BMJ Learning

Feverish illness in young children: in association with NICE

د. حسين محمد جمعة
اختصاصي الامراض الباطنة
البورد العربي
كلية طب الموصل
2010

Assessing a child with a feverish illness is not always easy. It usually indicates an underlying infection and is very common in young children, with between 20 and 40% of parents reporting such an illness each year. As a result, fever is probably the most common reason for a child to be taken to the doctor.

Fever in young children can be a diagnostic challenge .In most cases, the illness is due to a self limiting viral infection. But fever may also be the presenting feature of serious bacterial infections such as meningitis or pneumonia.
Infections remain the leading cause of death in children under the age of 5 years.

Many children have no obvious cause of fever despite careful assessment. Children with fever without an apparent source are of particular concern to healthcare professionals because it is particularly difficult to distinguish between simple viral illnesses and life threatening bacterial infections in this group.

Peer review

This module was reviewed by Dr John Jenkins, senior lecturer in child health and consultant paediatrician, Paediatric Department, Antrim Hospital; Dr Chetan Sandeep Ashtekar, consultant paediatrician, Nevill Hall Hospital, Abergavenny; and Dr P Ramnarayan, consultant in paediatric intensive care, Children's Acute Transport Service and St Mary's Hospital.

National Institute for Health and Clinical Excellence guidelines

The guidelines in this module offer practical advice, but they are not meant to replace clinical judgment. Even though the modules unfold in a linear manner, we realise that you will often manage children often by doing the history and examination in one step.


Treatment and care should take into account children's needs and preferences and those of their parents or carers. Parents and carers of children with fever should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals.

Treatment and care of children with fever, and the information parents and carers are given about it, should be culturally appropriate. It should also be accessible to people with additional needs such as physical, sensory, or learning disabilities, and to people who do not speak or read English.

Table 1: Traffic light system for identifying risk of serious illness

Children with fever and any of the symptoms or signs in the red column should be recognised as being at high risk. Similarly, children with fever and any of the symptoms or signs in the amber column and none in the red column should be recognised as being at intermediate risk. Children with symptoms and signs in the green column and none in the amber or red column are at low risk. The management of children with fever should be directed by the level of risk.

Green - low risk

Amber - intermediate risk
Red - high risk
Colour
Normal colour of skin, lips and tongue
Pallor reported by parent/carer
Pale/mottled/ashen/blue
Activity
Responds normally to social cues
Content/smiles
Stays awake or awakens quickly
Strong normal cry/not crying
Not responding normally to social cues
Wakes only with prolonged stimulation
Decreased activity
No smile
No response to social cues
Appears ill to a healthcare professional
Unable to rouse or if roused does not stay awake
Weak, high pitched, or continuous cry
Respiratory


Nasal flaring
Tachypnoea:
RR >50 breaths/minute
age 6-12 months
RR >40 breaths /minute
age >12 months
Oxygen saturation ≤95% in air
Crackles
Grunting
Tachypnoea:
RR >60 breaths/minute
Moderate or severe chest indrawing
Hydration
Normal skin and eyes
Moist mucous membranes
Dry mucous membrane
Poor feeding in infants
CRT ≥3 seconds
Reduced urine output
Reduced skin turgor
Other
None of the amber or red symptoms or signs
Fever for ≥5 days
Age 0-3 months, temperature ≥38°C
Age 3-6 months, temperature ≥39°C


Swelling of a limb or joint
Non-weight bearing/not using an extremity
Non-blanching rash
Bulging fontanelle
Neck stiffness
Status epilepticus
Focal neurological signs
Focal seizures

A new lump >2 cm

Bile stainedvomiting
CRT=capillary refill time; RR=respiratory rate.

• Learning bite

• Always do a thorough clinical examination. Children and sometimes their parents may not fully understand the significance of certain signs. You may pick up something unexpected - such as impetigo in this small child.
•

Learning bite

You should assess children with fever for signs of dehydration. You should look for:
Prolonged capillary refill time
Abnormal skin turgor
Abnormal respiratory rate
Weak pulse
Cool extremities.


Learning bite
Children with any "red" features but who are not considered to have an immediately life threatening illness should be referred urgently to the care of a paediatrician.

If any "amber" features are present and no diagnosis has been reached, you should provide parents or carers with a "safety net" or refer to specialist paediatric care for further assessment. The safety net should be one or more of the following:
Providing the parent or carer with verbal and/or written information on warning symptoms and how further health care can be accessed
This safety net is important and is much valued by parents.

Children with "green" features and none of the "amber" or "red" features can be managed at home with appropriate advice for parents and carers, including advice on when to seek further attention from the healthcare services.

Remember that classical signs of meningitis (neck stiffness, bulging fontanelle, high pitched cry) are often absent in infants with bacterial meningitis.

Tachypnoea is a respiratory rate of:

>50 breaths/minute in a child age
6-12 months
>40 breaths/minute in a child age >12 months.

Learning bite - advice for home care

Parents or carers looking after a feverish child at home should be advised:
To offer the child regular fluids (where a baby or child is breast fed the most appropriate fluid is breast milk).

