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Now, as a new graduate, I had a bunch of struggles. One of the things that I was super afraid of was missing a sick kid. If I looked at a kid that had a fever and I sent them home and I thought that they had a URI or some benign self limiting infectious disease like Otitis Media, but they really were early sepsis, I do not know how I would have lived with myself. So I found myself working up a lot of kids. The nurses must have hated working with me because if I wasn’t sure I was working the kid up right.

It took hundreds, thousands of kids before I realized there’s a very big difference in a kid with 103 temp that has Otitis Media versus a kid with 103 temp that has sepsis. This is taught in PALS, Pediatric Advanced Life Support, but the mnemonic that I’d like to share with you has never steered me wrong. It’s been of great benefit for me and it’s something you need to apply immediately and make sure you communicate and document it.


So, what’s the difference between a kid with 103 temp that’s got Otitis Media versus sepsis? The mnemonic I teach is TICKLES. You TICKLES them. T-I-C-K-L-E-S, TICKLES. If they fall off the TICKLES mnemonic and the TICKLES does not apply to them, they’re sick.


So, T is tone. Do they have a strong tone or a weak tone? With a strong tone, they’re going to fight your ear exam, they’re going to push your stethoscope away, they’re going to cry when you walk in. That’s great! If it’s a weak kid and they’re floppy, that is sinister. Otitis Media kids are strong; they have a strong tone, a good tone.

I and C

The I stands for irritable and the C stands for consolable. They go together. I document this classically. Patients are appropriately irritated by provoking exam and are consolable by parent. So I walk in the room, the kid’s not going to like me, be afraid of me and just want Mom, okay? That’s a good thing, that’s what we want and that’s not a sick kid, it’s an Otitis Media kid. So, I and C kind of go together: irritable, consolable.


K is cry. I need to qualify their cry. Is it a loud, aggressive, vigorous cry or is it a wimpy cry? It really is very closely related to tone. Now I’m going to document it. “Hey, they have a loud, vigorous cry versus this soft, wimpy cry.” And holy cow is it sinister when you do a venipuncture on a kid and they have this little, “Ahhh, ahhh, ahhh!” This wimpy cry without a change in their tone or pitch is very concerning.


The L is labor. You have to know what laborious breath sounds and looks like. If you do not know what that looks like, if you can’t close your eyes right now and picture it, you need to YouTube it. You need to know what retractions look like; you need to know what nasal flaring looks like. You have to know a kid who’s got laborious breathing. That’s mild, moderate, or severe.

If you said, “John, I’ll give you an option. You could look at a kid’s vital signs or you can just look at their chest wall for eight seconds.” I would take the chest wall, because that’ll give me a much better feel for how sick my kid is.


The E is environment. Are they appropriately stimulated when I walk into the room? That kind of goes with the I and the C. Are they looking at me? If I dangle my keys, are they looking at the noise? If I clap my hands, are they looking to see where that sound came from? A sick kid will not be appropriately stimulated by the environment.


And the S is suckling, meaning that I really need to get a good history on their eating. Have they been eating and drinking? Typically, kids with Otitis Media, their solids are going to go pretty much non-existent, but their liquids should be half normal. Really sick kids won’t eat anything. In PALS, we call that the look. They have the look, they have the look of a sick kid.

So, make sure you look for these, document them and communicate it.

Have I ever been fooled by this? No, not in a way that you’d think. I’ve had kids that looked really poopy and sick and I’m like, “Okay, this person looks like they might be septic.” And I realized they’re just febrile and dehydrated, and once I gave them an antipyretic and tank them some fluids they looked fantastic. I’ve never had the opposite way, have a sick kid slip by me. Thank God I’ve never sent home a sick kid that I know of!

Now, don’t be fooled by something. If you have a kid with 103 temp and you give them Tylenol or Ibuprofen and their temperature goes down to 99, what does that mean? Does it mean the kid is less sick or more sick or we don’t know? Defervescence of fever really makes no difference in any kind of clinical judgment about how sick they are. So, it’s nice that we can get the temperature down and good medicine, but overall it does not tell me that the kids is sick or not sick. Do not use response to antipyretics to give you any clinical information about how sick the kid is or how possibly self-limiting the problem is.

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