Chapter 41. Health problems in early childhood
Arija Nikola Parker
LEARNING OUTCOMES
• Identify the health problems that may specifically affect the early childhood period.
• Link the problems to the preschool developmental stage of childhood.
• Utilise the brief discussions to expand and develop knowledge and understanding in relation to children’s nursing practice.
• Acquire a basic understanding of how the Activities of Living (Roper et al 1996) apply to children’s nursing practice.
Introduction
This chapter will address the health problems specifically related to preschool children, with the obvious exclusion of issues covered directly in other chapters. Each section, structured by a heading relating to Activities of Living (Box 41.1), will detail the developmental and physiological aspects that relate specifically to the preschool child. This is followed by a brief description of the health-related problem, its management and the implications for the healthcare professional, most usually a practice nurse, children’s nurse, health visitor or community children’s nurse. These implications relate particularly to the nurse’s role in offering parental advice and education, ensuring that this chapter has a health promotion/education focus. The broad range of topics covered means that detailed information will have to be gained by reading the more specifically focused chapters, utilising the companion PowerPoint presentation and consulting the related websites and further reading references evident at the end of the chapter.
Powerpoint
PowerpointThe companion PowerPoint presentation contains supplementary information and answers to questions posed within this chapter.
Box 41.1 Activities of living (from Roper et al 1996)
• Maintaining a safe environment
• Communicating
• Controlling body temperature
• Breathing
• Eating and drinking
• Personal cleansing and dressing
• Mobilising
• Working and playing
• Expressing sexuality
• Sleeping
• Dying.
The overall aim is to take a tour around the child and family’s daily life, identifying where health problems may occur that will bring them into contact with healthcare professionals and, more particularly, children’s nurses and/or health visitors. In light of the need for a holistic approach to subject coverage and a felt requirement for this chapter to have a structure, the Roper–Logan–Tierney model of Activities of Daily Living (1996) will be used as subheadings to ensure subject coverage. Although this model is not utilised exclusively in the children’s nursing world, its influence is evident in any piece of nursing documentation used in paediatric clinical areas. It is generally integrated into a framework to support the philosophy of family-centred care widely cited and utilised in the practice of children’s nursing.
The model uses a framework of 12 activities (Box 41.1) of living used within the context of the biological, psychological, sociocultural, environmental and politico-economic factors that will impinge and affect an individual’s life in society today. The model of living incorporates the idea of lifespan from birth to death, however short or long an individual’s life may be. The children’s nurse is thus usually involved in her client’s care for only one stage of a person’s lifespan and has a significant role in assisting child and family to reach adulthood by optimising health potential. The idea of a dependence/independence continuum, which is another element of the model, transfers readily to a children’s health and social care setting, although the process of gaining independence is not motivated by the notion of being healthy or being ill but via the process of a developing child making the first steps to doing things on his or her own and gaining independence in activities of living. In the same way as with an adult patient, illness will scupper the drive for independence temporarily, where in a child’s case re-learning skills barely learned should be achieved with relative ease. Thus the preschooler’s dependence on parents/carers fluctuates as he or she starts learning to perform the activity of living tasks alone, although dependence on parents is high because of the need for constant supervision.
Reflect on your practice
Reflect on your practice• Are nursing models used in the clinical areas in which you have clinical experience?
• If so, which models are used?
• Do they improve the quality of care children and families receive?
From the perspective of the children’s nurse caring for a sick child during a period of illness, regression in skill acquisition may occur, which will cause great frustration to a child who is gaining independence, and confusion may arise in relation to a child’s developing independence if, for example, a nurse may take on the caring role without understanding the roles the child is developing, i.e. dressing a child who usually, with minimal assistance, would work through getting dressed in the morning. Insight into the child’s developmental stage and an appreciation of the family dynamics gained via questions triggered by such a model give the nurse valuable information regarding her client to then individualise care via the use of the nursing process (Roper et al 1996).
Maintaining a safe environment
The preschool period of development is a time when a child has the opportunity to explore a world, which expands by the minute, hour and day as mobility increases and as, with growth in height and the ability to climb, different objects become more visible and new targets are more readily achievable. The need to climb higher, explore in greater detail and play more exciting games is a necessary stage in learning and developing limits and boundaries in relation to preventing harm and accidents during later years, although at this stage it means little to the person directly involved, namely the child him- or herself. It is the adult who has the responsibility of averting a potential accident seemingly at every minute of the day. This responsibility can be overwhelming and, even with the best intentions and correct interventions, accidents still happen.
