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The ill and feverish child

Children produce a high temperature very easily. They also change very fast and symptoms and signs can be very non-specific. This, along with the emotive factors of caring for an ill child, can make the situation very demanding. Children under 5 and especially those under 18 months may suffer febrile convulsions.
Sometimes it can be quite difficult to make a diagnosis without invasive investigations but it is important to try to differentiate between serious and potentially life threatening illness like meningitis and self-limiting illness like a cold. It is not uncommon for a doctor in primary care to have a child whom he cannot diagnose but the child is obviously very unwell and needs admission to hospital for investigation, observation and management.

Fever is defined as a rise in core body temperature. There is considerable debate over the role of fever in the immune system response to infection, and therefore how aggressively it should be treated with antipyretics. Various sources give different core threshold values for a significant fever. Oral and axillary temperatures are approximately 0.5°C and 1.0°C below rectal (core) temperature respectively. Body temperature fluctuates with a circadian rhythm, varying by more than 1°C over a day. Tympanic thermometers are very popular. There is some doubt over their reliability especially in young children but they do seem to be reasonably reliable.¹ Many parents do not know how to use a standard thermometer² and fever strips applied to the forehead are very popular but of little use.

Epidemiology: It is an extremely common problem that may account for up to 30% of patients seen in an emergency setting.

History: In the hospital setting of an A&E department parents present with the child but in primary care they usually telephone first. One of the first questions to ask is what they have given the child to bring down the temperature. Very often they have given nothing or they may have given an inadequate dose like 120mg of paracetamol to a child of 7 or the dose may have been given a long time ago and has worn off. In a study of a paediatric accident and emergency department in Sheffield about a third of pyrexial children had been given nothing.³ Paracetamol lasts about 4 hours. Ibuprofen lasts about 6 to 8 hours. Sometimes parents are reluctant to give an antipyretic before the child is seen for fear of masking signs. They must be reassured on this count. On other occasions parents give alternating paracetamol and ibuprofen doses in the hope of achieving continuous effect but this is not effective and might even increase the risk of adverse effects. Often the child is wrapped up and so cannot loose heat. Parents are sometimes reluctant to bring a feverish child out on a cold night and want a domiciliary visit. They must be reassured and when they arrive at the primary care centre they usually find that the cold night air has had a beneficial effect, lowered temperature and the child appears much better.

The doctor should be careful not to put too much emphasis upon the exact level of the temperature or the effectiveness of the response to an antipyretic. Temperature is purely a response to infection and the degree of reduction with medication does not help differentiate between severe and mild infections. Reducing temperature will help the child to feel better and it may even prevent febrile convulsion but pyrexia should be treated as a symptom rather than an illness. It is a labile parameter and measurement by either a parent in the home or a doctor in a consulting room may be fraught with much inaccuracy. Other features to indicate whether or not the child is severely unwell are more important. The doctor's clinical acumen is challenged.

History should proceed in the usual manner trying to find a cause for the pyrexia but also asking about feeding, apparent awareness of surroundings and such features as give a general indication of wellness of the child. Note past medical history including asking about recurrent urinary tract infection. Given the chance to talk, parents may express anxiety as the child has been seriously ill before or a sib or friend's child has had a serious illness.

Ask about immunisations too. A child with coryzal symptoms who has not had the MMR vaccine may be in the early stages of measles.

If there are convulsions and status epilepticus it must be treated as meningitis until proved otherwise.⁴

Examination: Examination of the child proceeds in the normal way.

• Use a reliable instrument to record temperature and note the site of recording.
• Note the general condition of the child. Is he alert and responsive? Is he interested in the examiner and do his eyes follow you around the room? If the child is totally listless and lethargic with no interest in the new person this suggests serious illness. Is the child irritable?
• Look at the skin. There may be evidence of dehydration. There may be a vague heat rash or one suggestive of infectious disease, including a macular rash that does not blanche on pressure implying meningococcal meningitis or, more correctly, meningococcal septicaemia.
• Examination of ears, nose and throat may show coryza, tonsillitis or otitis media.
• Note expiratory rate and examine the chest. Note colour and perfusion.
• Examine the abdomen. There may be tenderness over the renal angles in pyelonephritis or suprapubic tenderness in urinary tract infection. Remember acute surgical problems in children including appendicitis.

