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Dr. Gwenn: How can you tell if a student is really sick?

Posted August 26, 2007 11:00 pm

Gwenn Schurgin O'Keeffe, MD, FAAP

Dear Dr. Gwenn:

My question is regarding children's illnesses. I am not a parent but I work with 60 elementary school children. I have completed a senior first aid course so I am capable of assessing and treating severe illness when it comes up but I'm not particularly comfortable what to do when a child complains of illness yet shows little if any symptoms.

Often these complaints have a social trigger(for example, the child is unsatisfied with some aspect of their play environment and is looking for a little attention and comfort, or is feeling a little homesick being away from home for 6-8 hours). That said, on several occasions a child who has no symptoms is found to be quite ill within a short time (30 minutes to a few hours).

I worry that I have sometimes pandered to the attention seeking methods of a child, while at other times I may have neglected to provide sufficient comfort, care and treatment to others in need but without noticeable symptoms. I am looking for some rough guidelines for when to accept a child's diagnosis of "I'm not well" and when it is better to make my own judgment based on what I can observe. - Lindsay

Dear Lindsay:

Thank you for your question. This is a common dilemma for anyone who works with kids, teachers and parents alike! The real crux of your question is something we grapple with as pediatricians daily and can be a challenge to sort out at times.

Any one who works with children becomes part of the overall triage system when a child complains of feeling "off " or sick. Triage is an art and a skill all at once and is the medical term used to sort people according to how sick they are. In an emergency room, for example, the triage nurse determines who gets seen first based on who is the sickest and most severely injured.

The same concept applies to a school setting as well. If a child complains of being sick, a teacher is the child's first moment of triage in the health care system. Is he well enough to stay in class, does he need to visit the nurse or should you call mom and dad? Most of those moments will honestly amount to much to do about nothing.

As a teacher and not a health care professional, your role is a bit different than the school nurse's. The school nurse will be focused on the evaluation of illness, your role will be focused on wellness. Is the child off from baseline enough to be potentially sick?

As your letter illustrates, illnesses in children often evolve. If a child's illness evolves during school, you'll know that and can act accordingly. But, if a child's illness evolves so slowly that during school there are no symptoms and the child seems otherwise fine, there is really not much more you can do. All you can do is triage that child's symptoms as they are at that moment and not focus on the future.

So, when present with a moment of "I don't feel well", first be mindful of what that child's normal baseline is. Issues to consider include:

Energy level

Ability to complete tasks normally

Mood and social interactions with peers

Visible signs of illness

Overall appearance of the child

Asking yourself these questions will give you a quick picture in your mind if a child is off enough from baseline to call mom and dad.

<li>How is the child's activity level? A child who is playing normally is likely not very sick. That is always a reassuring sign. A child who complains of feeling sick but can play normally and attend to school work, does not need to leave school but can be evaluated further by his or her parents.</li>

<li>Does the child have a specific complaint or a vague complaint? Specific complaints may be more sickness driven but may not need immediate attention if the child is otherwise fine.</li>

<li>How is the child's appetite that day? Sick kids or kids getting sick tend to have a loss of appetite, even if subtle.</li>

<li>Any similar illness in the classroom or home? Kids do share their germs! If other kids have similar complaints, then sickness is more likely the culprit.</li>

<li>Does the child have a history of this sort of complaint, and what was the outcome? The child's parents are your best resource for this - some kids have a pattern they follow when they get sick but others do not.</li>

</ol>

Remember, your goal is to determine changes from baseline, not whether illness is present. If a child is off from baseline, and you have a school nurse, the school nurse can help you decide if the child is well enough to stay in school or if that child needs to go home. You should never feel you are operating in a vacuum especially if you are worried a child is becoming ill. Rely on your school nurse and rely on mom and dad. And, in the end, keep in mind that a well appearing child is almost always well at that moment.

Best,

Dr. Gwenn

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