General
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Fever | • Hot and unwell | • Depends on cause (must be sought and found) | • Exclude serious cause | • Care at home, refer for further investigations if cause cannot be identified and child significantly unwell or serious cause cannot be excluded |
• Miserable | • Symptomatic treatment |
• May be off food/fluids | • Cause must be sought (including urine culture if no other cause found) |
| • Do not give antibiotics if cause unknown |
Vomiting | • Frequency ? blood | • Rule out: | • Exclude abdominal or other serious pathology | • Care at home unless very unwell/dehydrated or significant pathology cannot be excluded |
• ?tolerating clear fluids • ?bile stained | ○ dehydration ○ other sign of infection ○ Surgical pathology | • If tolerating clear fluids, encourage clear fluids till improving then solid diet |
| | • Do not give antiemetics |
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Diarrhoea | • Need description ?blood ?slime ?watery ?amount ? smell | • Rule out: ○ abdominal abnormalities ○ signs of dehydration | • Encourage clear/electrolyte replacement fluids to re-hydrate only | • Care at home unless very unwell/dehydrated or history of bloody diarrhoea, or significant pathology cannot be excluded |
• May be vomiting or anorexic | ○ other signs of infection | • Exclude occult infection and dehydration |
| | • Exclude other abdominal pathology |
| | • Continue breastfeeding throughout. Recommence solids and formula feeds after re-hydrating |
| • Mild fever | • Avoid foods high in fat or simple sugars |
| | • Do not give antidiarrhoeal agents |
Respiratory
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Upper respiratory tract infection | • Cough | • Inflamed throat | • Symptomatic treatment | • Care at home |
• “Cold” | • Otitis media | • No antibiotics |
• Sore throat | • Coryza, | • Review if fluid intake poor |
• Snuffly | • Chest clear | |
• Hot and miserable | • Fever | |
• May be off food | | |
Croup (mild) | • Barking cough | • Barking cough | • Nebulised budesonide or oral dexamethasone | • Care at home unless systemically unwell or deteriorating |
• Noisy breathing | • May have mild stridor |
• May be worse at night | • Child not distressed |
| • Mild fever possible |
Asthma (mild) | • Wheeze • Cough | • Bilateral wheeze • Good air entry | • Adjustment of dose of bronchodilator | • Care at home unless no response to treatment, deteriorating, or history of previous ITU admission |
• May be URTI | • May be tachypnoeic • Child not distressed | • Check technique of administration using spacer |
| | • Oral (soluble) prednisolone |
Bronchiolitis (mild) | • URT symptoms followed by lower respiratory symptoms | • Not distressed | • Symptomatic treatment | • Care at home; consider need for follow up visit and encourage recall if condition deteriorates (especially reluctance to feed or breathing difficulty). Very low threshold for admission in babies under 2 months old |
• Mild tachypnoea |
• Mild fever possible |
• Bilateral inspiratory fine crackles and wheeze |
ENT/eyes
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Conjunctivitis | • Sore gritty eyes • Normal visual acuity | • Mildly inflamed conjunctiva, often bilaterally | • Regular cleaning with cooled boiled water | • Care at home |
| • Sometimes purulent discharge | • Antibiotic eye drops |
Foreign body | • History of witnessed insertion of object in nose, ear | • Foreign body visible • Stridor • Wheeze | • May be possible to remove—if not refer to appropriate specialist | • Care at home if object removed, otherwise refer to A&E |
• “Missing” object | • Unequal air entry | • Do not attempt to remove blindly if lodged in pharynx |
• Sudden respiratory distress | | |
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Tonsillitis | • Sore throat • Systemically unwell • Sore neck • Difficulty swallowing | • Swollen inflamed tonsils • Exudate • Lymphadenopathy • Fever | • Mild—symptomatic treatment, otherwise penicillin (unless allergic when use suitable alternative) for 10 days and symptomatic treatment | • Care at home with advice to recall if swallowing becomes impossible or airway becomes noisy |
Teething | • Miserable | • Teeth erupting | • Symptomatic treatment | • Care at home |
Otitis media | • Miserable | • Inflamed ear drum +/− perforation | • Symptomatic treatment • Consider antibiotics if | • Care at home • If eardrum perforated, refer |