At the end of history and examination it is possible to identify a source of infection in about 80%.⁵ Absence of an apparent source is commoner in younger children.

To admit or discharge? This will depend largely upon the diagnosis if one has been made, but social factors including parental anxiety, ability of the parents to cope and the confidence of the doctor may all influence the decision of admission to hospital or return home.
If the doctor has not made a firm diagnosis to influence his decision there are a number of factors to sway him:

• Lethargy, irritability, poor perfusion or tachypnoea all suggest admission
• The younger the child the greater the risk of missing serious illness because of lack of physical signs. Risk groups can be stratified as under 1 month, 1 to 3 months, 3 months to 3 years and over 3 years
• Suspicion of an infectious disease like measles or chicken pox should push the balance away from admission without ruling it out. If such a disease spreads to children being treated for leukaemia, for example, it can be fatal.
• A high core temperature of over 38.0-38.5°C for a child of 3 months or less and 39.0-39.5°C for over 3 months suggest admission. In a study from Newcastle, a third of children with a temperature above 38ºC had serious illness.⁶
• Any child that is known to be immunodeficient.

Investigation:

• In primary care there is usually little that is done in terms of investigation although GPs have been criticised for not getting urine examination performed more often.⁷ Obtaining a clean and reliable sample from a child who is not yet continent is not easy. If the child is admitted to hospital this will probably be routine. UTI occurs in about 4% of boys under 1 and 9% of girls under 2 who are admitted to hospital with fever where a source has not been identified.⁵
• Sometimes CXR may show unexpected lung disease
• In small children clinical signs of meningitis like neck stiffness and Kernig's sign may be negative and so lumbar puncture may be required to exclude meningitis
• FBC may give an indication of severity of infection. Some paediatricians like to get ESR or CRP. Blood culture may show unsuspected septicaemia. This tends to affect children under 2 years of age. 90% of cases are due to pneumococcus but 1% are due to meningococcus. In a child with a temperature above 39.5ºC the risk of bacteraemia is between 1 and 5% if the WCC is under 15,000 mm^-3 but between 10 and 15% if it is over 15.⁵

Management: An expert committee from UCLA (Los Angeles) drew up guidelines for the management of children under 36 months old.⁸ Toxic and febrile children under 28 days old should receive parenteral antibiotics. Between 1 and 3 months of age, if laboratory results suggested low risk they could be managed outside hospital. If WCC exceeds 15,000 mm^-3 there should be blood culture although it may be more practical to take the blood culture at the time of the initial FBC rather than waiting for the WCC result. Urine cultures should be obtained from all boys 6 months of age or less and all girls 2 years of age or less who are treated with antibiotics. Ideally a suprapubic aspirate or a catheter should be used in an infant or young child who has not yet mastered continence. A clean midstream catch is suitable for older children but a urine bag collection gives unreliable results.
The American approach is orientated towards early administration of antibiotics but other care pathways suggest a more expectant approach and being slower to start antibiotics. What is essential with any regime is early review of the child.

Where applicable the underlying condition is treated. This means giving an appropriate antibiotic for a bacterial infection but this is not a substitute for treating the temperature and this must be impressed on the parents. The 3 drugs that have been most examined for antipyretic and analgesic effect in children are aspirin, paracetamol and ibuprofen. The doses recommended below are for guidance only and are not invariable. If a child is rather small and at the younger end of the age range the stated dose may be too high, especially if given repeatedly over 48 hours or more.

• Aspirin is associated with a small but finite risk of Reye's syndrome. Although it is rare aspirin must not be used for children under 12
• Paracetamol is safe and has been used for many years. The dose for acute fever, according to the BNF, is:
  • 3 months to 1 years old, 60 to 120mg
  • 1 to 5 years old 120 to 250mg
  • 6 to 12 years old 250 to 500mg
  • All these doses can be repeated at 4 to 6 hours intervals with no more than 4 doses in 24 hours

• Ibuprofen has also stood the test of time and is reasonably safe. There are some reports of gastrointestinal haemorrhage, rashes and asthma. There is no reason to believe that coxibs are any safer.⁹ According to the BNF the dose is:
  • 1 or 2 years old, 50mg 3 or 4 times daily
  • 3 to 7 years 100mg, 3 or 4 times daily
  • 8 to 12 years 200mg, 3 or 4 times daily.