The acceleration of gross motor skill acquisition means that a toddler at 20 months of age is throwing and kicking a ball quite effectively, although the direction and purpose of the act itself may be inconsistent. They climb with no fear of falling. At 2 to 3 years they are jumping, running and riding a tricycle with no problems and their abilities, from a fine motor and gross motor skills perspective, are developing at speed. At this time, cognitive abilities mean that, in Piagetian terms, the child is egocentric, i.e. unable to separate his or her own perspective from others: ‘You see what I see, you think what I think’, which will affect the child’s perceptual and communication behaviour (Bukatko & Daehlar 2004). Thus, the ability to predict what might happen as a result of his or her actions is limited. Using Piaget’s theoretical terms, during the preoperational (or intuitive) period, language is developing, although intelligence is evident before starting to utilise words, as is evident by observing the way children act and behave in their environment. However, although children can link words together by the age of 2 it is clear that they cannot reason or make sense of the world in a logical way (Sylva & Lunt 1982).
When environmental factors, such as the houses we live in, the toys children play with and the areas children play in – all key components to modern living – are taken into account, it is not surprising that, even with the most safety-conscious and aware parents, accidents happen. In addition, inadequate adult supervision, the influence of stress and the size of the child are factors that contribute to an increased risk of accidents taking place.
These factors account for the fact that 500,000 children under the age of 5 attended A&E departments in 1999, and that in this year 90 children died as a result of accidents in the home in England and Wales. Although perceived as a place of safety, the home actually provides the necessary combination of obstacles and risks to ensure that the 0–4 age group is at a high risk of falls, strikings (i.e. bumping into static objects or being the victim of being hit by moving objects), burns, foreign bodies in eye or other orifices, and so on. The vast majority of these will be dealt with in the A&E department, as minor injuries, with no need for follow-up (Department of Trade and Industry (DTI) 2001). However, this is not to devalue the implications on child health and the important role of nurses in preventing such accidents. Thus the role of health visitors, children’s nurses in health education and health promotion are key to preventing the health problems that may result due to accidents. According to information from the Royal Society for the Prevention of Accidents (ROSPA), in conjunction with the above statistics, falls account for the majority of non-fatal accidents and the highest numbers of deaths are due to fire. ROSPA argues that most accidents are preventable through increased awareness, improvements in the home environment and greater product safety. The nursing care of children who have sustained injuries as a result of accidents is discussed in the related chapters. What follows are additional statistics and recommendations with regard to the nursing role as a health educator/promoter in some very specific areas related to the preschool child.
www
Reflect on your practice
wwwThe Royal Society for the Prevention of Accident’s website contains fact sheets including one dealing with child safety in the home:
Other links which may be useful include the following:
Health Development Agency (2003) ‘Prevention and reduction of accidental injury in children and older people – evidence briefing’, which can be accessed at:
Reflect on your practiceOn the link to the ROSPA child safety pages you can access the European Child Safety Alliance (2009), Child Safety Report Card Scotland accessed at:
This identifies that children and young people from more deprived families of being at higher risk of injury and death from unintentional injury.
Why should this be so?
Accidental poisoning
In the years 2006/07 the National Poisons Information Service (NPIS) received around 500,000 poisons-related enquires. Of these enquiries 35% related to children under 10 years of age and of these 88% related to the under-5 age group (HPA 2007). Cases involve intentional overdose in adults and adolescents, and accidental ingestion in children, which accounts for about 7% of all accidents (Pickford 2000). The most commonly implicated drugs are iron, methadone and tricyclic antidepressants, although, realistically, anything can be accidentally ingested by a child.
Management of the child
The management will depend on the amount of drug ingested and how long it takes the child and parent to seek medical assistance. The care is based on advice offered by the NPIS. If attending A&E, the parents should take the container, packaging or part of plant/fungi with them and have an idea of time it was ingested. In the case of herbicidal poisoning it is important that the brand name as well as manufacturer’s name is known so that the active ingredient and solvents can be identified by the poisons centre (Northall & Cullen 1999).
PowerPoint
PowerPointAccess the companion PowerPoint presentation and read the advice offered to parents with regard to preventing accidental ingestion in pre-school age children.
