Too Quiet

Scene

Attack One responds to a report of a “child ill.” This call resulted from a pair of young parents waking in the middle of the night when they heard “funny noises” from their child’s crib. The parents picked up the child, who felt hot and seemed to be having difficulty breathing. She had not vomited. The child—who was delivered in a routine manner three weeks earlier—had no other medical problems and had received no immunizations as yet. The Attack One crew finds the child sleeping in her father’s arms, and in no apparent distress on initial evaluation. She has a pulse rate of 140, a respiratory rate of 32, and is perfusing well. She has no signs of trauma on complete assessment. Her diaper is dry.

Transportation

The child’s parents discussed just staying home with her and contacting her pediatrician in the morning. The crew acknowledged everyone’s desire to get some sleep, but thought the story provided some clues that the infant was ill and should be evaluated immediately. The Children’s Hospital was about 10 minutes farther away than the local community hospital, but the crew felt the Children’s Hospital was the appropriate receiving facility. The transport was unremarkable, with the child remaining in her infant seat.

Impressions

Most emergency providers prefer a quiet patient, but “too quiet” is a concern to most experienced EMTs. This child was born prematurely, and Mom had some type of febrile illness at delivery. The child woke the parents with “funny noises” (perhaps a febrile seizure), and the parents felt the child was warm. The Attack One crew did not have an infant thermometer, but the child was not obviously febrile. Initial vital signs did not indicate serious problems; but the child’s diaper was dry after 5–6 hours, and the parents reported that the child had an episode of difficulty breathing. Now the infant was quiet. Serious problems can be hidden in infants, so the crew made a strong recommendation that the child be transported immediately.

Hospital

On arrival at the ED, the child deteriorated rapidly and developed respiratory distress. She was found to be ill with meningitis and had a stormy course in the Intensive Care Unit, but was discharged without known sequelae. The infectious agent was one that was not contagious to the EMS providers, but one that is very harmful to newborns.

Summary/Discussion

The child with a fever (or a reported fever, as in this case) has a wide range of potential illnesses that must be considered. The pediatric community approaches children in three age groups: those younger than three months, those between 3–24 months, and those over 24 months. Those under three months of age are most at risk for serious problems, and the physical examination of the child is most unreliable. Infants most at risk for infection have smaller birth weights, mothers with infectious diseases such as chlamydia or HIV, and labor following premature rupture of membranes. Infants cannot offer complaints; have poorly functional muscles that do not allow the demonstration of neck stiffness or stiff joints; and cannot cough productively to demonstrate pneumonia. The most strenuous activity for an infant is eating, so ill infants will often feed poorly.

The emergency physician or pediatrician will want the prehospital emergency provider to observe the behavior of an ill child to gain an indication of the seriousness of the illness. The Yale Observation Scale uses six criteria to stratify the ill child. The ill child will have poor color, a weak or high-pitched cry, poor hydration (dry diaper and mucous membranes), little reaction to parental stimulation, little arousal or continuous sleeping and no smile.

This child demonstrated many criteria of an ill child. Her temperature was likely high at the onset of illness (while in her crib), which was not detectable by the time the EMS crew did its evaluation. Difficulty breathing is a common observation in ill infants by their parents, and the child had a dry diaper. A quiet child is not to be considered a healthy child, and like many EMS situations, the crew was appropriately “worried most about the quiet one.”