Fifteen minutes and a well-looking baby

The infant from one month to one year, in general practice

The hospital sees the infant who has already declared themselves. You see the one who has not — and you see forty of them for every one who is seriously unwell. Every one of those visits matters to the family in front of you. Only some of them are dangerous, and they do not announce which.

That is the whole difficulty, and it is not a knowledge problem. The febrile infant in a paediatric emergency department arrives pre-selected: somebody was worried enough to bring them. In your room they arrive unselected, in a fifteen-minute appointment, often with a parent apologising for wasting your time. The skill is not recognising a sick baby. It is deciding about a well-looking one, forty times a week, and being right often enough.

I spent years in rural general practice before intensive care, and this remains, to me, the harder job.

The ones to worry about

Send, or discuss, today

Under three months with a fever of 38 °C or more. Regardless of how well they look — and they very often look well. This age group does not localise, and a urinary tract infection or bacteraemia can be entirely occult.
Any non-blanching rash. Meningococcaemia until proven otherwise, and the interval between the first petechia and collapse can be measured in hours.
Bilious vomiting at any age. Malrotation until proven otherwise. Green is surgical.
Intermittent pallor with drawing up of the legs, and lethargy in between. Intussusception, and the lethargy phase is what makes it look like sepsis.
A bruise in a baby who is not yet cruising. Examine fully, document, and escalate the same day. You are a mandatory reporter and the threshold is suspicion, not proof.
The parent who has brought them back. A second presentation for the same illness is a risk factor in its own right, whatever you find. Something changed, or they would not have returned.

The common thing, done well

Bronchiolitis is most of what walks in between May and September, and the decision is rarely about the diagnosis. It is about feeding and about trajectory.

SendFeeding below about half of normal, apnoea (particularly under two months or ex-preterm), saturations persistently below 92%, marked recession or grunting, or a family who cannot get back to you.
Watch, with a planFeeding reasonably, comfortable at rest, day two or three of the illness, and a household that can return easily. Bronchiolitis peaks around day three to five, so timing matters more than the snapshot in front of you.
Do notOrder a chest film routinely — it mostly finds atelectasis and generates antibiotics. Salbutamol, steroids and antibiotics do not help ordinary bronchiolitis.
Ask about the householdHow far away are they, do they have a car, is there phone reception, and is anyone else at home unwell? In a rural practice this changes the decision more than the examination does.

Safety-netting that actually works

“Come back if you're worried” is not safety-netting. It transfers the whole judgement to someone who has no way of making it, and it is the sentence that turns up in the coronial file.

Try instead “I think this is a virus and I expect him to be worse tomorrow before he gets better — that is normal and it peaks around day three. I want you to come back, or go to the hospital, if any of these happen: he takes less than half his usual feeds, he has fewer than four wet nappies in a day, his breathing looks harder than it does now, or he stops being interested in you. And if you are frightened at any point, that is reason enough. Do not wait for one of my list.”

Specific, time-bound, and with the parent's own instinct written in as a valid trigger. Then write in the notes that you gave it, because you did.

And the sentence worth saying out loud. When a parent apologises for coming, tell them they were right to. The ones who were made to feel foolish at a first presentation are measurably slower to come back at a second, and the second is the one that matters.

If you have to hold them

In a practice an hour or more from a hospital, the interval before transfer is yours. Weight in kilograms is approximately (age in months + 9) ÷ 2 for an infant under one. Fluid boluses are 10 mL/kg, not 20. Check a blood glucose in every unwell infant; it is quick, it is often the answer, and it is regularly forgotten. Give oxygen, get access, and telephone early. In New South Wales that is NETS on 1300 36 2500, and they would far rather advise on a child who turns out to be fine than be called an hour later.

Over to you

What is the safety-netting sentence you actually use — the one you say out loud, in your own words?

I would like to collect them. The good ones are specific, they name what to look for, and they give the parent permission to trust themselves. Send me yours and I will publish a set of them.

Send me your words

The button opens a reply straight to me. If your device blocks it, write to icuandyou@icloud.com instead.