Implications for the healthcare professional
Many strategies can be employed to prevent the accidental ingestion of many substances, which include controlling the child’s access to poisons, making the environment safer and/or changing the child’s behaviour (Pickford 2000). The main reasons for accidental ingestion are inappropriate storage of medicines, lack of safety awareness and insufficient supervision of children. Liquid preparations, purposely formulated to make them more palatable for children, add to the probability that, when children get access to these medicines, they are more likely to consume large amounts. For example, iron and vitamin preparations generally look attractive and taste good as well. Thus the health message involves ensuring safety of medicines within the home are out of reach and out of sight in child-resistant containers. Any chemicals, i.e. cleaning fluids like bleach, should be stored in their original containers and be out of reach and any unwanted medicines and chemicals should be disposed of accordingly.
Part of the developmental aspect of care involves educating the child with regards to encouraging them not to put things like berries in their mouths, in terms they will understand, as well as encouraging parents not to buy plants with poisonous leaves or berries or those that irritate skin. Toddlers put anything and everything in their mouths, so home safety is of prime importance.
In most localities in England, children presenting in A&E with accidental ingestion are followed up by their health visitor to prevent re-occurrence via a system of post-accident support visits (Cernik 1999a).
Reflect on your practice
Reflect on your practiceJenny, aged 3, has been admitted to the ward having ingested an unknown quantity of her mum’s iron tablets, which she takes because she has iron-deficiency anaemia due to pregnancy. Jenny’s mum could not remember how many tablets were left in the bottle and Jenny, wanting to be like mummy, climbed onto a stool and helped herself to the container, which is kept in a kitchen cupboard.
• What are the risks of iron overdose to Jenny?
• What will be the nursing management of Jenny while admitted to the ward?
• What advice should be given to her mother on discharge?
The answers to these questions can be found in the PowerPoint presentation.
Choking
Anatomical aspects, including an obviously smaller airway, contribute to the problems children can experience when playing with certain toys. Children of this age persist in putting all sorts of things in their mouths. It is a problem that has the potential to lead to death, where almost anything can be inhaled including, obviously, food sources. Children aged 3 are more likely to have enlarged tonsils and adenoids, which also increases the risk of choking.
Management of the child
The general advice regarding physical removal of the object from the mouth is to leave well alone unless it is clearly visible and easy to remove. The problem is likely to be exacerbated if the foreign body is pushed further down the airway. Diagnosis is not always very clear but the obvious signs of choking are respiratory compromise, which is accompanied by coughing, gagging and stridor. Evidence-based intervention should follow the Advanced Life Support Group guidance (2005) for managing a choking child, which utilises a basic life support approach, incorporating an algorithm that includes cycles of back blows and chest/abdominal thrusts to relieve the obstruction.
www
wwwLook at this BBC interactive resource, which tests your first aid knowledge, as well as being of use for parents:
Implications for the healthcare professional
All children’s nurses should be trained in basic and advanced paediatric life support and should be able to teach parents about basic life support and how to manage the choking child. Attendance on a first aid course should be encouraged for parents (and nurses) generally. For greater discussion and detail see Chapter 27.
Scenario
www
ScenarioPeanuts are seen as the prime suspects in cases of preschool choking episodes. Why do they pose such a risk and what other food and objects could be a cause of concern, particularly for this age group?
wwwThe Ontario Sick Children’s Hospital is an excellent resource for information giving for families. It includes a child physiology section, aimed at parents and caregivers, which will help you as a healthcare professional explain visually how and why choking is more likely to occur in this age group as well as discussing the mechanics of breathing more generally:
•http://www.aboutkidshealth.ca/HowTheBodyWorks/default.aspx (the front page of the section)
•http://www.aboutkidshealth.ca/HowTheBodyWorks/Respiratory-System.aspx?articleID=10130&categoryID=XL (this will take you direct to the section on the respiratory system)
Burns and scalds
In 1999, 47,000 children sustained a burn or scald. The most vulnerable group is the under-3s, in whom injury sustained is with hot fluids, steam, hot fat and boiling or hot water (DTI 2001). Other sources of burning are dry heat (contact with a hot surface such as an iron or directly from flames), chemicals, electrical appliances and radiation (i.e. overexposure to sunlight). Again, this age group has a particular vulnerability to physical damage due to physiological aspects, including the fact that they have proportionally more extracellular fluid than adults. As a result fluid loss is higher if burned or scalded. Children under 5 years of age account for nearly 45% of all severe burns and scalds and half of the accidents happen in the kitchen. The most likely suspects are cups of hot drinks, which are inadvertently placed where the child can reach up and pull them over themselves. Other causes include unsupervised children falling or climbing into a bath of hot water and accidents involving kettles, saucepans, fires and chip pans.