How to detect signs of dehydration by looking for the following features:

Sunken fontanelle
Dry mouth
Sunken eyes, absence of tears
Poor overall appearance
To encourage their child to drink more fluids and consider seeking further advice if they detect signs of dehydration


How to identify a non-blanching rash
To check their child during the night
To keep their child away from nursery or school while the child's fever persists but to notify the school or nursery of the illness.

There is no evidence that antipyretic agents prevent febrile convulsions - they should not be used specifically for this purpose.

Paracetamol and ibuprofen should not be given at the same time to children with fever. Either paracetamol or ibuprofen can be used to reduce temperature but you shouldn't give them at the same time.

Tepid sponging is not recommended for the treatment of fever. Nor should children with fever be under dressed or over wrapped.

You should avoid aspirin in children under the age 16 due to the risk of Reye's syndrome.

Learning bite - urinary tract infection
You should consider urinary tract infection in any child younger than
3 months with fever.
You should test the urine in children with fever when you suspect a urinary infection.

Kawasaki syndrome typically causes fever for more than five days and at least four of the following:
Bilateral conjunctival injection
Change in mucous membranes (for example, injected pharynx, dry cracked lips, or strawberry tongue)
Change in the extremities (for example, oedema, erythema, or desquamation)
Polymorphous rash
Cervical lymphadenopathy.


Key points
Detection of fever
In children aged 4 weeks to 5 years, you should measure body temperature by one of the following methods:
• Electronic thermometer in the axilla
• Chemical dot thermometer in the axilla
• Infrared tympanic thermometer.
You should take seriously any reported parental perception of a fever.

Clinical assessment of the child with fever

You should use the traffic light system to assess for the presence or absence of serious symptoms and signs.
You should measure and record temperature, heart rate, respiratory rate, and capillary refill time as part of routine assessment.

Management by remote assessment

Children with any "red" features but who are not considered to have an immediately life threatening illness should be urgently assessed by a healthcare professional in a face to face setting within two hours.

Management by the non-paediatric practitioner

If any "amber" features are present and no diagnosis has been reached, healthcare professionals should provide parents or carers with a "safety net" or refer to specialist paediatric care for further assessment.

The safety net should be one or more of the following:

Providing the parent or carer with verbal and/or written information on warning symptoms and how further healthcare can be accessed
Arranging further follow up at a specified time and place,Liaising with other healthcare professionals, including out of hours providers, to ensure direct access for the child if further assessment is required.You should not prescribe oral antibiotics if there is no apparent source of infection


Table 2: Summary table for symptoms and signs suggestive of specific diseases

Diagnosis to be considered

Symptoms and signs in conjunction with fever
Meningococcal disease
Non-blanching rash, particularly with one or more of the following:
An ill looking child
Lesions larger than 2 mm in diameter (purpura)
A capillary refill time of ≥3 seconds
Neck stiffness.
• classically palatal petechiae.

Meningitis

One or more of the following:
Neck stiffness
Bulging fontanelle
Decreased level of consciousness
Convulsive status epilepticus.
Herpes simplex encephalitis
Herpes simplex encephalitis should be considered in children with fever and any of the following features:
Focal neurological signs
Focal seizures
Decreased level of consciousness


Pneumonia
You should consider pneumonia in children with fever and any of the following signs:
Tachypnoea
• (RR > 60 breaths per minute Age 0-5 months,
• RR > 50 breaths per minute Age 6-12 months;
• RR > 40 breaths per minute Age >12 months)
Crackles
Nasal flaring
Chest indrawing
Cyanosis
Oxygen saturation ≤95% on air.

Urinary tract infection

You should think of a urinary tract infection in a child aged 3 months and older with fever and one or more of the following:
Vomiting
Poor feeding
Lethargy
Irritability
Abdominal pain or tenderness
Urinary frequency or dysuria
Offensive urine or haematuria.


Septic arthritis
Septic arthritis/osteomyelitis should be considered in children with fever and any of the following signs:
Swelling of a limb or joint
Not using an extremity
Non-weight bearing.

Kawasaki disease

Fever for more than five days and at least four of the following:
Bilateral conjunctival injection
Change in mucous membranes (for example, injected pharynx, dry cracked lips, or strawberry tongue)
Change in the extremities (for example, oedema, erythema, or desquamation)
Polymorphous rash
Cervical lymphadenopathy.
Healthcare professionals should be aware that, in rare cases, incomplete/atypical Kawasaki disease may be diagnosed with fewer features.

Learning bite - when to seek further help

Following contact with a healthcare professional, parents and carers who are looking after their feverish child at home should seek further advice
if:
• The child has a fit
• The child develops a non-blanching rash
• The parent or carer feels that the child is less well than when they previously sought advice
• The parent or carer is more worried than when they previously sought advice
• The fever lasts longer than five days
• The parent or carer is distressed, or concerned that they are unable to look after their child.


Learning bite
In infants under the age of 4 weeks, you should measure temperature with an electronic thermometer in the axilla.