Dr Jennifer Parkhouse shares 10 top tips on diagnosing and managing children with fever

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Read this article to learn more about:

  • how to measure a child's or baby's temperature accurately
  • establishing a working diagnosis and excluding the possibility of a serious infection
  • managing fever appropriately.

 

A child with fever is a very common presentation in general practice: 20–40% of parents report such an illness each year.1 Fever is usually associated with an infection but elucidating the exact cause of the fever and, more importantly, confidently excluding a potentially serious infection can be difficult. The fear of missing a serious infection in a child is compounded by the fact that infection is the leading cause of death in children under 5 years of age.2

NICE Clinical Guideline 160 (CG160) on Fever in under 5s: assessment and initial management aims to address this issue by assisting healthcare professionals in the initial assessment and management of young children with fever.2 This article will discuss the approach to and management of a child with fever through implementation of the recommendations in CG160.

1 Observe the child outside of the consultation room

It can often seem that within a 10-minute consultation there is simply not enough time to say confidently that the child you have just seen has, for example, a simple viral illness. For this reason, it can be helpful to view the waiting room as an extension of the consultation room, and to use it as a place to make first observations of the child.

Children can often get extremely upset in the consultation room, particularly when feeling unwell. It may help to reaffirm a diagnosis of a simple viral illness if a child who is screaming in the consultation room was earlier observed to be playing happily and actively in the waiting room.

It is also important to remember that a clinical decision does not have to be static. An advantage in general practice is that the majority of patients are local—if necessary arrange to see the child either later that day or within 24–48 hours.

2 Listen to parental concerns

As is the case with any consultation, a good patient history can make the diagnosis much easier to determine. Although very young children cannot provide a history themselves, they will be accompanied by someone who knows them better than anyone else and it is imperative that parental or carer concerns are elicited and addressed.

If a parent/carer is extremely concerned about their child this should raise a red flag,1 and parental reports of a history of fever should be considered valid, even if the child has a normal temperature in the consultation room.2

3 Measure temperature accurately

Measuring a child's temperature accurately is an important part of the examination, and there is specific guidance on how to do this. It is recommended that babies under 4 weeks have their temperature measured using an electronic thermometer in the axilla, while the temperature of children aged 4 weeks to 5 years can be measured using either an electronic thermometer in the axilla, a chemical dot thermometer in the axilla, or an infrared tympanic thermometer.2

The importance of measuring the temperature of a child with fever accurately is highlighted by the recommendations in CG160, which state that children under the age of 3 months with a temperature of 38oC or higher are in the high-risk group for serious illness, while those aged 3–6 months with a temperature of 39oC or higher are in at least the intermediate-risk group.2

4 Examine the child thoroughly

Examining a child who is feeling unwell can be challenging and if the child is fractious it is generally helpful to examine ad hoc rather than systematically. Leave examinations that are most likely to upset the child, such as the throat examination, until last.

Examine the child thoroughly; this does involve fully undressing the child so as not to miss rashes or other clinical signs that could point to the cause of fever. Look carefully for common causes of temperature in children, such as tonsillitis and upper and lower respiratory tract infections.2

NICE Quality Standard 64 (QS64) on Fever in under 5s advises that in children presenting with fever, the following should be routinely documented:1

  • temperature.
  • heart rate
  • respiratory rate
  • capillary refill time

If heart rate and capillary refill time are abnormal (see Table 1, below), blood pressure should be measured using a child’s blood pressure cuff.2

Table 1: Traffic light system for identifying risk of serious illness*2
 Green—low riskAmber-intermediate riskRed-high risk
Colour (of skin, lips, or tongue)
  • Normal colour.
  • 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
  • No smile
  • Wakes only with prolonged stimulation
  • Decreased activity.
  • No response to social cues
  • Appears ill to a healthcare professional
  • Does not wake or if roused does not stay awake
  • Weak, high-pitched or continuous cry.
Respiratory  
  • Nasal flaring
  • Tachypnoea—respiratory rate:
    • >50 breaths/minute, age 6–12 months
    • >40 breaths/minute, age >12 months
  • Oxygen saturation ≤95% in air
  • Crackles in the chest.
  • Grunting
  • Tachypnoea—respiratory rate >60 breaths/minute
  • Moderate or severe chest indrawing.
Circulation and hydration
  • Normal skin and eyes
  • Moist mucous membranes.
  • Tachycardia:
    • >160 beats/minute, age <12 months
    • &150 beats/minute, age 12–24 months
    • >140 beats/minute, age 2–5 years
  • Capillary refill time ≥3 seconds
  • Dry mucous membranes
  • Poor feeding in infants
  • Reduced urine output.
  • Reduced skin turgor.
Other
  • None of the amber or red symptoms or signs.
  • Age 3–6 months, temperature ≥39°C
  • Fever for ≥5 days
  • Rigors
  • Swelling of a limb or joint
  • Non-weight bearing limb/not using an extremity.
  • Age <3 months, temperature ≥38°C
  • Non-blanching rash
  • Bulging fontanelle
  • Neck stiffness
  • Status epilepticus
  • Focal neurological signs
  • Focal seizures.
* This traffic light table should be used in conjunction with the recommendations in the guideline on investigations and initial management in children with fever. See www.nice.org.uk/cg160
National Institute for Health and Care Excellence (2013). Fever in under 5s: assessment and initial management. Available from: www.nice.org.uk/cg160. NICE has not checked the use of its content in this article to confirm that it accurately reflects the NICE publication from which it is taken.

