ICU AND YOU · Superquiz #62 — The toddler and preschool child

1A two-year-old with three days of high fever is brought in by her mother. She sits quietly on the couch, allows you to examine her chest and abdomen without protest, and does not object when you look in her throat. Her observations are within normal limits for age. The most useful interpretation of her cooperation is that she is:

AWell, since a distressed child is the one to worry about BSimply a placid child, and her temperament is not clinical information CPossibly unwell, because objecting takes energy and an intact conscious state DDehydrated, since lethargy is the earliest sign of fluid loss

A well two-year-old meeting a stranger should object; wariness of unfamiliar adults is a developmental achievement, not a defect of character. Resisting you costs muscle, breath and enough spare capacity to care what is happening, so a child with none to lend is easy to examine. That is a finding rather than a convenience, and it is usually written down as “cooperative”. It is not diagnostic on its own — placid, neurodiverse and chronically hospitalised children exist — which is why it is a question rather than an answer, and why change matters more than state.

See Aphorism #37 for the argument, including the case against it.

2A previously well three-year-old is brought in ninety minutes after his mother saw him with the open back of a television remote. He is drooling slightly but is otherwise well, with a clear chest. A chest radiograph shows a round radio-opaque object in the upper oesophagus with a double-ring or halo appearance. The most important next step is:

AObserve for 24 hours to see whether it passes spontaneously BArrange urgent endoscopic removal, and give honey while waiting CGive an oral contrast study to define the level before intervening DReassure and discharge, as the object is below the airway

The halo or double-ring sign identifies a button battery rather than a coin, and an oesophageal battery generates hydroxide at its negative pole and begins burning through mucosa within about two hours. This is a now problem, not a morning problem. Australian guidelines support giving honey while awaiting removal in a child over twelve months who presents within twelve hours — jam is an alternative, and is the option under one because it carries no botulism risk. Neither ever delays endoscopy.

Royal Children's Hospital Melbourne and Children's Health Queensland guidelines; see Mind Map #33 and Superpuzzle #50.

3A healthy eighteen-month-old had a sudden coughing and choking episode while eating peanuts two hours ago. It settled after a minute and he has seemed himself since. He is now afebrile with mild reduction in air entry on the right. His chest radiograph is reported as normal. You should:

AReassure the family, since a normal film excludes an inhaled foreign body BTreat as viral wheeze and review in the morning CRefer for potential bronchoscopy, because the history outweighs the normal film DRepeat the radiograph in six hours before deciding

A normal chest film excludes nothing. Most inhaled foreign bodies are radiolucent, and the classic pattern is a choking episode followed by a quiet interval that reassures everybody. Unilateral reduced air entry or wheeze after a witnessed choking episode is a referral, and the history is the test. Removal is by bronchoscopy — rigid has been the standard, and flexible is increasingly used with comparable success in selected cases.

See Podcast #57 and Mind Map #33.

4A four-year-old of Chinese heritage attends with fever and cough. On undressing her you find symmetrical parallel linear red-purple streaks running along both sides of her spine and following the line of the ribs, with normal skin between and either side. She is well grown, engaged and comfortable. The most appropriate response is to:

AReport immediately without discussing the findings with the family BRecord the marks as bruising of unknown origin and take no further action CAsk openly what was done and by whom, while keeping child protection in mind DAccept the marks as gua sha and exclude inflicted injury on that basis

The pattern described — orderly, parallel, symmetrical, sharply confined, with no impact point and no clustering in protected sites — fits gua sha, a widely used and well-meant domestic treatment for fever. Recognising it lets you ask a better question rather than an accusation, and families will usually describe exactly what was done. But recognition is not exclusion: a family that practises gua sha can also be a family in which a child is being hurt. The error runs both ways — reporting a family for treating a fever, or waving through a real injury because somebody said the words.

See Nǐ hǎo Chinatown No. 1.

5A two-year-old presents at midnight with a barking cough and stridor at rest, with mild intercostal recession. He is alert, pink and settled on his father's lap. Which single action is most likely to make him worse?

AGiving oral dexamethasone BTaking him from his father to examine his throat with a tongue depressor CGiving nebulised adrenaline DLeaving him undisturbed while the steroid takes effect

Distress increases turbulent flow through an already narrowed airway and can convert stridor at rest into obstruction. Examining the throat adds nothing in typical croup and risks a great deal, and separating the child from the parent guarantees distress. Every child with croup gets dexamethasone regardless of severity; nebulised adrenaline buys time in moderate to severe disease and wears off in a couple of hours, so the child is watched. The most useful thing you can do for the airway of a frightened toddler is to leave it alone.

See Mind Map #33, second station, and Medical Students' Place No. 3.

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