Helping parents identify severe illnesses in their children

General practice p 1740

The management of sick children is both a microcosm of primary care and a test of its success—if we cannot get this right we cannot justify any claims to excellence. General practitioners see lots of children, and most of them have minor, self-limiting illness. The fourth national morbidity survey reports a consulting rate of 4.97 for children aged 4 and under, a rate exceeded only by those aged 75 and over. When the illnesses are classified as minor, intermediate, or serious the consulting rate for minor illness is the highest of any age group.1 General practitioners have the task of dealing with this high volume of work quickly and efficiently, without overtreating the children or making parents feel they have been the victims of perfunctory or, worse, incompetent care. At the same time, and most important of all, they must be able to identify the small numbers of children with serious illness.

For many general practitioners the amount of time that work with minor illnesses takes up, among adults as well as children, is a source of frustration. We know we can do next to nothing to alter the course of the illness and often it is hard so see what either doctor or patient gets out of the encounter. If patients could be encouraged to deal with minor illness without professional help their confidence in their health and their sense of independence would be enhanced, and professionals' time could be liberated to address other tasks where our skills are more effectively deployed. Any intervention that supports parents' ability to identify minor illness correctly and professionals' ability to identify serious illness correctly is welcome.

In this week's issue Thomson and colleagues report a randomised controlled trial using Baby Check to improve parents' assessment of their babies' health (p 1740).2 Baby Check is a scoring system using 19 symptoms and signs, designed to enable parents and professionals to assess the seriousness of illness in babies aged 6 months and under. It grades infantile illness into four levels of severity.3 The study by Thomson et al confirms the prediction of the original Baby Check authors, that its use would not increase the numbers of mothers seeking medical care.4 Neither, however, did Baby Check reduce the demand for care. Nor did it influence the demand for out of hours services or the patterns of prescribing that took place in the subsequent consultations.

Enthusiasts for Baby Check should not be disappointed with this result. At one end of the range of illness severity it does have the potential to empower parents with better information. In the original field trials up to 81% of mothers found it useful and 96% would recommend it to others.4 In a subsequent qualitative study Kai has reported on the use of Baby Check in a group of socioeconomically disadvantaged families: the parents found that it was helpful, reducing anxiety and increasing their confidence in coping with illness and dealing with doctors.5 General practitioners both trusted it and reported that they would want mothers, health visitors, and midwives to use it.6

Baby Check has established its ability to identify severe illness accurately, both in the original papers,6 and more specifically in two case-control studies of deaths in infancy, where Baby Check scores were estimated after death for index babies and compared with scores for controls. In the New Zealand study, where sharing a room for sleeping with one or more adults was associated with a reduced risk of sudden infant death syndrome, the risk of death was associated with an increased Baby Check score in the previous two days.7 The report of the fifth annual confidential inquiry into sudden infant death focused on the explained group of sudden unexpected deaths, comprising 20% of the total. In this small group, when the third grade of illness (“the baby is ill and needs a doctor”) was used as the cut off, Baby Check identified 44% of index cases as requiring attention, compared with 3% of controls.8

In the end reducing the consulting rates for minor illness, particularly among this vulnerable age group, may not be a worthwhile outcome to aim for. A study published many years ago evaluating a leaflet containing information on illness among children aged under 5 years showed that the leaflet did succeed in reducing the consulting rates for three of the six symptoms covered. However, the authors acknowledged the concern (which they were unable to answer) that such interventions could deter patients from consulting when it is desirable.9 Parents might legitimately ask how to cope with public information messages that simultaneously exhort them “Don't trouble your doctor unless it's absolutely necessary” and “If you're bothered that your child might possibly have meningitis, consult your doctor immediately.”

We should, perhaps, aim not at fewer consultations but better ones. For instance, in Thomson et al's study prescriptions were issued in more than half of the consultations, with oral antibiotics being the largest category. This sounds worrying, and is an echo of general concerns about excessive prescribing of antibiotics. Mothers consulting general practitioners with sick children continue to have difficulty communicating with doctors and making sense of the information received.10 If used widely by mothers and professionals, Baby Check could improve the quality of many consultations, and might yet prevent some deaths in infancy.