Ill and Feverish Child

This document is mainly based on the NICE guidelines 'Feverish illness in children' published in May 2007.¹ It includes information on assessment and pre-hospital care by non-paediatric specialists.

Fever, or pyrexia, is when the body temperature rises above normal. The average normal body temperature taken in the mouth is 37°C but anywhere between 36.5°C and 37.2°C is deemed as normal. When temperatures are measured in the axilla they can be 0.2ºC to 0.3ºC lower than this. Aural (tympanic) thermometers may measure the temperature as higher.

Fever is one of the commonest reasons for a child to be taken to see a doctor and is the second most common reason for a child to be admitted to hospital.¹

The cause of the fever can sometimes be hard to elicit and this can be a worry for healthcare professionals. It is usually due to a viral infection that is self-limiting but it can also be a sign of serious bacterial infection including meningitis. Early diagnosis of serious infections in general practice is difficult as incidence is low, the child may present early in the disease process and diagnostic tools are more or less limited to history and examination.²

History should include:

• How long has the fever been present?
• Has the parent/carer been measuring temperature themselves and if so by what method?
• Is there a rash? If so, is it blanching or non-blanching?
• Are there any respiratory symptoms, e.g. cough, runny nose, wheeze?
• Has the child been clutching at their ears?
• Has there been excessive or abnormal crying?
• Are there any new lumps or swellings?
• Are there any limb or joint problems?
• Any history of vomiting or diarrhoea? Is the vomiting bile-stained or is there any blood in the stool?
• Has there been any recent travel abroad?
• Has there been any contact with other people who have infective diseases?
• Is the child feeding normally (fluids and solids as appropriate)?
• What is the urine output? Have nappies been dry?
• How is the child handling? Normal self/drowsy/clingy etc.?
• Have there been any convulsions?
• Is there any significant past medical history/regular medication/allergies?

Other points to consider from the history:

• Level of parental anxiety and instinct (they know their child best).
• Social and family circumstances.
• Other illnesses affecting the child or other family members. Has there been a previous serious illness or death due to febrile illness in the family?
• Has the child been seen before in the same illness episode?

1. Identify any immediately life-threatening features: Assess Airway, Breathing, Circulation and Consciousness.
2. Measure body temperature:
   • Infants < 4 weeks: Measure with electronic thermometer in axilla.
   • Child aged 4 weeks to 5 years: Measure with either electronic thermometer in axilla, chemical dot thermometer in axilla or infra-red tympanic thermometer.
   • Take parental reported fever seriously.
   • Temperature ≥ 38°C in an infant aged 0-3 months is a red-light sign. (see below)
   • Temperature ≥ 39°C in a child aged 3-6 months is a red-light sign. (see below)
3. Look at skin, lips and tongue colour: Normal/pallor/mottled/ashen/blue?
4. Look at activity level of child: Responsive/content and smiling/awake or easily rousable/normal cry?
5. Examine the respiratory system:
   • Measure respiratory rate. There is tachypnoea if respiratory rate is:
     > 60 breaths/minute age 0-5 months
     > 50 breaths/minute age 6-12 months
     > 40 breaths/minute age older than 12 months.
   • Look for nasal flaring/grunting/chest indrawing.
   • Auscultate the chest for crackles or wheeze.
   • Measure oxygen saturation if possible.
6. Examine the cardiovascular system: Measure heart rate, auscultate the heart. Is the pulse volume normal or weak? Blood pressure should be measured if the heart rate or capillary refill time are abnormal and there are the facilities to measure it.
7. Assess the level of hydration: Do the eyes and skin look normal? Is there reduced skin turgor? Are the mucus membranes moist? What is the capillary refill time (capillary refill time ≥ 3 seconds is considered abnormal)? Are the extremities warm or cool? Is the child feeding normally? Is the urine output reduced?
8. Examine for other features:
   • Rash: If there is a rash, is it blanching or non-blanching?
   • Any new lumps?
   • Is there limb or joint swelling or problem with weight bearing?
   • Normal or bulging fontanelle?
   • Neck stiffness?
   • Focal neurological signs/convulsions?

After history and examination have been performed, specific illnesses should be considered.