Children with fever should also be assessed for signs of dehydration by looking specifically for prolonged capillary refill, abnormal skin turgor, abnormal pulse, cool extremities, and an abnormal respiratory pattern.2

5 Exclude serious infection and establish a working diagnosis

A working diagnosis should be established after the child has been fully examined and all necessary information has been acquired. In some cases, the cause of fever may be obvious, for example gastroenteritis, but it can be difficult in the early stages of a febrile illness to ascertain the cause. In these situations, it can be helpful to review the child at another time if the fever continues, provided that they are well enough to return home.

It is helpful to ask if a child has been in contact with anyone with a recent infection; many children attend nursery and it is often useful to ask about any recent outbreaks of infection that may have occurred there.

The possibility of a more serious infection needs to be excluded, and should be considered both during the examination and when taking a patient history. NICE CG160 advises that symptoms should be considered in relation to specific, serious infections to either exclude these or to help diagnose the cause of fever. Specific serious infections to consider include bacterial meningitis, herpes simplex encephalitis, Kawasaki disease, meningococcal disease, pneumonia, septic arthritis, and urinary tract infection (UTI). A UTI should be considered in all children under the age of 3 months presenting with fever.2 Table 2 (below) lists some signs and symptoms of specific serious infections, which, if present in conjunction with fever, should be looked for and asked about in the consultation.

Table 2: Summary table for symptoms and signs suggestive of specific diseases2
Diagnosis to be consideredSymptoms 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)
    • capillary refill time of ≥3 seconds
    • neck stiffness.
Bacterial meningitis
  • Neck stiffness
  • Bulging fontanelle
  • Decreased level of consciousness
  • Convulsive status epilepticus.
Herpes simplex encephalitis
  • Focal neurological signs
  • Focal seizures
  • Decreased level of consciousness.
Pneumonia
  • Tachypnoea—respiratory rate:
    • >60 breaths/minute, age 0–5 months
    • >50 breaths/minute, age 6–12 months
    • >40 breaths/minute, age >12 months
  • Crackles in the chest
  • Nasal flaring
  • Chest indrawing
  • Cyanosis
  • Oxygen saturation ≤95%.
Urinary tract infection
  • Vomiting
  • Poor feeding
  • Lethargy
  • Irritability
  • Abdominal pain or tenderness
  • Urinary frequency or dysuria.
Septic arthritis
  • Swelling of a limb or joint
  • Not using an extremity
  • Non-weight bearing.
Kawasaki disease
  • Fever for more than 5 days and at least four of the following:
    • bilateral conjunctival injection
    • change in mucous membranes
    • change in the extremities
    • polymorphous rash
    • cervical lymphadenopathy.
National Institute for Health and Care Excellence (2013). Fever in under 5s: assessment and initial management. Available from: www.nice.org.uk/cg160
NICE has not checked the use of its content in this article to confirm that it accurately reflects the NICE publication from which it is taken.

6 Use appropriate investigations

Children and infants presenting with an unexplained fever of 38°C or higher should have their urine tested within 24 hours.1 Urine should be collected by clean catch as recommended in NICE Clinical Guideline 54 (CG54) on Urinary tract infection in under 16s: diagnosis and management.3

NICE CG160 recommends that chest X-rays are not routinely organised for children thought to have pneumonia if they are not being admitted to hospital.2

7 Assess risk of serious illness

NICE has developed a traffic light system that can be used to assess the risk of serious illness. Signs and symptoms are categorised as red, amber, or green, as shown in Table 1 (above). A child with any red feature should be regarded as being at high risk of developing serious illness, while a child with any amber feature is viewed as being at intermediate risk. Those with no red or amber features are seen as low risk.2

The traffic light system is used to help guide further management of children with fever:2

  • immediate, life-threatening symptoms (e.g. airway is compromised or the child is unconscious)—call 999
  • red features, but no life-threatening symptoms—refer urgently to a paediatrician
  • amber features and no specific diagnosis—refer for specialist paediatric care and provide parents/carers with a safety net advice (see below)
  • green features only—manage at home with appropriate safety netting.