• Fever possible | very severe or if eardrum is perforated | to GP for review and keep ear dry |
Skin and viral rashes
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Chicken pox (uncomplicated—see fig 2) | • Mild URTI symptoms • Rash | • Blistering rash in crops, most severe on trunk | • Symptomatic treatment | • Care at home |
| • Mild fever |
Scabies | • Itchy rash | • Itchy papules, may be more generalised than in adults, with some “tracks” | • Non-urgent referral to GP | • Care at home and non-urgent referral to GP |
Impetigo | • Crusting rash | • Yellow/golden crusting spreading rash | • Systemic antibiotics unless very tiny lesion when topical antibiotics may be tried | • Care at home |
• May occasionally be systemically unwell | • Advise on reducing spread to other family members |
• May be painful especially if secondary infection | |
Mumps (uncomplicated) | • Swollen neck | • Parotid swelling | • Symptomatic treatment | • Care at home |
• Difficulty opening mouth and swallowing | • Loss of palpable angle of mandible |
• Mild fever/malaise | |
Rubella (see fig 5) | • Fine pink rash | • Fine macular rash | • Symptomatic treatment | • Care at home |
• May be very slightly unwell | • Posterior cervical lymphadenopathy | • Check no contact with pregnant adult is likely |
| • Minimal systemic upset | |
Roseola infantum | • High fever which settles when rash comes out | • Discrete rash that may coalesce | • Symptomatic treatment | • Care at home |
• May be oedema of eyelids |
• Fever |
Measles (uncomplicated—see fig 6) | • Upper respiratory symptoms | • Unwell child | • Symptomatic treatment | • Care at home |
• Rash | • Kopliks spots early in illness | • Notifiable disease |
| • Typical rash | |
| • Upper respiratory tract signs | |
| • No sign of complications (for example, pneumonia) | |
Neurology
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Increase in seizures | • In child known to have seizures | • Infection or any obvious cause | • Look for infection | • Refer to GP if not currently seizing and otherwise well; refer to A&E if currently seizing or seizures very frequent (see article 5 on primary survey positive children) |
• Recent change in medication dose; not taking medication or malabsorbing (for example, GI upset) |
Head injury (mild) | • No symptoms | • May be bruising | • Rule out significant mechanism of injury | • Care at home in the absence of history of loss of consciousness and significant symptoms; advise recall if symptoms present. |
• If no loss of consciousness, persistent vomiting, unusual drowsiness, or visual disturbance since injury, advise that treatment should be sought if these symptoms present | • Provide written head injury instructions |
Headache | • Ask for type, when it occurs in day, associated features | • Exclude serious infection | • Look for signs of raised intra-cranial pressure and meningitis | • If child well with no signs of meningitis, provide symptomatic treatment and refer to GP |
• Past history investigations | • Arrange urgent review if unwell or condition worsens |
Febrile convulsions | • Fever, child known to have febrile convulsions | • Fever • Infection • Usual age range approx. 6 months to 6 years | • Locate source of infection and treat, referring to hospital if serious cause found or if no cause found • Check blood sugar | • Care at home for simple febrile convulsions, provided |
○ This is not the first fit |
○ It is a simple convulsion |
○ The cause of the fever has been identified and is benign |
○ No more than one fit in a 24 hour period |
○ The parents are confident about caring for the child |
Abdomen
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Abdominal pain (colicky) | • May be irritable | • Rule out surgical problem abnormalities • Look for associated features | • Exclude appendicitis, obstruction. or other pathology | • If child is completely well, refer to GP. If child is unwell or parents are concerned, refer urgently to GP or hospital |
(see above) | • Symptomatic treatment |
Dysuria | • Complaining of pain when passing urine | • Balanitis possible | • Mild balanitis can be treated with salt baths | • Care at home; refer for further investigations if no cause found |
• Rule out renal tenderness | • If balanitis is severe will require antibiotics |
• Check otherwise well or minimum systemic upset | • If no balanitis check urine culture and treat for urinary tract infection till results of culture available |