• Meningococcal disease: This should be considered in any child with a fever and a non-blanching rash especially if the child looks ill, there are purpura present (non-blanching lesions > 2 mm in diameter), capillary refill time is ≥ 3 seconds or there is neck stiffness.
• Meningitis: Consider this if there is fever plus any of neck stiffness, bulging fontanelle, decreased consciousness or convulsive status epilepticus. Classical signs of meningitis may be absent in infants.
• Herpes simplex encephalitis: Consider if fever plus focal neurological signs, seizures or reduced level of consciousness.
• Pneumonia: Consider if fever plus increased respiratory rate, chest crackles, nasal flaring or chest indrawing, cyanosis or oxygen saturation ≤ 95% on air.
• Urinary tract infection: Consider in any child < 3 months with fever. In children older than 3 months, consider if there is associated vomiting, poor feeding, lethargy, irritability, abdominal pain or tenderness, urinary frequency or dysuria or offensive urine or haematuria.
• Septic arthritis and osteomyelitis: Consider if there is limb or joint swelling or non-use or non-weight bearing of an extremity.
• Kawasaki disease: Consider this if there is fever that has lasted > 5 days plus 4 of the following:
  • Bilateral conjunctival injection
  • Change in mucous membranes in the upper respiratory tract (injected pharynx, dry cracked lips, strawberry tongue)
  • Change in the extremities (oedema, erythema, desquamation)
  • Polymorphous rash
  • Cervical lymphadenopathy

NICE recommends that a traffic light system should be used to predict the risk of serious illness when the symptoms and signs have been elicited from the history and examination. The following table summarizes this system. If the child has any of the symptoms or signs in the amber column, they are at intermediate risk of serious illness. If they have any of the symptoms or signs in the red column they are at high risk of serious illness.

Management by remote assessment, e.g. by telephone

• The history should be elicited from the parent/carer as outlined above.The parent/carer should be questioned as to any signs that they may be able to recognise.
• If immediate life-threatening illness is suspected due to obvious difficulty of the airway, breathing, circulation or conscious level, 999 should be called and the child should be referred for emergency medical care.
• Children with any red features not considered to have an immediate life-threatening illness should be seen within 2 hours by a healthcare professional.
• Children with any amber features should be seen by a healthcare professional but the assessment of urgency of the appointment is left to the clinical judgement of the assessor.
• Children with only green features can be managed at home with advice for parents and carers, including advice on when to seek further help.

Management by the non-paediatric practitioner

This includes professionals working in primary care and also those working in general accident and emergency departments.

• If immediate life-threatening illness is suspected due to obvious difficulty of the airway, breathing, circulation or conscious level, and the child is not already in hospital, 999 should be called and the child should be referred for emergency hospital care. If the child is in hospital, the paediatric team should be called. Basic life support measures should be undertaken by the practitioner.
• Otherwise, clinical assessment, including history taking and examination, should be carried out and any symptoms and signs of serious illness and specific diseases should be elicited.
• Assessment using the traffic light system should be performed.
• Children with any red features should be referred for urgent assessment by a paediatrician.
• Children with any amber features in whom a specific diagnosis has not been made should either be referred to urgent paediatric care or the carers of the child should be given a 'safety net' either detailing exactly when to seek further help (i.e.specific warning symptoms or signs) or arranging a further follow-up assessment.
• Children with only green features can be managed at home with advice for parents and carers, including advice on when to seek further help.
• Oral antibiotics should not be prescribed if there in no identifiable source of the fever.

Management of specific diseases

• If there is no obvious source of infection, urine should be tested in children presenting with fever.
• If meningococcal disease is suspected, antibiotics should be given at the earliest opportunity.

• Antipyretic treatment: Tepid sponging is not recommended. Do not under dress or over wrap children. Give either paracetamol or ibuprofen, using the alternative drug if the child does not respond to the first agent.
• Give regular fluids: Breastmilk if the child is breastfed.
• Monitor for signs of dehydration: Sunken fontanelle or eyes, dry mouth, absence of tears, poor appearance.
• Monitor for appearance of rash: Advise on how to assess if a rash is non-blanching.
• Get up in the night to monitor the child.
• Keep the child away from school or nursery while they have a fever and notify them.
• When to seek further help: If the child has a fit, develops a non-blanching rash, appears less well, the parent or carer is worried, the fever lasts > 5 days, the parent or carer is distressed or feels they cannot look after the child.
• Provide written information: Give the parent or carer a copy of the NICE 'Feverish illness in children: Discharge advice sheet' (see below).