Sick or tired?

Pediatricians tend to be rather easygoing or at least to survive they must learn to appear calm. It is our job to keep our heads when all about us are losing theirs. However, there are certain words that can rattle even the most apparently unflappable pediatrician. For example, when a parent or nurse says a child is "grunting," I begin to get twitchy. I drop everything I’m doing, and that child receives all of my professional attention.

"Lethargic" used to be one of those pulse-quickening words for me, but over the years, it began to lose some of its coronary-tightening qualities. I had always considered "lethargic" to be a rather ominous descriptor. But, people seem to apply the term to children who were merely sleepy, listless, or just plain unmotivated. It took me a decade or two of rushing to bedsides or opening the office in the middle of the night to see a "lethargic" child who turned out, in my vocabulary, to be just a bit "droopy" or unusually quiet but not seriously ill.

I found that to minimize the number of false alarms, I just needed to ask more questions to flesh out the child’s appearance and determine what had prompted the caller to use the "L" word. "Lethargy" seemed to mean too many different things to too many people to be of much use as a descriptor. Nonetheless, I still feel twinges of fear when I hear the word. When I encounter it in a nurse’s progress note, I always feel the need to counter it in my own note by providing a more specific description of the child’s condition.

A recent study in Pediatric Emergency Care (Webb, T. et al. 2014;30: 151-6) mirrors my experience with "lethargy." In a retrospective chart review of 272 patients aged 0-6 months, the investigators found that only 12.5% of the children who were described as having poor feeding or lethargy had a condition that required intervention. Infants who were feverish, hypothermic, or less than 35 weeks’ gestation were excluded from the study. However, infants that were described as appearing "ill" were much more likely to require intervention.

So what does a pediatrician mean when she or he describes a child as "ill looking" or "sick looking?" That is the $64,000 question (actually $560,000 in today’s dollars). We could generate a list that include abnormal vital signs, a spectrum of colors from pale to blue, and some neurologic observations, but a child looking sick or ill (and here I mean sick at level of needing immediate attention and probably intervention) is a gestalt.

Knowing when a child is seriously ill is a skill that is difficult to teach and can only come with seeing scores, and scores, and scores of children with a variety of conditions. The physician in training may not necessarily be directly involved with the care of those children, but she or he should have been close enough long enough to feel, see, smell, and hear what is going on. House officers and students should be encouraged to seek out as many of these chances to see sick and well children as they can to sharpen this skill. A mentor may help by pointing out a certain finding or collection of findings that are useful in forming the impression that this is a seriously ill child. But, it is a mistake to focus on one or two observations and not to emphasize the total picture. The ability to correctly determine that a child is desperately ill requires that the physician be able to see the trees, but not ignore the forest.

While most parents have that special sense when things are terribly wrong, we have all witnessed tragic situations when a focus on the thermometer has blurred the bigger picture that the child is desperately ill. Unfortunately, I have seen cases when a physician or nurse has been similarly deceived by a normal vital sign or laboratory result and failed to step back, look at the child, and say to themselves, "But, this child looks sick."

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at [email protected].

Pediatricians tend to be rather easygoing or at least to survive they must learn to appear calm. It is our job to keep our heads when all about us are losing theirs. However, there are certain words that can rattle even the most apparently unflappable pediatrician. For example, when a parent or nurse says a child is "grunting," I begin to get twitchy. I drop everything I’m doing, and that child receives all of my professional attention.

"Lethargic" used to be one of those pulse-quickening words for me, but over the years, it began to lose some of its coronary-tightening qualities. I had always considered "lethargic" to be a rather ominous descriptor. But, people seem to apply the term to children who were merely sleepy, listless, or just plain unmotivated. It took me a decade or two of rushing to bedsides or opening the office in the middle of the night to see a "lethargic" child who turned out, in my vocabulary, to be just a bit "droopy" or unusually quiet but not seriously ill.

I found that to minimize the number of false alarms, I just needed to ask more questions to flesh out the child’s appearance and determine what had prompted the caller to use the "L" word. "Lethargy" seemed to mean too many different things to too many people to be of much use as a descriptor. Nonetheless, I still feel twinges of fear when I hear the word. When I encounter it in a nurse’s progress note, I always feel the need to counter it in my own note by providing a more specific description of the child’s condition.

A recent study in Pediatric Emergency Care (Webb, T. et al. 2014;30: 151-6) mirrors my experience with "lethargy." In a retrospective chart review of 272 patients aged 0-6 months, the investigators found that only 12.5% of the children who were described as having poor feeding or lethargy had a condition that required intervention. Infants who were feverish, hypothermic, or less than 35 weeks’ gestation were excluded from the study. However, infants that were described as appearing "ill" were much more likely to require intervention.

