in part 1 or 2 of the
death certificate
3544 death certificates reviewed, 2644 excluded as
either over 75 or asthma not thought to be cause of
death
900 deaths included
After data review 195 deaths thought to be from
asthma
80 male, 115 female

Paediatric data
40 (of 195) children identified
12 cases no data returned therefore only 28
paediatric deaths reviewed

28 under 19 years
10 under 10 years
18 aged 10 19 years

12 though to have mild / moderate asthma

4 had PAAP (Personal Asthma Action Plan)
Most died before reaching hospital
4 known to social services

Key recommendations all ages

All patients prescribed more than 12 short acting reliever
inhalers in previous 12 months must be reviewed urgently
Assessment of inhaler technique should be done at every
asthma review. This should be checked by the pharmacist
for any new device
Use of combination inhalers is encouraged
Monitor adherence
Electronic surveillance of prescribing should be introduced
as a matter or urgency
Document smoking / smoke exposure, and
refer current smokers or carers to smoking cessation
service

Red flags
Excessive beta agonist use
Poor adherence to preventer treatment
Long acting beta agonist (LABA) as
monotherapy
Lack of PAAP
Poor perception of worsening symptoms

Key recommendation - children

Parents and children, and those who care for or teach
them, should be educated about managing asthma.

To include
how, why and when to use asthma medications,
recognising when asthma is not controlled
knowing when and how to seek emergency advice

Emphasise minimising exposure to allergens and

second hand smoke, especially in young people with
asthma

Personal Asthma Action Plan

Other Resources

e-LfH Learning Module

Spotting the Sick Child

Short Film for parents and carers