You will notice first

The infant from one month to one year — and what to do with what you have seen

Almost every review of a missed deterioration in a child contains the same sentence somewhere: a nurse was worried before the observations changed.

That is not flattery. It is a description of where you stand. You are in the room repeatedly across a shift, you handle the child, you see the feed and the nappy and the mother's face, and you hold a comparison — how they were an hour ago — that nobody arriving at the bedside for the first time has. The chart cannot hold that. You can.

This is about the part that follows: what you are seeing, and how to make it count.

What you see before the chart does

FeedingThe first thing to go, and the last thing anyone asks about. Not just whether they fed, but how long it took, how hard they worked, and whether they finished. A baby who tires halfway through a feed is telling you about their work of breathing.
Tone in your handsYou pick these babies up. Floppy, or stiff, or simply not gripping the way they were. There is no box on the chart for this and it is one of the earliest things to change.
The cryHigh-pitched, weak, or absent. A baby who has stopped protesting at being handled is not settled; they are conserving.
Colour and skinMottling, a grey cast around the mouth, cool hands creeping up the forearm. The line where warm becomes cool moves proximally as perfusion fails, and you will feel it before a machine registers anything.
Wet nappiesFewer than four in a day is dehydration until proven otherwise. Weigh them if you can — it is the only objective measure of output you have.
Work of breathingRecession, flaring, head bobbing, grunting. Count for a full minute; infants breathe irregularly and a ten-second count multiplied by six is a guess.
The parent's faceWatch the person watching the baby. A parent who has gone quiet, or who keeps looking at the door, has often noticed something they have not found words for yet.

And the trap. An infant holds a normal blood pressure by clamping down and speeding up, long past the point where an adult would have declared themselves. So a full set of observations can read entirely reassuringly in a child who is a short way from arresting. When your eyes and the chart disagree, the chart is the one that is behind.

Making it count

Noticing is the hard part and you have already done it. What remains is getting it into the record and into somebody's ears, and there are three things that make that work.

Chart the words, not the impression “Mother reports he has taken 40 mL of a 120 mL feed over 35 minutes, stopping frequently. Says he is ‘not himself’. Cool to mid-forearm. Nappy dry since 0400.”

That is a set of observations. “Appears unsettled” is not, and it is what gets written instead. Quote the parent directly — their words carry weight in a way your summary of them does not.

Escalate on the trend, not the number “Four-month-old, six kilos. Two hours ago he was feeding and settled. He has now taken a third of a feed, he is cool to the elbows, and his respiratory rate has gone from 40 to 62. His blood pressure is normal. I need you to come and see him.”

Lead with the change over time and finish with what you want. “I need you to come and see him” is a request; “I'm a bit worried about bed four” is not, and it is much easier to agree with and do nothing about.

Say it again if nothing happens

If you have escalated and the response does not match your concern, escalate again, higher. Every hospital has a formal pathway for exactly this and it exists because people have died while somebody waited to be taken seriously. Using it is not a complaint about a colleague. It is the system working as designed.

Three practical things

Get a real weightEvery drug, every fluid volume and every tube size comes from it. An estimate carried through a resuscitation is an error waiting to be scaled up.
Minimal handlingIn bronchiolitis in particular, every examination costs the baby oxygen. Cluster your cares, and say so at handover, so the next four people do not each decide to have a look.
Look at the groinEvery vomiting infant. An incarcerated hernia is easy to find and catastrophic to miss, and it is under a nappy nobody has opened.

Over to you

Tell me about a time you knew something was wrong before the numbers did — and what happened when you said so.

Both halves matter. I am interested in what you noticed, and I am just as interested in whether raising it was easy or hard. Names are never published without asking, and you are welcome to be anonymous.

Tell me what you saw

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