Clinical judgment should be an important aspect of any decision that is made; if a child looks clinically unwell they should be classified as being at high risk. Not all children present neatly into one category; if there is sufficient concern about a child, arrange for them to be reviewed by a paediatrician. Box 1 (see below) lists some factors that should be considered alongside clinical condition when deciding whether to admit a child with fever to hospital.

Box 1: Factors to consider in addition to clinical condition when deciding whether to admit a child with fever to hospital2

  • Social and family circumstances
  • Other illnesses that affect the child or other family members
  • Parental anxiety and instinct (based on their knowledge of their child)
  • Contacts with other people who have serious infectious diseases
  • Recent travel abroad to tropical/subtropical areas, or areas with a high risk of endemic infectious disease
  • When the parent or carer’s concern for their child’s current illness has caused them to seek healthcare advice repeatedly
  • Where the family has experienced a previous serious illness or death due to feverish illness which has increased their anxiety levels
  • When a feverish illness has no obvious cause, but the child remains ill longer than expected for a self-limiting illness.

National Institute for Health and Care Excellence (2013). Fever in under 5s: assessment and initial management. Available from: www.nice.org.uk/cg160

NICE has not checked the use of its content in this article to confirm that it accurately reflects the NICE publication from which it is taken.

8 Manage fever appropriately

Specific guidance on how to manage a fever is given in CG160, which states that children should only be given antipyretics if they are distressed. Antipyretics should not be used solely to reduce a temperature or to try and prevent a febrile convulsion, which they do not. A response to antipyretics should not be relied upon to provide guidance on the seriousness of the illness.2

Paracetamol or ibuprofen should be used only for the period of time that the child appears distressed. If the child’s distress is not alleviated, then a switch to the alternative agent should be considered. If the child continues to be in distress or if symptoms recur before the next dose, consider alternating. Paracetamol and ibuprofen should never be used simultaneously.2

If the cause of the fever has been identified and antibiotics are required, these should be prescribed.

9 Reassure parents or carers and provide them with a safety net

Reassurance and provision of a safety net is an important part of any consultation, particularly involving children, and should be part of every consultation with a child who presents with fever. NICE CG160 advises that for a child with fever, a safety net should include one or more of the following:2

  • providing the parent or carer with written or verbal information on warning symptoms and how to access help
  • arranging follow up at a specified time and place
  • liaising with other healthcare professionals, such as out-of-hours providers, so that the child can be assessed at a later time, if necessary.

Parents or carers looking after children with fever at home should be given specific guidance on:2

  • detecting signs of dehydration
  • offering the child regular fluids
  • how to identify a non-blanching rash
  • keeping the child away from nursery or school until they are well
  • checking the child at night.

There is no guidance on how often a child with fever should be checked during the night, so this is dependent on the degree of clinical concern, but could be every 2–4 hours. If it is felt that a child needs to be checked more often, then it may be appropriate for them to be admitted to hospital.

Parents caring for children with fever at home should be advised to seek medical attention if:2

  • the child has a fit
  • the fever lasts longer than 5 days
  • the child becomes more unwell
  • the parent/carer is distressed or concerned that they are unable to look after their child
  • a non-blanching rash develops.

If there is concern that a parent may not be able to make a good judgment about a child's illness if it progresses, arrangements should be made to see the child again in person.

10 Assess the risk of serious illness over the phone

The principles of assessing the risk of serious illness and excluding a more severe cause for the infection should be applied to telephone consultations involving children with fever.

There should be a low threshold for seeing the child following a telephone consultation and this should be guided by the traffic light system:2

  • child with symptoms and signs suggesting an immediately life-threatening illness—refer immediately for emergency medical care (usually 999 ambulance)
  • child with red features (and no life-threatening features)—arrange for the child to be seen in person within 2 hours by a medical practitioner
  • child with amber features only—arrange for the child to be seen in person by a medical practitioner within a clinically appropriate timeframe, generally it would seem prudent to ask the parent to bring the child to the surgery as soon as they are able to
  • child with green features only—can be managed at home with safety netting.

References

  1. NICE. Fever in under 5s. Quality Standard 64. NICE, 2014. Available at: nice.org.uk/qs64
  2. NICE. Fever in under 5s: assessment and initial management. Clinical Guideline 160. NICE, 2013. Available at: nice.org.uk/cg16.
  3. NICE. Urinary tract infection in children: diagnosis, and management. Clinical Guideline 54. NICE, 2007. Available at: nice.org.uk/cg54. G