Signs that a child is seriously ill: Interview with Professor Middleton

Interview conducted by April Cashin-Garbutt, BA Hons (Cantab) on 3rd July 2012

Paul Middleton

What are the main symptoms that indicate that a child is seriously ill and not just slightly unwell?

There are several signs that indicate that a child is seriously ill. These can be spotted by parents, teachers and carers as well as by me or any other doctor or nurse.

The first impressions of the child are really important. For example, I am really concerned if I see a child who is not interacting with the parents; not taking notice of its surroundings; and not playing, or smiling and so forth.

The next thing is a more structured assessment of specific symptoms. When we assess both children and adults in an emergency room we use a system known as the ABCDE method.

The ABCDE method means that we assess the Airways, Breathing, Circulation, Disability (which is level of consciousness and the function of the brain and the nerves), Exposure (making sure we check the whole body from top to toe) and Everything else.

The reason that we have this structured system is not just because it is alphabetically convenient, but also as these things are the in the order in which they may harm the child.

For example, an airway problem, such as a foreign body or swelling due to anaphylaxis, can kill someone within 3 or 4 minutes. This is because they can’t get any oxygen at all. When assessing for an airway problem I listen to whether they are breathing properly and whether there are noises when they breathe, which may meant there is an obstruction.

A breathing problem is the next most urgent after an airway problem, followed by circulation problems such as those that affect the heart and blood vessels.

I determine whether they have to work hard to breathe. This can be shown by the nostrils flaring when they breathe in, and/or the skin between the ribs being sucked in.

I also look at how fast they breathe. Breathing rate is very important. Breathing really fast in children often indicates a problem in the breathing mechanism or the body compensating for something else, such as an infection.

To assess circulation you look at whether the child is very pale or is a normal colour. If they are very pale and if they are sweaty you worry that they have poor circulation.

If you feel them and they are cool and when you press the skin the colour does not come back to the skin very quickly, such as in a couple of seconds, then this is an indicator that something may be seriously wrong.

Another symptom that you can spot, without having to know much at all about medicine, is the child’s level of drowsiness. This relates to the D part of the ABCDE method. This is particularly important in relation to a history of other things, such as a breathing problem or infections. Children who are difficult to wake, particularly when you know they have an infection, breathing problems or head injury, are a real worry.

E stands for exposure, which means that you should ensure you always look for serious rashes, such as meningococcal rashes, or rashes that don’t blanch when you press on them, or injuries that may be hidden by hair or clothes.

Do these symptoms change depending on the age of the child?

The symptoms do change depending on the age of the child. There are a few reasons for this.

When a child is very young, under 3 months or so, they can’t really display anything that localises a problem. For example, a problem with infection may not be found by looking for clear signs of that infection in the lungs or other parts of the body, but there may be just a decrease in responsiveness and alertness. This is problematic itself because a stimulus which would cause a response in older children may not have the same effect in very young children, as they are often generally less responsive anyway.

Often in very young children you should be suspicious if they are not doing what they normally do. For example, if they are sleeping a lot longer than they normally do.

Drowsiness is a very important symptom in children, but particularly in very young children. For example, if there are decreases in the number of times they wake to eat per day, or the amount that they are waking in general, then you should be suspicious. You should be particularly worried if they don’t wake when you stimulate them.

As children get older they tend to be able to localise the symptoms to where the problem is. For example, if they have a breathing problem it will be more obvious that they have something wrong with their breathing rather than a general lack of responsiveness.

You can also test things like counting breathing rate much more effectively when a child is a bit older.

Also, things like pulse rate and breathing rate do actually change as you get older. They are normally fast in a baby and they get slower as you get older.

Despite these changes, the very important signs, like whether a child is interested in its surroundings, still remain very important signals of illness.

How should you decide whether to take a child to the GP, to the hospital’s emergency department or to call for an ambulance?

This is one of the toughest things to decide. In the book that we recently wrote, we tried to put together a traffic light scheme to help parents and carers make these decisions.