This subject area is a topic in its own right and thus is given the attention required in the related chapters. What will suffice here is the first aid advice that may be offered by health visitors, nurses and/or NHS Direct in the case of a child that has sustained a minor burn (i.e. sunburn) or scald in the home situation (Table 41.1).
www
www
wwwLook at the BBC interactive first aid website. Test your first aid knowledge in relation to burns and scalds:
wwwLook at the NHS Clinical Knowledge Summaries (CKS) guidance for the management of burns and scalds:
| Action | Rationale/evidence base | Additional information |
|---|---|---|
| Run the affected area under a cold water tap or in a bath for at least 10 minutes | Reduce the risk of further heat damage by cooling the affected area | Cold water should be applied even if a delay occurs |
| Remove bracelets, rings, watches and any other restrictive objects | Will cause constriction if swelling occurs | |
| After cooling remove clothing from affected area | To assess the extent of the damage and prevent further damage | Do not do immediately following injury – it may cause further damage and removal of skin |
| Apply cold compress if further relief needed and/or apply a dressing | To promote comfort and reduce distress to a child who might not want to see the burn/scald To protect the burn/scald from further damage Application of a dressing promotes moist healing | Do not advise application of adhesive, sticky or fluffy dressings The choice of dressing has to be guided by the fact that it should promote the maximum amount of movement of the affected area |
| Analgesia | To relieve pain In the home the analgesic of choice is paracetamol | |
| De-roof blisters or not? | The evidence base is unclear as demonstrated by the following comments for and against: The wound assessment process is clearer and joint movement is enhanced if you de-roof the blisters (Bosworth 1997) The blisters have a protective function and should be aspirated (as opposed to de-roofed) to reduce pressure only if necessary (Flanagan and Graham, 2001 and Gowar and Lawrence, 1995) | The guidance from CKS based on best evidence base, recommends leaving the blister intact unless they are very big or in an awkward place where aspirating them would be the treatment of choice |
Non-accidental injury
The issue of non-accidental injury within this age group is also relevant here. See Chapter 19 for a more in-depth discussion.
www
wwwThe NSPCC website offers information leaflets for parents, which are also relevant to healthcare professionals, identifying how to manage challenging toddler behaviour:
Mobilising
Again in this chapter we ignore the pre-existing health problems identified pre-, peri- or postnatally. The inquisitive nature of the child in relation to exploring his or her environment means that falls and many other accidents can occur, resulting in a range of injuries from simple bruising and sprains to complex fractures. Chapter 35, on orthopaedics, focuses on conditions that relate directly to this age group and gives detailed information of the nursing interventions and health promotion that should be offered to parents/carers and children.
Communicating
The acquisition of language and the whole process of a child’s voyage from preverbal to verbal communication is complex and little understood. It is clear that a child’s verbal communication increases with exposure to, and experience of, language. It is a healthy response to environmental stimulation, associated with normal development of hearing, neurological function and intellectual development (Woodfield 1999). The area of developing communication skills encompasses many factors, where the key to development is a healthy parent/child relationship. Again the use of developmental milestones, in the hands of community healthcare professionals working in partnership with parents and carers, will identify the very particular problems within the early childhood experience that can pose obstacles to development of effective communication skills.
During early childhood, the child will progress from speaking single words at 12–18 months to speaking in sentences, with a massive growth in vocabulary and the use of syntax – inflections, negatives, questions and passive voice – by the age of 5. The child also develops a sense of humour and starts to understand the pragmatics of a situation, i.e. the use of voice, form in sentence construction and choice of word in achieving a given end, for example, a favourable response to question by the use of words like ‘please’ and ‘thank you’ (Bukatko & Daehlar 2004).
Again, community-nursing staff – especially health visitors – are at the forefront of identifying where potential problems are of issue. Any hearing problems will have been identified ideally within the first year of life via parental concerns and/or the distraction test which is performed by health visitors at 6–9 months via the usual child surveillance screening (Hall & Elliman 2003).
Developmental stages again define when children will display problems in hearing due to language development. The rate of speech and language acquisition varies from child to child and, if English is the child’s second language, it can be difficult for an English-speaking healthcare professional to assess how language is developing (Cernik 1999b).
