THE CHILD THAT NEEDS A DOCTOR
When should you take your child to see your doctor? When is your child sick enough to warrant a trip to the doctor’s office? This is a dilemma facing parents frequently in the current medical ambience of long waits, limited consultations allowed by medical aids, the high price of medications, and the difficulty in affording or being able to see a paediatrician. Parents often have to rationalize these obstacles in the face of a child that may, or may not, be ill enough to warrant a doctor’s consideration of a sick little person.
Parents will often initiate a consultation with an apology to the doctor. They apologize for being there, for taking up the doctor’s time when he is "so busy", for initiating therapy with medications which they obtained from a pharmacist or had left over from the last paediatric adventure. Why the apology I ask? You should take your child to see a doctor when you start to worry. When your child does not respond to a medication, does not follow the disease pattern which you expect, presents with an unexpected symptom, or when you start to worry for any reason at all, then you should take your child to see your doctor, even if it is only for re-assurance. It is difficult to list all of the features that may make you consider a consultation, but what follows is a cooks’ tour of symptoms which should make you consider getting an expert opinion.
Common airway problems that should make one worry may include a child with noisy respiration, that is to say that when air moves in and out of a child’s airway a noise is produced on breathing in and / or breathing out. This could mean the child has a wheeze as in an asthmatic child, or possibly croup which is a viral infection of the airway. A whooping noise may indicate whooping cough, and a foreign body lodged in an airway might cause a noise with breathing or respiratory difficulties. These conditions require a doctor’s intervention, and might be life threatening if left unattended. Excessive mucous production in the nose and chest are also worrisome. If the mucous is clear the cause is probably an allergy or even a virus, but green or rust coloured mucous may need an antibiotic.
Breathing disorders may be reflected in a child with a faster than normal rate of breathing (tachypnoea), a blue colour around the mouth or face (cyanosis), shallow breathing that may also be fast or an altered level of consciousness (where the child is listless, ‘goofy’ or unconscious). Any of these symptoms require immediate medical intervention. Don’t even consider NOT taking a child with these symptoms to a doctor – this child needs help fast. Mortality or death in children occurs mostly due to respiratory (airway and breathing) pathology, often when the above symptoms are ignored. Little people have a very limited capacity to adjust to an airway threat, so where an airway problem exists rather get an expert opinion.
Circulatory disorders might be seen in the cold or clammy child, the child with cold hands and feet, the child with a high fever, a rapid pulse rate (a fast heart rate, often with a faint or "thready" pulse) or the dehydrated child. An altered level of consciousness, as in a listless or unconscious child is certainly cause for concern. Any of these features indicate that a serous insult is being imposed on the child’s’ defence mechanisms and requires a professional opinion.
A child with a rash, especially in the presence of a fever needs assessment. Measles, chicken pox, meningitis and allergies may all present with a rash, with or without a fever. All of these conditions still cause many child deaths in any part of the globe. If you don’t know what the rash is, get a professional opinion.
A list of failures which are cause for concern and may require a medical opinion would include the following:
A failure of a child to respond to an antibiotic might mean that the child has an atypical infection such as tuberculosis, or a drug resistant infection. Bacteria which are resistant to antibiotics are becoming more prevalent and the so-called "superbugs" which respond only to the strongest intravenous antibiotics are a very real problem in many developed countries. Concurrent use of more than one antibiotic ("combination therapy") is becoming a much more accepted practice in the fight against drug resistant bacteria.
A failure of the child to perform adequately at school in comparison to his peers is a common problem. The causes which might result in this presentation are numerous, and range from a middle ear infection, through attention deficit disorders, to asthma which is not being adequately treated and results in a nocturnal cough which precludes a quality sleep and equates to a constantly tired child. A thorough physical examination of the child that fails to perform as expected is mandatory.
A child that fails to respond to verbal commands when not watching your lips may mean that the child cannot hear you, due to an accumulation of pus in the middle ear, such as in a middle ear infection. So when you are standing behind your child who might be watching television, and the child fails to respond repeatedly to your voice, ask your doctor to check for a middle ear infection or to do a tympanogram. Chronic, longstanding ear infections are readily treated with various antibiotics sometimes, nasal sprays often, and when these fail, and then grommets may be required.
The child that fails to sleep well, and wakes up with a cough in the early morning hours might suffer from asthma. If the child also develops a cough with exercise, or wheezes with exercise, or fails to perform physically in sporting activities, then asthma must be considered. There is absolutely no reason why a child with asthma should not lead a normal, productive and physically active life given the treatment options available to the doctor in the treatment of asthma today. The child who fails to thrive, that is to say doesn’t put on weight or grow as expected may suffer from a medical problem. The problems may range from tuberculosis or some other infectious disease, to malnutrition or gastrointestinal absorption problems or parasites, to heart disorders or metabolic problems such as diabetes. The important criteria in the child that does not thrive is to have a complete physical examination which includes the testing of the child’s urine, glucose, a possible laboratory examination of the stool and even a chest X-ray may be appropriate.
Diarrhoea which is persistent or excessive and vomiting which is persistent are also worrying. In the newborn, this could represent an anatomical problem, and in older children might mean a gastro-intestinal infection, a metabolic disorder, an absorption problem or intolerance to certain food types. A medical opinion is certainly warranted in cases where the parent is experiencing any worry as to the child’s’ intestinal habits.
Falls from a height which result in excessive swelling to any part of the body or head, an altered conscious state or loss of consciousness, or the refusal of the child to use a limb or part of a limb require medical investigation. Lacerations which penetrate deeper than the skin thickness and bites from animals or other children require an expert opinion may require suturing or an alternative such as the newer "glues" available today, and an opinion as to the necessity of tetanus prophylaxis.
Burns are always scary in kids. As a rule of thumb, burns to the face, genitals, circumferential burns to limbs and torso and hand burns require the assessment of a doctor. It is often very beneficial and therapeutic to the burn victim to cover the burned area with Burnshield or an equivalent product as soon as possible after the accident. One of these products should be in every first aid box in every home. To plunge a burned hand or foot into an opened packet of Burnshield relieves pain very effectively, and reduces the amount of tissue damage sustained by the affected organ. Lacerations, bites and burns often go septic. A septic area is characterized by eat, swelling and an expanding area of redness or inflammation, and generally requires an antibiotic, which only a doctor can prescribe.
On the subject of antibiotics, I have a few opinions. Here they are. Antibiotics are often over prescribed by doctors because parents feel that a child needs one, when in fact, the child may not. An antibiotic script is often the purchase acquired in the price of a consultation. Antibiotics are specific to certain pathologies or sites of infection, so to phone your doctor for an antibiotic script is inappropriate and irresponsible. Rather let the doctor assess the child, and then prescribe an antibiotic if appropriate. Antibiotics do not work for viral infections or for allergies, and both of these conditions could present in a manner similar to a bacterial infection, where an appropriate antibiotic is very beneficial. In order to differentiate between these three conditions, a doctor must clinically assess the child in a clinical examination.
The little people have a much smaller ability to adapt to illness in comparison to those of us who are bigger. Bigger people can absorb a bigger physiological insult to their systems before they start to crash. Children crash fast. If you are concerned about a problem your child has, then seek medical advice rather than wait. If your child has a high fever, suddenly deteriorates, or is sick for longer than seven consecutive days then rather seek a medical opinion.
The little people may have little problems, which may become big problems in a very short space of time. Don’t be a little parent, with a little concern, for a little problem, which worries you a little. If you are worried, then listen to your instincts and get a medical opinion.
Dr A.G.R. Carlston B.Sc(Hons)(Wits) MBBCh (Wits) Cresta HEALth-WorX
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