Generally we started off with things that we knew were very serious and potentially life-threatening. For example, not breathing very much at all or not breathing properly; unconsciousness; unable to swallow and so forth. These are signs that you should immediately call an ambulance.

If the child can swallow and drink but they are very tired and unwell looking or are getting drowsy, then you should take the child straight to the emergency department but you can often sit in the waiting room once they have been seen by the triage nurse.

If the symptoms have gone on for a while and they are not getting worse, and the child can get on with its normal activities but just doesn’t feel very well, then you should take them to a GP.

In summary, the important signs to look out for in terms of serious illness and ones that mean you should call an ambulance are:

  • unconsciousness
  • becoming more drowsy and less responsive
  • any signs that there are some obstructions to the airways, such as if you can hear noises when they are breathing in and out, especially when breathing in, this can be due to a foreign body or a severe infection
  • if they are having to work hard to breathe, such as if they are getting exhausted

Are there any tests that a parent/carer can do at home to determine whether the child’s symptoms indicate a serious illness?

There are some specific tests such as for meningococcal disease you can roll a glass over the rash and see if it disappears, or blanches, or if it stays dark red.

However, it is really about knowing the signs that a child is seriously ill. Although these are seemingly simple principles, people need to learn these things.

People often learn how to do CPR and first aid but the problem with these two things is that in children they are far less relevant than in adults. This is because children don’t have cardiac arrests and die for the same reasons that adults do.

Consequently CPR is often ineffective in children. This is not because the CPR itself is any less effective, but because children that have a cardiac arrest do so, largely not as a result of something happening suddenly such as a heart attack in adults, which happens because of years of smoking, high cholesterol, high blood pressure etc, but because of a long process of getting sicker and sicker.

Children often die because they are at the end of a process of becoming more and more unwell, and then do not respond to CPR because their bodies have become unable to maintain themselves. The key is to recognise this process, and intervene to prevent it ever getting to that point.

We are going to be running courses that teach parents and carers that it is about spotting signs that a child is sick and getting sicker, not about treating with CPR once the child has reached a cardiac arrest.

I’ve seen children die in emergency rooms who (unless it’s a trauma), could conceivably have lived if the signs had been spotted earlier.

I would rather teach people CPR and they never have to use it, as they spot the signs that a child is getting ill long before the child has a cardiac arrest.

Do you have any plans to run courses that help parents to spot the signs that a child is seriously ill?

A couple of years ago we published a book that was originally written as a manual for a course to teach people on how to spot signs that a child is seriously ill.

We ran a couple of courses in London around 10 years ago, and then I moved to Australia. We were asked to turn the manual into a book for an Australian publisher, which has now been published. It aims to teach people why children get sick and to bridge the gap between first aid and CPR.

We are going to start the courses again early next year. We will get nurses, doctors and paramedics, to teach parents, teachers, carers and nannies etc. face to face on how to spot the signs that a child is seriously ill.

The teaching will involve similar principles to when we teach doctors, nurses and paramedics themselves. We give them scenarios and ask them what they would do. This will help them with decision making.

I would like to see this teaching becoming standard for teachers, rather than them just having to get a CPR and first aid certificate. This would allow teachers to spot signs, so that they never let it get to the stage where CPR was needed.

Are there any technical gadgets that may help in determining the seriousness of a child’s symptoms, such as thermometers etc.?

I think a thermometer is always useful. People try to estimate a temperature by putting a hand on a child’s head. This is ok, but it is not very accurate.

Things have moved on since we wrote the book and paediatricians now think that the level of fever is less important to some degree. However, being able to quantify your temperature is still important and it still means something if it is continuing to go up and if it is not responding to paracetamol and other fever-reducing drugs.

I think in terms of other helpers, the best thing to have is the knowledge of the signs to spot. It is important to train your brain to look for the sort of things that we would look for.

For example, counting breathing rate and assessing drowsiness are not difficult things to do. None of these simple ways to spot signs that a child is ill are beyond anybody.