Glue ear
Glue ear (which can also be defined as chronic secretory otitis media or otitis media with effusion) is an inflammation of the mucous membranes that line the middle ear and is associated with malfunction in the drainage mechanism of the middle ear. The result is a build-up of fluid and increased pressure behind the tympanic membrane. The reason children are susceptible to this problem is the anatomically shorter, wider and more nearly horizontal Eustachian tubes and the frequent upper respiratory tract infections they seem to acquire. It is very much a preschool child problem, whereby one in four children under the age of 10 will have an episode of acute otitis media, with a peak incidence of diagnosis between the ages of 3 and 6 (Scottish Intercollegiate Guidelines Network (SIGN) 2003).
Acute otitis media is caused by bacterial or viral infection, as opposed to glue ear, which usually has a non-infectious cause as described above. Glue ear is also associated with perennial and/or seasonal allergic rhinitis, enlarged adenoids, prolonged exposure to cigarette smoke, lack of breastfeeding in infancy and living in a household with many family members (Wong 1997).
PowerPoint
PowerPointAccess the companion PowerPoint presentation and find the diagram of the major parts of the ear. Test your knowledge by completing an unlabelled diagram.
The problem of otitis media is usually diagnosed by parents, perhaps in partnership with health visitors or the GP, because of problems with language development and speech. The child may present with other signs, including tugging at ear lobes due to pain and earache, discharging ears, and general tiredness and fatigue due to having to concentrate to hear, especially in social situations such as nursery. Other signs are deterioration in behaviour, obvious difficulty in hearing – the child asks for the television to be turned up – and speech difficulties generally, i.e. difficulties with pronunciations and shouting inappropriately (Wong 1997). The acute form of the disease will present with the characteristic signs of inflammation including earache, pyrexia and general irritability and may be preceded by a cough or other upper respiratory tract symptoms, whilst a child with glue ear may present only with the signs of hearing loss as discussed earlier (SIGN 2003).
Management of the child
Pain and discomfort is treated with paracetamol and/or other analgesics and the infection, if present as an acute otitis media, may be treated with antibiotics. With recurrent infections, i.e. more than four in 6 months, and in the case of a secretory otitis media, if the child is aged 3 and over and presents with speech and language problems, he or she will be referred to an otolaryngologist (SIGN 2003), which may result with an admission to a local hospital, on a day-case basis, for surgical intervention in the shape of myringotomy and grommet insertion. Surgical intervention remains controversial and the mainstay of glue ear management is the watch and wait approach (or ‘watchful waiting’; SIGN 2003), and all forms of glue ear should improve spontaneously (Maw 2000). The National Institute for Heath and Clinical Excellence (NICE) have published guidelines identifying the group of children who will benefit from surgical intervention (2008). An alternative approach to managing glue ear is via autoinflation, which involves blowing a balloon with the nose, resulting in a raise in intranasal pressure, which opens up the Eustachian tubes. The evidence base is yet unclear and conflicting, but there may be some clinical benefit (Reidpath et al 1999). NICE (2008) advise that autoinflation should be considered for children who will cooperate with the procedure.
www
Activity
wwwUseful website for users of healthcare services:
More specifically, information about myringotomy and grommet insertion:
Royal National Institute for the Deaf:
The RNID’s leaflet relating to insertion of grommets:
ActivityWilliam, aged 2, has been admitted to a day-case ward for insertion of grommets:
• On recording his baseline observations what would you expect the normal ranges of observations be for a preschool age child?
See PowerPoint presentation for answers.
Implications for the healthcare professional
The role of the health visitor, midwife, practice nurse and community nurse in monitoring for problems in communication has already been mentioned. They perform a valuable function in health promotion and illness prevention, via advice to parents to stop smoking and promote breastfeeding.
Breathing
This is the period of time, when starting nursery, attending playgroups or just socialising generally, when a runny nose seems to be a permanent feature of early childhood. It is not a very attractive or helpful addition to a child’s development, but a requirement in developing immunity and resistance to infection. Life in the 21st century means that the need for childcare in this preschool age group is on the increase, especially where there is an economic need for the main carer to go out to work. Many studies have shown that care outside the home does contribute to acute respiratory illness in childhood and that these children experience these infections generally at an earlier age but fare better in the long term than children who are exposed to infection only when starting school. It has to be mentioned that there are no clear conclusions as to whether this is a risk or benefit overall (McCutcheon & Fitzgerald 2001). Physiologically, children aged 1–4 are more susceptible to respiratory illness due to immaturity of the respiratory system and, anatomically, they have narrower airways and as a result are more likely to have enlarged adenoids and tonsils.
