This site is intended for health professionals only

Maisie: a quiet child

There are plenty of examples of the value of telephone triage in general practice. Janet Webb has mixed views, especially when it's her doing the triage. On this occasion, she was very thankful that Maisie's mum had brought her to the open access minor illness clinic. She dreads to think what she might have made of Maisie's symptoms over the phone …

Janet Webb
BSc(Hons) RGN
DiPN(Lond)
Practice Nurse
Lindum Medical Practice
London

Maisie is three. Her mum describes her as never having been naughty. She apparently walked and talked early, does as she is told at the first telling and behaves herself at all times. She is the first child, was born at term with a normal delivery and is of mixed race, her father being of Caribbean descent and mother white Caucasian.
She has always been the delight of her parents and their extended family, being apparently especially devoted to her father - a "proper daddy's girl" - but lately the family has been ecstatic to learn that Maisie's parents are to have another long-awaited baby, and celebrations have been ongoing for the past couple of months. This has brought Maisie's increasing withdrawal into sharp focus and her devoted parents were becoming increasingly concerned at her lack of energy, failure to play and laugh, and lately her disinterest in even her favourite food.
Because Maisie had always been quite a mature child for her tender years, she responded to the news of the pregnancy by wanting to take care of her mum, and had amused the family by "helping" around the house, and encouraging her mum to sit down at every opportunity - taking the lead apparently from her dad. When her mum had morning sickness, Maisie would stand with her and rub her back or hold her hand, and would bring her a glass of water to make her feel better.
Maisie's mum found it hard to define any specific symptoms, but wondered whether it was possible for a three-year-old to be depressed. Because Maisie had taken on the role of trying to look after her mum, she wondered whether she was becoming so anxious about her mum's health that she was making herself ill. Maisie seemed to be "fading away" - the family was running out of ways to make her "snap out of it".  They had devised a series of treats and distractions, only to find Maisie feigning interest out of politeness, which was apparently typical of her, but clearly not really enthused by any of them.
What to do? As Maisie stood solemnly in front of me, the thing that struck me was the colour of her ears - the pinnas of which were butter yellow. Her sclera were clear and white, she had no rash or fever, her ears and throat seemed normal enough, no pains anywhere, bladder and bowels worked well. Her extremities were not particularly cold, urinalysis unremarkable and she was apyrexial. There was some bruising on her left shin, two fading blue bruises that were about 3 cm diameter each. Her mucous membranes seemed a little pale; I could find no other signs, but already we had the "red flag" of an undoubtedly quiet child.(1)
I have no paediatric qualifications and have no delusions about the extent of my knowledge (as Clint Eastwood said when he failed to be a jazz musician, "A man's gotta know his limitations"). I took her, with her mum, to see "my friend" (the doctor) who listened to our concerns and asked for blood tests. 
Everything happened rather quickly after that. The haematology lab telephoned the results to the surgery a couple of hours later. Maisie's haemoglobin was - unbelievably - 2.8 (normal range is 11.5-13.5). The white cells, red cells and platelets were all low, C-reactive protein raised, sodium and bicarbonate low. The doctor went round to Maisie's house; she was admitted for an emergency transfusion and bone marrow puncture, then transferred with her mum to a specialist unit. Her diagnosis of common acute lymphoblastic leukaemia (ALL) was confirmed and chemotherapy started within days. 
ALL is the commonest childhood leukaemia, and occurs in four cases per 100,000 per year, with an incidence of 450 per year in the UK with a median age of between three and seven years of age.(2) It is not typically genetic in origin.(3) There are few risk factors associated with it; a primary one being prenatal exposure to X-rays. Interestingly many cases can be found to have a prenatal origin, since the rearrangement of the T-cell receptor antigen is unique to individual leukaemia cells, and can be detected in blood samples obtained at birth. The outlook is that more than 95% achieve remission, with 75-85% surviving without recurrence for at least five years.(4)
It scares me to think of what might have happened, and it emphasises Johnson's advice: "It is important to listen to the concerns of parents, they know their own child well".(1) What might have happened if her family had been so swept along with their celebrations that Maisie's increasing withdrawal had been missed; if indeed the family had been less observant and taken a quiet three-year-old as a blessing; if her mum had telephoned for advice and been told to "keep an eye on her" (how many times we say that!). In view of her nonspecific symptoms in an habitually quiet child, I wonder how much lower her haemoglobin could have become and still been compatible with life.
Maisie is in remission now and happily helping mum to make plans for her new brother or sister, due in a month. Remission is permanent in many cases and Maisie will be followed up closely.(3)
Thank goodness for caring families.

References

  1. Johnson W. Assessing unwell children: advice for nurses. NiP 2008;40:30-3.
  2. Leukaemia Research. Childhood acute lymphoblastic leukaemia. Available from: http://www.lrf.org.uk
  3. Cancerbackup. Acute lymphoblastic leukaemia (ALL) in children. Available from: http://www.cancerbackup.org.uk
  4. National Cancer Institute. Childhood acute lymphoblastic leukaemia treatment. Available from: http://www.cancer.gov/cancertopics/pdq/treatment/childALL/healthprofessi...