Is there anything a parent can do if they are unsure of where to take a child?

In the UK there is a helpline you can call known as NHS direct, and there are similar things in other countries.

However, I think parents tend to not be any worse at decision making than these helplines. This is because parents tend to know their child better than anyone else. They know what is normal for the child.

Trend is very important. It is about watching a child over a period of time and seeing whether they are getting worse, getting better or staying the same.

As a rule of thumb, I would say the following indicate that the child needs to get to an emergency department as soon as possible:

  • if a parent is really worried that there is something wrong
  • if the child is deteriorating, for example if they are getting a fever, getting more drowsy and so forth
  • if there are problems in the child’s breathing, or if the breathing rate keeps increasing

What are the most common causes of serious illness in children?

This depends on the age of the child. In the youngest of children the most common causes are congenital disorders that they are born with. These have the highest mortality rates in the youngest of children, of below a month old.

When they get a bit older problems like infections are common causes of serious illness.

A lack of oxygen and a lack of fluids are probably the two most common causes of serious illness in children. A lack of oxygen is caused by their airways being blocked or their respiratory system not functioning properly, this could be due to an infection.

A lack of fluids is often due to diarrhea, vomiting and bleeding. In infections you often have the fluid in the wrong place.

Diarrhea is the biggest killer of children in the world. This is because it profoundly affects children, as they have small bodies and are unable to cope with losing fluids.

Often sick children that are given oxygen and fluids will perk up and get better quickly.

As soon as children get more mobile and they run around; then trauma becomes a big cause of serious illness. The rate of death from trauma goes up exponentially at around 3 or 4 years of age.

This is because this is the age that children can move around very quickly; however, they often have little or no sense of danger. Consequently, they often run out in front of cars; they climb on things and fall off them and so forth.

This trend continues into adulthood. Trauma is the biggest killer of adults under 40 in the world.

What ways can you prevent a child from becoming seriously ill?

The main thing is immunisation. Despite all the controversy, the fact is that immunisation has caused many preventable diseases to disappear in several countries.

For example, things that killed many children only a hundred years ago in England, such as diphtheria and whooping cough, have now almost been completely eradicated.

Getting immunisations regularly and according to the NHS scheme is essential for preventing a child from becoming seriously ill.

Another way to prevent a child from becoming seriously ill is to be alert to problems. Understand a child’s normal behaviour and spot departures from that normal behaviour, especially when they are young.

Never be afraid to ask, and never be afraid to take a child to the emergency department. Also, if you don’t feel happy when you come home from the emergency department, then go back.

Where can readers find more information?

Readers can purchase our book in Australia and New Zealand, or from our website:

Our courses will also be available in Australia and New Zealand, and we are going to make them available in other countries as soon as possible.

About Professor Middleton

Paul Middleton is a specialist in Emergency Medicine, and Clinical Associate Professor in Emergency Medicine at the University of Sydney. He is Chair of the NSW branch of the Australian Resuscitation Council and works as a Visiting Medical Officer in Emergency Departments of major hospitals in NSW and ACT.

Paul Middleton

He is Director of the Australian Institute for Clinical Education which teaches doctors and nurses how to treat serious illness and injury, and is the author of What To Do When Your Child Gets Sick: The Essential Emergency Manual for Parents and Carers, published by Allen and Unwin.

Professor Middleton’s clinical and research expertise is in assessment of the severity of illness and injury, pre-hospital medicine, and first aid.

April Cashin-Garbutt

Written by

April Cashin-Garbutt

April graduated with a first-class honours degree in Natural Sciences from Pembroke College, University of Cambridge. During her time as Editor-in-Chief, News-Medical (2012-2017), she kickstarted the content production process and helped to grow the website readership to over 60 million visitors per year. Through interviewing global thought leaders in medicine and life sciences, including Nobel laureates, April developed a passion for neuroscience and now works at the Sainsbury Wellcome Centre for Neural Circuits and Behaviour, located within UCL.


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