Upper respiratory tract infections
Around 80% of respiratory infections involve only the nose, throat, ears and sinuses and cover a number of different conditions, such as common cold (coryza), sort throat, acute otitis media and sinusitis (Lissauer & Clayden 2007). Thus a child will typically present with sore throat, fever, nasal blockage and discharge and earache accompanied by a troublesome cough. The discussion at this point is brief and covers minor illness only due to the detailed coverage offered in Chapter 27.
Management of the child
The illness is most likely to be managed at home and affect all the family with maybe only a visit to the GP and/or advice from organisations like NHS Direct as a healthcare intervention. The advice usually consists of the use of antipyretics such as paracetamol, rest and encouraging plenty of fluids, although hospital admissions may occur due to febrile convulsions, wheezy episodes and severe upper respiratory tract infections, which will require greater medical intervention.
Implications for the healthcare professional
General advice, if sought, will come from community staff, GPs and NHS Direct and/or primary care centres.
Asthma
Asthma is a chronic condition characterised by hyper-responsiveness of the airway due to inflammation. This results in the narrowing of the airway with associated cough and wheeze. The causative agents include genetic predisposition and environmental factors, including parental smoking, exposure to allergens in infancy and viral infection in infancy (Budd & Gardiner 1999). Chapter 27 provides much greater detail about the ever-increasing incidence of this illness. It will suffice in this section to give a brief introduction in relation to the specific needs of this age group.
Management of the child
Attaching the diagnosis of asthma to the preschool child is controversial because at least one child in seven will have a wheezing episode before they reach the age of 5. Assessment is difficult, although a diagnosis will require an accurate history of predisposing factors, incidence of wheeziness as well as auscultation and investigation via chest X-ray when a child presents with a wheezy episode initially. Peak expiratory flow rate (PEFR) is not a useful measure in this age group, who are unable cognitively to comply with the complex instructions, thus careful monitoring by parents in the form of a diary, if recurrent wheezing is becoming a problem, is an aid to diagnosis.
The mainstays of treatment and management are through the avoidance of triggers, i.e. allergens and smoking, use of inhalers ‘preventers’ and ‘relievers’ using the stepwise approach as advocated by the British Thoracic Society (BTS), which outlines the specific needs of the under-5 age group of children (BTS/SIGN 2008).
Implications for the healthcare professional
Nurses caring for children have a health education role to play, facilitated by the production of evidence-based guidelines that aid a consistent approach to health promotion. The National Asthma Campaign is an excellent source of information for healthcare professionals and parents/children alike. The outpatient clinic and dedicated asthma clinics, in the acute sector and in the community, ensure that very specific needs in relation to symptom management are offered to ensure that a child can live life to the full and not be restricted by the diagnosis of asthma.
Croup (laryngotracheobronchitis)
Again, the information offered here is supplemented significantly in Chapter 27. Croup has been defined as a ‘swelling of the submucosa in the subglottic area’ (Webster et al 1998). It can occur at any age, but is particularly common in the 6 months to 3 year age group. The infection is usually viral in origin and results in narrowing of the upper airway, presenting as hoarseness of voice, with a barking cough and inspiratory stridor. Any swelling in an already narrow airway will potentially cause respiratory distress (Box 41.2) and this is the case with croup, where the narrowest area, the cricoid cartilage, is affected.
Box 41.2 Signs of acute respiratory distress
• Increased respiratory rate
• Recession: intercostal, subcostal or sternal
• Inspiratory or expiratory noise: stridor or wheeze
• Grunting (usually only seen in infants)
• Accessory muscle use
• Flaring of the alae nasi
• Skin colour, i.e. cyanosis
• Mental status, i.e. agitation and/or drowsiness
• Increased heart rate
Management of the child
The key to management is careful assessment of respiratory function as per the Advanced Life Support Group guidelines (ALSG 2005), i.e. airway, breathing and circulation (ABC) followed by a detailed examination of respiratory function. This involves ensuring that the child has a patent airway as a matter of emergency intervention, then proceeding to assess the extent of respiratory distress which includes respiratory rate, effort, pattern of breathing and airway resistance. Croup scoring systems are available to facilitate the assessment.
The potential diagnosis attached, due to the presenting symptoms, may be epiglottitis, although, because of the Haemophilus influenzae type b vaccination, this is very rarely seen today. The awareness of epiglottitis as a potential cause still has to be evident if planning to carry out throat inspection or take a throat swab especially for unvaccinated children.
Use of humidity is the mainstay of croup management though the evidence base for using this method of management is debatable (D’Amore & Campbell Hewson 2002
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