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Whether you are looking to learn more about paediatric musculoskeletal problems, or are involved in the care of children, then PMM and PMM-Nursing will help you change your clinical practice for the better.

Recognition of the Sick Child

Red Flags typically refer to features that may suggest serious life threatening disease such as malignancy (e.g., leukaemia), infection (e.g., septic arthritis or osteomyelitis) or non-accidental injury.   Red flags may also suggest multisystem or inflammatory disease.

Further information is available:

Features that suggest severe life threatening conditions:

Non-accidental injury (NAI)

  • Delay in seeking medical attention. History inconsistent with pattern of injury. Explanation of injury incongruent with developmental stage of child. Repeated presentations. Un-witnessed injury
  • Patterns of injury suggestive of NAI (e.g., bruising over soft tissue areas, multiple bruises, bruises that carry the imprint of an implement or instrument), distinctive burns e.g., round cigarette burn, forced immersion burn.
  • Complete non-weight bearing with occult fracture. Type of fracture e.g., metaphyseal fracture, posterior rib fractures, skull fracture, any type of fracture in a non-ambulant child. Multiple injuries.
  • Unkempt appearance and poor hygiene.


  • Night pain. Pain severe and non-remitting. Bone pain.
  • Pallor, Bruising, Lymphadenopathy, Hepatosplenomegaly.
  • Abnormal blood count (Anaemia, thrombocytopenia).
  • Systemic symptoms (lethargy, weight loss, night sweats, fever).
  • Complete non-weight bearing.
  • Back pain in the unwell child.


  • Complete non-weight bearing. Pseudo-paralysis of limb. Any attempt to passively move the limb is resisted and causes extreme distress. Limb held in a position which accommodates increased joint volume due to effusion, e.g., a flexed knee with a mild effusion. Back pain in the unwell child.
  • Pain severe and non-remitting. Night pain and waking. 
  • Fever or absence of fever in immunosuppressed patients.
  • Immunocompromised child - due to primary disease or medications.

Red flag features may also suggest inflammatory disease (muscles, joints or multisystem)

  • Malaise or / systemic upset (fever, reduced appetite, weight loss, sweating, lethargy, pallor, lymphadenopathy, organomegaly).
  • Night pains - not responding to simple (paracetamol/ibuprofen) analgesia.
  • Myoglobinuria – “coca-cola coloured" urine (sign of muscle destruction).
  • Pain in bones - often described as deep and throbbing in nature, rather than joints.
  • Bone tenderness - consistent with Inflammatory conditions, malignancy.
  • Behavioural change (irritable, poor sleep) 
  • Swollen joint(s) (often subtle or difficult to appreciate).

Assessment of the sick child 

  • When a patient is deteriorating or critically ill the 'ABCDE' structured approach to assessment should be used i.e., Airway, Breathing, Circulation, Disability, Exposure. This approach ensures that life-saving treatment is provided before moving on to the next stage of the assessment.  
  • Children who are immunosuppressed (through their disease or their treatment) may not demonstrate typical features of infection.
  • A low threshold to be concerned is needed and specialist advice should be sought. Such patients are often admitted for observation.  
  • The Paediatric Early Warning Score (PEWS) is often used to monitor children who may deteriorate rapidly (e.g., with sepsis).

Further resources are available