So what does a pediatrician mean when she or he describes a child as "ill looking" or "sick looking?" That is the $64,000 question (actually $560,000 in today’s dollars). We could generate a list that include abnormal vital signs, a spectrum of colors from pale to blue, and some neurologic observations, but a child looking sick or ill (and here I mean sick at level of needing immediate attention and probably intervention) is a gestalt.

Knowing when a child is seriously ill is a skill that is difficult to teach and can only come with seeing scores, and scores, and scores of children with a variety of conditions. The physician in training may not necessarily be directly involved with the care of those children, but she or he should have been close enough long enough to feel, see, smell, and hear what is going on. House officers and students should be encouraged to seek out as many of these chances to see sick and well children as they can to sharpen this skill. A mentor may help by pointing out a certain finding or collection of findings that are useful in forming the impression that this is a seriously ill child. But, it is a mistake to focus on one or two observations and not to emphasize the total picture. The ability to correctly determine that a child is desperately ill requires that the physician be able to see the trees, but not ignore the forest.

While most parents have that special sense when things are terribly wrong, we have all witnessed tragic situations when a focus on the thermometer has blurred the bigger picture that the child is desperately ill. Unfortunately, I have seen cases when a physician or nurse has been similarly deceived by a normal vital sign or laboratory result and failed to step back, look at the child, and say to themselves, "But, this child looks sick."

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at [email protected].

Pediatricians tend to be rather easygoing or at least to survive they must learn to appear calm. It is our job to keep our heads when all about us are losing theirs. However, there are certain words that can rattle even the most apparently unflappable pediatrician. For example, when a parent or nurse says a child is "grunting," I begin to get twitchy. I drop everything I’m doing, and that child receives all of my professional attention.

"Lethargic" used to be one of those pulse-quickening words for me, but over the years, it began to lose some of its coronary-tightening qualities. I had always considered "lethargic" to be a rather ominous descriptor. But, people seem to apply the term to children who were merely sleepy, listless, or just plain unmotivated. It took me a decade or two of rushing to bedsides or opening the office in the middle of the night to see a "lethargic" child who turned out, in my vocabulary, to be just a bit "droopy" or unusually quiet but not seriously ill.

I found that to minimize the number of false alarms, I just needed to ask more questions to flesh out the child’s appearance and determine what had prompted the caller to use the "L" word. "Lethargy" seemed to mean too many different things to too many people to be of much use as a descriptor. Nonetheless, I still feel twinges of fear when I hear the word. When I encounter it in a nurse’s progress note, I always feel the need to counter it in my own note by providing a more specific description of the child’s condition.

A recent study in Pediatric Emergency Care (Webb, T. et al. 2014;30: 151-6) mirrors my experience with "lethargy." In a retrospective chart review of 272 patients aged 0-6 months, the investigators found that only 12.5% of the children who were described as having poor feeding or lethargy had a condition that required intervention. Infants who were feverish, hypothermic, or less than 35 weeks’ gestation were excluded from the study. However, infants that were described as appearing "ill" were much more likely to require intervention.

So what does a pediatrician mean when she or he describes a child as "ill looking" or "sick looking?" That is the $64,000 question (actually $560,000 in today’s dollars). We could generate a list that include abnormal vital signs, a spectrum of colors from pale to blue, and some neurologic observations, but a child looking sick or ill (and here I mean sick at level of needing immediate attention and probably intervention) is a gestalt.

Knowing when a child is seriously ill is a skill that is difficult to teach and can only come with seeing scores, and scores, and scores of children with a variety of conditions. The physician in training may not necessarily be directly involved with the care of those children, but she or he should have been close enough long enough to feel, see, smell, and hear what is going on. House officers and students should be encouraged to seek out as many of these chances to see sick and well children as they can to sharpen this skill. A mentor may help by pointing out a certain finding or collection of findings that are useful in forming the impression that this is a seriously ill child. But, it is a mistake to focus on one or two observations and not to emphasize the total picture. The ability to correctly determine that a child is desperately ill requires that the physician be able to see the trees, but not ignore the forest.

While most parents have that special sense when things are terribly wrong, we have all witnessed tragic situations when a focus on the thermometer has blurred the bigger picture that the child is desperately ill. Unfortunately, I have seen cases when a physician or nurse has been similarly deceived by a normal vital sign or laboratory result and failed to step back, look at the child, and say to themselves, "But, this child looks sick."

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at [email protected].