Urgent considerations

See Differentials for more details

Sepsis

It is important to consider sepsis in any febrile unwell child with acute limp, not weight-bearing, or unable to move the joint (septic arthritis or osteomyelitis).[13]

Sepsis is a spectrum of disease, where there is a systemic and dysregulated host response to an infection.[14] Presentation ranges from subtle, non-specific symptoms (e.g., feeling unwell with a normal temperature) to severe symptoms with evidence of multi-organ dysfunction and septic shock. Patients may have signs of tachycardia, tachypnoea, hypotension, fever or hypothermia, poor capillary refill, mottled or ashen skin, cyanosis, newly altered mental state or reduced urine output.[13] Sepsis and septic shock are medical emergencies.

Risk factors for sepsis include: aged under 1 year, impaired immunity (due to illness or drugs), recent surgery or other invasive procedures, any breach of skin integrity (e.g., cuts, burns), and indwelling lines or catheters.[13]

Early recognition of sepsis is essential because early treatment improves outcomes.[13][15][Evidence C]​​​​​​ However, detection can be challenging because the clinical presentation of sepsis can be subtle and non-specific. The key to early recognition is the systematic identification of any patient who has signs or symptoms suggestive of infection and is at risk of deterioration due to organ dysfunction. Criteria to identify sepsis and septic shock in children and people under the age of 18 years have been developed.[16]​ Several other risk stratification approaches exist. All rely on a structured clinical assessment and recording of the patient’s vital signs.[13]​​[16][17]​​​​​[18]​​​​​[19] ​It is important to check local guidance for information on which approach your institution recommends. The timeline of ensuing investigations and treatment should be guided by this early assessment.[19]

Treatment guidelines have been produced by the Surviving Sepsis Campaign and remain the most widely accepted standards.​[15]​ Within the first hour:[15]

  • Follow institutional protocols for management of sepsis/septic shock in children; these improve the speed and reliability of care

  • Obtain blood cultures before administering antibiotics (provided this does not substantially delay antibiotic administration)

  • Administer broad-spectrum antibiotics

  • Administer crystalloid fluids, titrated to clinical signs of cardiac output and stopped if there is evidence of volume overload. Consult local protocols.

Use trends in blood lactate levels to guide resuscitation. If the child’s hypotension is refractory to fluid resuscitation, consider use of vasopressors.[15]

​Several studies have demonstrated the importance of protocolised care and care bundles in paediatric sepsis.[15][20][21][22][23][24]​​​​​​​​​​

For more information see the BMJ Best Practice topic Sepsis in children.

Malignancy

Malignancy should be suspected in children with persistent pain, bone pain, bone/soft-tissue swelling, and systemic upset (fever, weight loss, night sweats, or presence of lymphadenopathy, abdominal mass, or organomegaly). Musculoskeletal complaints are common in the presenting symptoms of childhood leukaemia.[10]​ Early detection and prompt therapy have potential to reduce mortality.

Non-accidental injury

The presence of unusual skin marks, multiple bruises of varying ages, recurrent instances of 'unexplained' injury, delayed presentation and certain types of injuries (metaphyseal 'bucket handle' fractures, long-bone fractures, posterior rib fractures) should raise suspicion of non-accidental injury. If non-accidental injury is suspected, or if any behaviours trigger safeguarding concerns, local policies must be followed.[25][26][27]

Inflammatory disorders

Inflammatory disorders may present with fatigue, rash, myalgia, arthralgia, pain, fever, malaise, and multisystem involvement. In some cases of inflammatory arthritis (such as JIA or inflammatory muscle disease), the presentation can be indolent with regression of motor milestones, with or without systemic upset. There is significant morbidity and mortality associated with delay in diagnosis and access to appropriate treatment. Where suspected, prompt referral to paediatric rheumatology is recommended and should not be delayed while waiting for investigations. Local pathways for referral may differ and it is important to be aware of how to seek advice when concerned.

Further information about paediatric musculoskeletal medicine, including red flags, clinical skills and guidance on musculoskeletal examinations (pGALS, pREMS), investigations, and referral guidance, is available at Paediatric Musculoskeletal Medicine (PMM). Paediatric Musculoskeletal Matters (PMM): an e-resource to aid teaching and learning about the essentials of paediatric musculoskeletal medicine Opens in new window

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