Paracetamol has the advantage of being licenced for use under 1. Ibuprofen has a longer duration of action. Both seem to be very safe, even in children under 2.¹⁰ A paper from France in 1997 compared the efficacy of aspirin, paracetamol and ibuprofen for pain and temperature in children and found that ibuprofen was more effective than the other two.¹¹ It is of some concern that aspirin was included in such a recent trial.
There may be some reticence about using a NSAID like ibuprofen in children with a history of asthma but the evidence is very reassuring.^12,13 Obviously, if there is a history of asthma precipitated by ibuprofen it should be avoided.
Physical methods can also be used to cool children although the evidence suggests that they should be an adjunct to antipyretic treatment rather than a substitute.¹⁴ Sponging should be with tepid rather than cold water as the latter may cause vasoconstriction and even elevate core temperature. Mopping the fevered brow whilst the child is swathed in blankets is useless. The forehead represents a very small fraction of the surface area of the body. The child should be stripped to permit the loss of heat and sponged all over. A fan may be helpful and less distressing than sponging but probably it is less effective. If the child is stripped to just a nappy there is a large amount of exposed skin to loose heat.

References Used

1. Childs C, Harrison R, Hodkinson C; Tympanic membrane temperature as a measure of core temperature.;Arch Dis Child 1999 Mar;80(3):262-6.[abstract]
2. Blumenthal I; What parents think of fever.;Fam Pract 1998 Dec;15(6):513-8.[abstract]
3. Mason S, Thorp S, Burke D; Prehospital use of paracetamol among children attending the accident and emergency department.;Emerg Med J 2003 Jan;20(1):88-9.[abstract]
4. Chin RF, Neville BG, Scott RC; Meningitis is a common cause of convulsive status epilepticus with fever.;Arch Dis Child 2005 Jan;90(1):66-9.[abstract]
5. Baraff LJ; Management of fever without source in infants and children.;Ann Emerg Med 2000 Dec;36(6):602-14.[abstract]
6. Nademi Z, Clark J, Richards CG, et al; The causes of fever in children attending hospital in the north of England.;J Infect 2001 Nov;43(4):221-5.[abstract]
7. van der Voort J, Edwards A, Roberts R, et al; The struggle to diagnose UTI in children under two in primary care.;Fam Pract 1997 Feb;14(1):44-8.[abstract]
8. Baraff LJ, Bass JW, Fleisher GR, et al; Practice guideline for the management of infants and children 0 to 36 months of age with fever without source. Agency for Health Care Policy and Research.;Ann Emerg Med 1993 Jul;22(7):1198-210.[abstract]
9. Titchen T, Cranswick N, Beggs S; Adverse drug reactions to nonsteroidal anti-inflammatory drugs, COX-2 inhibitors and paracetamol in a paediatric hospital.;Br J Clin Pharmacol 2005 Jun;59(6):718-23.[abstract]
10. Lesko SM, Mitchell AA; The safety of acetaminophen and ibuprofen among children younger than two years old.;Pediatrics 1999 Oct;104(4):e39.[abstract]
11. Autret E, Reboul-Marty J, Henry-Launois B, et al; Evaluation of ibuprofen versus aspirin and paracetamol on efficacy and comfort in children with fever.;Eur J Clin Pharmacol 1997;51(5):367-71.[abstract]
12. Lesko SM; The safety of ibuprofen suspension in children.;Int J Clin Pract Suppl 2003 Apr;(135):50-3.[abstract]
13. Lesko SM, Louik C, Vezina RM, et al; Asthma morbidity after the short-term use of ibuprofen in children.;Pediatrics 2002 Feb;109(2):E20.[abstract]
14. Meremikwu M, Oyo-Ita A; Physical methods for treating fever in children.;Cochrane Database Syst Rev 2003;(2):CD004264.[abstract]

Internet:

• Great Ormond Street Hospital Febrile convulsions, information for patients

Acknowledgements EMIS is grateful to the Mentor authoring team for updating this article originally revised by Dr Adrian Bonsall. The final copy has passed peer review of the independent Mentor GP authoring team. ©EMIS 2005.

Last issued 02 Nov 2005